Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

OTHER VASCULAR PROCEDURES WITH CC

Facility

$69,158.10

Service Code	MSDRG 253
Min. Negotiated Rate	$29,523.03
Max. Negotiated Rate	$69,158.10
Rate for Payer: AlohaCare Medicare	$29,523.03
Rate for Payer: Devoted Health Medicare	$32,475.33
Rate for Payer: Hawaii Medical Service Association Commercial	$69,158.10
Rate for Payer: Hawaii Medical Service Association Medicare	$29,523.03
Rate for Payer: Humana Medicare	$29,523.03
Rate for Payer: Kaiser Permanente Commercial	$44,774.10
Rate for Payer: Kaiser Permanente Medicare	$29,523.03
Rate for Payer: Ohana Health Plan Medicare	$29,523.03
Rate for Payer: UnitedHealthcare Medicare	$29,523.03

OTHER VASCULAR PROCEDURES WITH MCC

Facility

$73,623.04

Service Code	MSDRG 252
Min. Negotiated Rate	$39,676.83
Max. Negotiated Rate	$73,623.04
Rate for Payer: AlohaCare Medicare	$39,676.83
Rate for Payer: Devoted Health Medicare	$43,644.51
Rate for Payer: Hawaii Medical Service Association Commercial	$73,623.04
Rate for Payer: Hawaii Medical Service Association Medicare	$39,676.83
Rate for Payer: Humana Medicare	$39,676.83
Rate for Payer: Kaiser Permanente Commercial	$60,173.18
Rate for Payer: Kaiser Permanente Medicare	$39,676.83
Rate for Payer: Ohana Health Plan Medicare	$39,676.83
Rate for Payer: UnitedHealthcare Medicare	$39,676.83

OTHER VASCULAR PROCEDURES WITHOUT CC/MCC

Facility

$49,987.96

Service Code	MSDRG 254
Min. Negotiated Rate	$20,265.51
Max. Negotiated Rate	$49,987.96
Rate for Payer: AlohaCare Medicare	$20,265.51
Rate for Payer: Devoted Health Medicare	$22,292.06
Rate for Payer: Hawaii Medical Service Association Commercial	$49,987.96
Rate for Payer: Hawaii Medical Service Association Medicare	$20,265.51
Rate for Payer: Humana Medicare	$20,265.51
Rate for Payer: Kaiser Permanente Commercial	$30,734.33
Rate for Payer: Kaiser Permanente Medicare	$20,265.51
Rate for Payer: Ohana Health Plan Medicare	$20,265.51
Rate for Payer: UnitedHealthcare Medicare	$20,265.51

OTITIS MEDIA AND URI WITH MCC

Facility

$20,392.95

Service Code	MSDRG 152
Min. Negotiated Rate	$12,472.72
Max. Negotiated Rate	$20,392.95
Rate for Payer: AlohaCare Medicare	$13,446.66
Rate for Payer: Devoted Health Medicare	$14,791.33
Rate for Payer: Hawaii Medical Service Association Commercial	$12,472.72
Rate for Payer: Hawaii Medical Service Association Medicare	$13,446.66
Rate for Payer: Humana Medicare	$13,446.66
Rate for Payer: Kaiser Permanente Commercial	$20,392.95
Rate for Payer: Kaiser Permanente Medicare	$13,446.66
Rate for Payer: Ohana Health Plan Medicare	$13,446.66
Rate for Payer: UnitedHealthcare Medicare	$13,446.66

OTITIS MEDIA AND URI WITHOUT MCC

Facility

$12,733.95

Service Code	MSDRG 153
Min. Negotiated Rate	$8,396.46
Max. Negotiated Rate	$12,733.95
Rate for Payer: AlohaCare Medicare	$8,396.46
Rate for Payer: Devoted Health Medicare	$9,236.11
Rate for Payer: Hawaii Medical Service Association Commercial	$10,798.37
Rate for Payer: Hawaii Medical Service Association Medicare	$8,396.46
Rate for Payer: Humana Medicare	$8,396.46
Rate for Payer: Kaiser Permanente Commercial	$12,733.95
Rate for Payer: Kaiser Permanente Medicare	$8,396.46
Rate for Payer: Ohana Health Plan Medicare	$8,396.46
Rate for Payer: UnitedHealthcare Medicare	$8,396.46

