Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS

Facility

$9,767.20

Service Code	APR-DRG 4214
Min. Negotiated Rate	$9,767.20
Max. Negotiated Rate	$9,767.20
Rate for Payer: AlohaCare Medicaid	$9,767.20
Rate for Payer: Hawaii Medical Service Association ABD	$9,767.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,767.20
Rate for Payer: Kaiser Permanente Medicaid	$9,767.20
Rate for Payer: Ohana Health Plan Medicaid	$9,767.20
Rate for Payer: UnitedHealthcare Medicaid	$9,767.20

MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS

Facility

$3,281.61

Service Code	APR-DRG 4212
Min. Negotiated Rate	$3,281.61
Max. Negotiated Rate	$3,281.61
Rate for Payer: AlohaCare Medicaid	$3,281.61
Rate for Payer: Hawaii Medical Service Association ABD	$3,281.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,281.61
Rate for Payer: Kaiser Permanente Medicaid	$3,281.61
Rate for Payer: Ohana Health Plan Medicaid	$3,281.61
Rate for Payer: UnitedHealthcare Medicaid	$3,281.61

MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS

Facility

$4,966.44

Service Code	APR-DRG 4213
Min. Negotiated Rate	$4,966.44
Max. Negotiated Rate	$4,966.44
Rate for Payer: AlohaCare Medicaid	$4,966.44
Rate for Payer: Hawaii Medical Service Association ABD	$4,966.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,966.44
Rate for Payer: Kaiser Permanente Medicaid	$4,966.44
Rate for Payer: Ohana Health Plan Medicaid	$4,966.44
Rate for Payer: UnitedHealthcare Medicaid	$4,966.44

MANDIBLE PLATE 3X3 04.503.716

Facility

$2,530.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,416.80
Max. Negotiated Rate	$2,454.10
Rate for Payer: Cash Price	$1,518.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,771.00
Rate for Payer: Health Management Network Commercial	$2,150.50
Rate for Payer: MDX Hawaii PPO	$2,454.10
Rate for Payer: University Health Alliance Commercial	$1,416.80

MANDIBLE PLATE 3X3 04.503.716

Facility

$2,530.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,290.30
Max. Negotiated Rate	$2,454.10
Rate for Payer: Cash Price	$1,518.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,771.00
Rate for Payer: Health Management Network Commercial	$2,150.50
Rate for Payer: Kaiser Permanente Commercial	$1,593.90
Rate for Payer: Kaiser Permanente Medicaid	$1,290.30
Rate for Payer: MDX Hawaii PPO	$2,454.10
Rate for Payer: University Health Alliance Commercial	$1,416.80

MANDIBLE RAMUS 4.0 04.305.100

Facility

$2,668.00

Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.68
Max. Negotiated Rate	$2,587.96
Rate for Payer: Cash Price	$1,600.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,867.60
Rate for Payer: Health Management Network Commercial	$2,267.80
Rate for Payer: Kaiser Permanente Commercial	$1,680.84
Rate for Payer: Kaiser Permanente Medicaid	$1,360.68
Rate for Payer: MDX Hawaii PPO	$2,587.96
Rate for Payer: University Health Alliance Commercial	$1,494.08

MANDIBLE RAMUS 4.0 04.305.100

Facility

$2,668.00

Hospital Revenue Code	278
Min. Negotiated Rate	$1,494.08
Max. Negotiated Rate	$2,587.96
Rate for Payer: Cash Price	$1,600.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,867.60
Rate for Payer: Health Management Network Commercial	$2,267.80
Rate for Payer: MDX Hawaii PPO	$2,587.96
Rate for Payer: University Health Alliance Commercial	$1,494.08

MANIPULATION, ELBOW, UNDER ANESTHESIA

Facility

$2,837.00

Service Code	CPT 24300
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,899.59

MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES)

Facility

$4,035.20

Service Code	CPT 27570
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$4,035.20

MANNITOL 20 % INTRAVENOUS SOLUTION [4749]

Facility

$81.00

Service Code	NDC 00990771503
Hospital Revenue Code	250
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$78.57
Rate for Payer: Cash Price	$48.60
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: MDX Hawaii PPO	$78.57

MANNITOL 20 % INTRAVENOUS SOLUTION [4749]

Facility

$81.00

Service Code	NDC 00990771513
Hospital Revenue Code	250
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$78.57
Rate for Payer: Cash Price	$48.60
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: MDX Hawaii PPO	$78.57