OUTBOARD TL ASSM 51-10440

Facility

$1,742.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,480.70
Max. Negotiated Rate	$1,689.74
Rate for Payer: Cash Price	$1,045.20
Rate for Payer: Health Management Network Commercial	$1,480.70
Rate for Payer: MDX Hawaii PPO	$1,689.74

OUTBOARD TL ASSM 51-10440

Facility

$1,742.00

Hospital Revenue Code	272
Min. Negotiated Rate	$888.42
Max. Negotiated Rate	$1,689.74
Rate for Payer: Cash Price	$1,045.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,654.90
Rate for Payer: Health Management Network Commercial	$1,480.70
Rate for Payer: Kaiser Permanente Commercial	$1,097.46
Rate for Payer: Kaiser Permanente Medicaid	$888.42
Rate for Payer: MDX Hawaii PPO	$1,689.74
Rate for Payer: University Health Alliance Commercial	$1,269.74

OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL

Facility

$13,923.44

Service Code	CPT 58925
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,923.44
Rate for Payer: AlohaCare Medicaid	$5,909.62
Rate for Payer: AlohaCare Medicare	$5,909.62
Rate for Payer: Devoted Health Medicare	$6,500.58
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	$5,909.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$5,909.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$5,909.62
Rate for Payer: Ohana Health Plan Medicaid	$6,500.58
Rate for Payer: Ohana Health Plan Medicare	$5,909.62
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$5,909.62
Rate for Payer: University Health Alliance Commercial	$13,923.44

OVERDRILL 2.0 705137

Facility

$826.00

Hospital Revenue Code	272
Min. Negotiated Rate	$421.26
Max. Negotiated Rate	$801.22
Rate for Payer: Cash Price	$495.60
Rate for Payer: Hawaii Western Management Group Commercial	$784.70
Rate for Payer: Health Management Network Commercial	$702.10
Rate for Payer: Kaiser Permanente Commercial	$520.38
Rate for Payer: Kaiser Permanente Medicaid	$421.26
Rate for Payer: MDX Hawaii PPO	$801.22
Rate for Payer: University Health Alliance Commercial	$602.07

OVERDRILL 2.0 705137

Facility

$826.00

Hospital Revenue Code	272
Min. Negotiated Rate	$702.10
Max. Negotiated Rate	$801.22
Rate for Payer: Cash Price	$495.60
Rate for Payer: Health Management Network Commercial	$702.10
Rate for Payer: MDX Hawaii PPO	$801.22

OVERTUBE ENDOSCOPIC ACCESS

Facility

$798.00

Hospital Revenue Code	272
Min. Negotiated Rate	$678.30
Max. Negotiated Rate	$774.06
Rate for Payer: Cash Price	$478.80
Rate for Payer: Health Management Network Commercial	$678.30
Rate for Payer: MDX Hawaii PPO	$774.06

OVERTUBE ENDOSCOPIC ACCESS

Facility

$798.00

Hospital Revenue Code	272
Min. Negotiated Rate	$406.98
Max. Negotiated Rate	$774.06
Rate for Payer: Cash Price	$478.80
Rate for Payer: Hawaii Western Management Group Commercial	$758.10
Rate for Payer: Health Management Network Commercial	$678.30
Rate for Payer: Kaiser Permanente Commercial	$502.74
Rate for Payer: Kaiser Permanente Medicaid	$406.98
Rate for Payer: MDX Hawaii PPO	$774.06
Rate for Payer: University Health Alliance Commercial	$581.66

OVOMATION 56X52MM 8HM2-5652-A

Facility

$8,670.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,855.20
Max. Negotiated Rate	$8,409.90
Rate for Payer: Cash Price	$5,202.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,069.00
Rate for Payer: Health Management Network Commercial	$7,369.50
Rate for Payer: MDX Hawaii PPO	$8,409.90
Rate for Payer: University Health Alliance Commercial	$4,855.20

OVOMATION 56X52MM 8HM2-5652-A

Facility

$8,670.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,421.70
Max. Negotiated Rate	$8,409.90
Rate for Payer: Cash Price	$5,202.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,069.00
Rate for Payer: Health Management Network Commercial	$7,369.50
Rate for Payer: Kaiser Permanente Commercial	$5,462.10
Rate for Payer: Kaiser Permanente Medicaid	$4,421.70
Rate for Payer: MDX Hawaii PPO	$8,409.90
Rate for Payer: University Health Alliance Commercial	$4,855.20

OVOMOTION SHOULDER SYS 54X50MM

Facility

$8,670.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,421.70
Max. Negotiated Rate	$8,409.90
Rate for Payer: Cash Price	$5,202.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,069.00
Rate for Payer: Health Management Network Commercial	$7,369.50
Rate for Payer: Kaiser Permanente Commercial	$5,462.10
Rate for Payer: Kaiser Permanente Medicaid	$4,421.70
Rate for Payer: MDX Hawaii PPO	$8,409.90
Rate for Payer: University Health Alliance Commercial	$4,855.20

OVOMOTION SHOULDER SYS 54X50MM

Facility

$8,670.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,855.20
Max. Negotiated Rate	$8,409.90
Rate for Payer: Cash Price	$5,202.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,069.00
Rate for Payer: Health Management Network Commercial	$7,369.50
Rate for Payer: MDX Hawaii PPO	$8,409.90
Rate for Payer: University Health Alliance Commercial	$4,855.20

OXACILLIN 10 GRAM SOLUTION FOR INJECTION [171652]

Facility

$218.00

Service Code	HCPCS J2700
Hospital Revenue Code	636
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$211.46
Rate for Payer: Cash Price	$130.80
Rate for Payer: Cash Price	$126.60
Rate for Payer: Cash Price	$126.60
Rate for Payer: Cash Price	$130.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.82
Rate for Payer: Hawaii Medical Service Association ABD	$0.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.82
Rate for Payer: Hawaii Western Management Group Commercial	$200.45
Rate for Payer: Hawaii Western Management Group Commercial	$207.10
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Health Management Network Commercial	$179.35
Rate for Payer: Kaiser Permanente Commercial	$137.34
Rate for Payer: Kaiser Permanente Commercial	$132.93
Rate for Payer: Kaiser Permanente Medicaid	$107.61
Rate for Payer: Kaiser Permanente Medicaid	$111.18
Rate for Payer: MDX Hawaii PPO	$211.46
Rate for Payer: MDX Hawaii PPO	$204.67
Rate for Payer: UnitedHealthcare Medicaid	$126.60
Rate for Payer: UnitedHealthcare Medicaid	$130.80
Rate for Payer: University Health Alliance Commercial	$153.80
Rate for Payer: University Health Alliance Commercial	$158.90

OXACILLIN 10 GRAM SOLUTION FOR INJECTION [171652]

Facility

$211.00

Service Code	HCPCS J2700
Hospital Revenue Code	250
Min. Negotiated Rate	$179.35
Max. Negotiated Rate	$204.67
Rate for Payer: Cash Price	$126.60
Rate for Payer: Cash Price	$130.80
Rate for Payer: Health Management Network Commercial	$179.35
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: MDX Hawaii PPO	$204.67
Rate for Payer: MDX Hawaii PPO	$211.46

OXACILLIN 1 GRAM SOLUTION FOR INJECTION [5924]

Facility

$37.00

Service Code	HCPCS J2700
Hospital Revenue Code	636
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$35.89
Rate for Payer: Cash Price	$22.20
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$22.20
Rate for Payer: Cash Price	$18.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.82
Rate for Payer: Hawaii Medical Service Association ABD	$0.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.82
Rate for Payer: Hawaii Western Management Group Commercial	$28.50
Rate for Payer: Hawaii Western Management Group Commercial	$35.15
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Commercial	$23.31
Rate for Payer: Kaiser Permanente Medicaid	$18.87
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: MDX Hawaii PPO	$35.89
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: UnitedHealthcare Medicaid	$18.00
Rate for Payer: UnitedHealthcare Medicaid	$22.20
Rate for Payer: University Health Alliance Commercial	$21.87
Rate for Payer: University Health Alliance Commercial	$26.97