MANNITOL 20 % INTRAVENOUS SOLUTION [4749]

Facility

$98.00

Service Code	NDC 00990771512
Hospital Revenue Code	250
Min. Negotiated Rate	$83.30
Max. Negotiated Rate	$95.06
Rate for Payer: Cash Price	$58.80
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: MDX Hawaii PPO	$95.06

MANNITOL 25 % INTRAVENOUS SOLUTION [4750]

Facility

$26.00

Service Code	HCPCS J2150
Hospital Revenue Code	636
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$15.60
Rate for Payer: Cash Price	$15.60
Rate for Payer: Hawaii Medical Service Association ABD	$2.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.24
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$16.38
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: University Health Alliance Commercial	$18.95

MANNITOL 25 % INTRAVENOUS SOLUTION [4750]

Facility

$26.00

Service Code	HCPCS J2150
Hospital Revenue Code	250
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: MDX Hawaii PPO	$25.22

MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION [177326]

Facility

$12,417.00

Service Code	HCPCS J9353
Hospital Revenue Code	250
Min. Negotiated Rate	$10,554.45
Max. Negotiated Rate	$12,044.49
Rate for Payer: Cash Price	$7,450.20
Rate for Payer: Cash Price	$2,887.80
Rate for Payer: Health Management Network Commercial	$10,554.45
Rate for Payer: Health Management Network Commercial	$4,091.05
Rate for Payer: MDX Hawaii PPO	$12,044.49
Rate for Payer: MDX Hawaii PPO	$4,668.61

MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION [177326]

Facility

$12,417.00

Service Code	HCPCS J9353
Hospital Revenue Code	636
Min. Negotiated Rate	$50.45
Max. Negotiated Rate	$12,044.49
Rate for Payer: AlohaCare Medicaid	$53.27
Rate for Payer: AlohaCare Medicaid	$53.27
Rate for Payer: AlohaCare Medicare	$53.27
Rate for Payer: AlohaCare Medicare	$53.27
Rate for Payer: Cash Price	$7,450.20
Rate for Payer: Cash Price	$2,887.80
Rate for Payer: Cash Price	$2,887.80
Rate for Payer: Cash Price	$7,450.20
Rate for Payer: Devoted Health Medicare	$58.60
Rate for Payer: Devoted Health Medicare	$58.60
Rate for Payer: Hawaii Medical Service Association ABD	$50.45
Rate for Payer: Hawaii Medical Service Association ABD	$50.45
Rate for Payer: Hawaii Medical Service Association Commercial	$66.59
Rate for Payer: Hawaii Medical Service Association Commercial	$66.59
Rate for Payer: Hawaii Medical Service Association Medicare	$53.27
Rate for Payer: Hawaii Medical Service Association Medicare	$53.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.45
Rate for Payer: Hawaii Western Management Group Commercial	$4,572.35
Rate for Payer: Hawaii Western Management Group Commercial	$11,796.15
Rate for Payer: Health Management Network Commercial	$10,554.45
Rate for Payer: Health Management Network Commercial	$4,091.05
Rate for Payer: Humana Medicare	$53.27
Rate for Payer: Humana Medicare	$53.27
Rate for Payer: Kaiser Permanente Commercial	$7,822.71
Rate for Payer: Kaiser Permanente Commercial	$3,032.19
Rate for Payer: Kaiser Permanente Medicaid	$2,454.63
Rate for Payer: Kaiser Permanente Medicaid	$6,332.67
Rate for Payer: Kaiser Permanente Medicare	$53.27
Rate for Payer: Kaiser Permanente Medicare	$53.27
Rate for Payer: MDX Hawaii PPO	$12,044.49
Rate for Payer: MDX Hawaii PPO	$4,668.61
Rate for Payer: Ohana Health Plan Medicaid	$58.60
Rate for Payer: Ohana Health Plan Medicaid	$58.60
Rate for Payer: Ohana Health Plan Medicare	$53.27
Rate for Payer: Ohana Health Plan Medicare	$53.27
Rate for Payer: UnitedHealthcare Medicaid	$7,450.20
Rate for Payer: UnitedHealthcare Medicaid	$2,887.80
Rate for Payer: UnitedHealthcare Medicare	$53.27
Rate for Payer: UnitedHealthcare Medicare	$53.27
Rate for Payer: University Health Alliance Commercial	$9,050.75
Rate for Payer: University Health Alliance Commercial	$3,508.20