OXACILLIN 1 GRAM SOLUTION FOR INJECTION [5924]

Facility

$30.00

Service Code	HCPCS J2700
Hospital Revenue Code	250
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$22.20
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: MDX Hawaii PPO	$35.89

OXACILLIN 2 GRAM SOLUTION FOR INJECTION [5926]

Facility

$71.00

Service Code	HCPCS J2700
Hospital Revenue Code	250
Min. Negotiated Rate	$60.35
Max. Negotiated Rate	$68.87
Rate for Payer: Cash Price	$42.60
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Health Management Network Commercial	$60.35
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: MDX Hawaii PPO	$68.87

OXACILLIN 2 GRAM SOLUTION FOR INJECTION [5926]

Facility

$71.00

Service Code	HCPCS J2700
Hospital Revenue Code	636
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$68.87
Rate for Payer: Cash Price	$42.60
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cash Price	$42.60
Rate for Payer: Cash Price	$19.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.82
Rate for Payer: Hawaii Medical Service Association ABD	$0.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.82
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Hawaii Western Management Group Commercial	$67.45
Rate for Payer: Health Management Network Commercial	$60.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$44.73
Rate for Payer: Kaiser Permanente Commercial	$20.79
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicaid	$36.21
Rate for Payer: MDX Hawaii PPO	$68.87
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: UnitedHealthcare Medicaid	$19.80
Rate for Payer: UnitedHealthcare Medicaid	$42.60
Rate for Payer: University Health Alliance Commercial	$51.75
Rate for Payer: University Health Alliance Commercial	$24.05

OXACILLIN SODIUM 10 G/100ML IV (WET SOLR VIAL) [430171652]

Facility

$218.00

Service Code	HCPCS J2700
Hospital Revenue Code	636
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$211.46
Rate for Payer: Cash Price	$130.80
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cash Price	$130.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.82
Rate for Payer: Hawaii Medical Service Association ABD	$0.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.82
Rate for Payer: Hawaii Western Management Group Commercial	$207.10
Rate for Payer: Hawaii Western Management Group Commercial	$247.95
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Kaiser Permanente Commercial	$137.34
Rate for Payer: Kaiser Permanente Commercial	$164.43
Rate for Payer: Kaiser Permanente Medicaid	$133.11
Rate for Payer: Kaiser Permanente Medicaid	$111.18
Rate for Payer: MDX Hawaii PPO	$211.46
Rate for Payer: MDX Hawaii PPO	$253.17
Rate for Payer: UnitedHealthcare Medicaid	$130.80
Rate for Payer: UnitedHealthcare Medicaid	$156.60
Rate for Payer: University Health Alliance Commercial	$158.90
Rate for Payer: University Health Alliance Commercial	$190.24

OXACILLIN SODIUM 10 G/100ML IV (WET SOLR VIAL) [430171652]

Facility

$218.00

Service Code	HCPCS J2700
Hospital Revenue Code	250
Min. Negotiated Rate	$185.30
Max. Negotiated Rate	$211.46
Rate for Payer: Cash Price	$130.80
Rate for Payer: Cash Price	$156.60
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: MDX Hawaii PPO	$253.17
Rate for Payer: MDX Hawaii PPO	$211.46

OXACILLIN SODIUM 1 G/10ML IJ (WET SOLR VIAL) [4305924]

Facility

$33.00

Service Code	HCPCS J2700
Hospital Revenue Code	636
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$4.80
Rate for Payer: Cash Price	$4.80
Rate for Payer: Cash Price	$19.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.82
Rate for Payer: Hawaii Medical Service Association ABD	$0.82
Rate for Payer: Hawaii Medical Service Association ABD	$0.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.82
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Hawaii Western Management Group Commercial	$28.50
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Commercial	$20.79
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: UnitedHealthcare Medicaid	$18.00
Rate for Payer: UnitedHealthcare Medicaid	$4.80
Rate for Payer: UnitedHealthcare Medicaid	$19.80
Rate for Payer: University Health Alliance Commercial	$5.83
Rate for Payer: University Health Alliance Commercial	$21.87
Rate for Payer: University Health Alliance Commercial	$24.05

Know your out-of-pocket cost for care.

All Charges