MARKERS MARGIN PAINT MMS6/MMC6

Facility

$421.00

Hospital Revenue Code	272
Min. Negotiated Rate	$214.71
Max. Negotiated Rate	$408.37
Rate for Payer: Cash Price	$252.60
Rate for Payer: Hawaii Western Management Group Commercial	$399.95
Rate for Payer: Health Management Network Commercial	$357.85
Rate for Payer: Kaiser Permanente Commercial	$265.23
Rate for Payer: Kaiser Permanente Medicaid	$214.71
Rate for Payer: MDX Hawaii PPO	$408.37
Rate for Payer: University Health Alliance Commercial	$306.87

MARKERS MARGIN PAINT MMS6/MMC6

Facility

$421.00

Hospital Revenue Code	272
Min. Negotiated Rate	$357.85
Max. Negotiated Rate	$408.37
Rate for Payer: Cash Price	$252.60
Rate for Payer: Health Management Network Commercial	$357.85
Rate for Payer: MDX Hawaii PPO	$408.37

MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST

Facility

$5,509.00

Service Code	CPT 56440
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$3,824.16
Rate for Payer: AlohaCare Medicare	$3,824.16
Rate for Payer: Devoted Health Medicare	$4,206.58
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,824.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,824.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,824.16
Rate for Payer: Ohana Health Plan Medicaid	$4,206.58
Rate for Payer: Ohana Health Plan Medicare	$3,824.16
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,824.16
Rate for Payer: University Health Alliance Commercial	$5,160.40

MARYLAND XP INLINESEAL DIVIDER

Facility

$1,782.00

Hospital Revenue Code	272
Min. Negotiated Rate	$908.82
Max. Negotiated Rate	$1,728.54
Rate for Payer: Cash Price	$1,069.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,692.90
Rate for Payer: Health Management Network Commercial	$1,514.70
Rate for Payer: Kaiser Permanente Commercial	$1,122.66
Rate for Payer: Kaiser Permanente Medicaid	$908.82
Rate for Payer: MDX Hawaii PPO	$1,728.54
Rate for Payer: University Health Alliance Commercial	$1,298.90

MARYLAND XP INLINESEAL DIVIDER

Facility

$1,782.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,514.70
Max. Negotiated Rate	$1,728.54
Rate for Payer: Cash Price	$1,069.20
Rate for Payer: Health Management Network Commercial	$1,514.70
Rate for Payer: MDX Hawaii PPO	$1,728.54

MASK COMPRESSION

Facility

$132.00

Hospital Revenue Code	272
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$79.20
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: MDX Hawaii PPO	$128.04

MASK COMPRESSION

Facility

$132.00

Hospital Revenue Code	272
Min. Negotiated Rate	$67.32
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$79.20
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$83.16
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: University Health Alliance Commercial	$96.21

MASTECTOMY FOR GYNECOMASTIA

Facility

$8,270.00

Service Code	CPT 19300
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$4,625.48
Rate for Payer: AlohaCare Medicare	$4,625.48
Rate for Payer: Devoted Health Medicare	$5,088.03
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,625.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$4,625.48
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,625.48
Rate for Payer: Ohana Health Plan Medicaid	$5,088.03
Rate for Payer: Ohana Health Plan Medicare	$4,625.48
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,625.48
Rate for Payer: University Health Alliance Commercial	$4,035.20

MASTECTOMY FOR MALIGNANCY WITH CC/MCC

Facility

$33,233.85

Service Code	MSDRG 582
Min. Negotiated Rate	$21,913.64
Max. Negotiated Rate	$33,233.85
Rate for Payer: AlohaCare Medicare	$21,913.64
Rate for Payer: Devoted Health Medicare	$24,105.00
Rate for Payer: Hawaii Medical Service Association Commercial	$25,624.90
Rate for Payer: Hawaii Medical Service Association Medicare	$21,913.64
Rate for Payer: Humana Medicare	$21,913.64
Rate for Payer: Kaiser Permanente Commercial	$33,233.85
Rate for Payer: Kaiser Permanente Medicare	$21,913.64
Rate for Payer: Ohana Health Plan Medicare	$21,913.64
Rate for Payer: UnitedHealthcare Medicare	$21,913.64

Know your out-of-pocket cost for care.

All Charges