Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

BONE HARVESTER 8MM STERILE BH8

Facility

$2,998.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,528.98
Max. Negotiated Rate	$2,908.06
Rate for Payer: Cash Price	$1,798.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,848.10
Rate for Payer: Health Management Network Commercial	$2,548.30
Rate for Payer: Kaiser Permanente Commercial	$1,888.74
Rate for Payer: Kaiser Permanente Medicaid	$1,528.98
Rate for Payer: MDX Hawaii PPO	$2,908.06
Rate for Payer: University Health Alliance Commercial	$2,185.24

BONE HARVESTER 8MM STERILE BH8

Facility

$2,998.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,548.30
Max. Negotiated Rate	$2,908.06
Rate for Payer: Cash Price	$1,798.80
Rate for Payer: Health Management Network Commercial	$2,548.30
Rate for Payer: MDX Hawaii PPO	$2,908.06

BONE TAP CANNULATED 4.5MM

Facility

$1,022.00

Hospital Revenue Code	272
Min. Negotiated Rate	$868.70
Max. Negotiated Rate	$991.34
Rate for Payer: Cash Price	$613.20
Rate for Payer: Health Management Network Commercial	$868.70
Rate for Payer: MDX Hawaii PPO	$991.34

BONE TAP CANNULATED 4.5MM

Facility

$1,022.00

Hospital Revenue Code	272
Min. Negotiated Rate	$521.22
Max. Negotiated Rate	$991.34
Rate for Payer: Cash Price	$613.20
Rate for Payer: Hawaii Western Management Group Commercial	$970.90
Rate for Payer: Health Management Network Commercial	$868.70
Rate for Payer: Kaiser Permanente Commercial	$643.86
Rate for Payer: Kaiser Permanente Medicaid	$521.22
Rate for Payer: MDX Hawaii PPO	$991.34
Rate for Payer: University Health Alliance Commercial	$744.94

BOOT HEELIFT SUSPENSION

Facility

$221.00

Hospital Revenue Code	274
Min. Negotiated Rate	$112.71
Max. Negotiated Rate	$214.37
Rate for Payer: Cash Price	$132.60
Rate for Payer: Hawaii Western Management Group Commercial	$154.70
Rate for Payer: Health Management Network Commercial	$187.85
Rate for Payer: Kaiser Permanente Commercial	$139.23
Rate for Payer: Kaiser Permanente Medicaid	$112.71
Rate for Payer: MDX Hawaii PPO	$214.37
Rate for Payer: University Health Alliance Commercial	$123.76

BOOT HEELIFT SUSPENSION

Facility

$221.00

Hospital Revenue Code	274
Min. Negotiated Rate	$123.76
Max. Negotiated Rate	$214.37
Rate for Payer: Cash Price	$132.60
Rate for Payer: Hawaii Western Management Group Commercial	$154.70
Rate for Payer: Health Management Network Commercial	$187.85
Rate for Payer: MDX Hawaii PPO	$214.37
Rate for Payer: University Health Alliance Commercial	$123.76

BOOT MULTI PODUS MED

Facility

$164.00

Service Code	HCPCS L4398
Hospital Revenue Code	274
Min. Negotiated Rate	$35.81
Max. Negotiated Rate	$159.08
Rate for Payer: Cash Price	$98.40
Rate for Payer: Cash Price	$98.40
Rate for Payer: Hawaii Western Management Group Commercial	$114.80
Rate for Payer: Health Management Network Commercial	$139.40
Rate for Payer: Kaiser Permanente Commercial	$103.32
Rate for Payer: Kaiser Permanente Medicaid	$83.64
Rate for Payer: MDX Hawaii PPO	$159.08
Rate for Payer: UnitedHealthcare Medicaid	$35.81
Rate for Payer: University Health Alliance Commercial	$91.84

BOOT MULTI PODUS MED

Facility

$164.00

Service Code	HCPCS L4398
Hospital Revenue Code	274
Min. Negotiated Rate	$91.84
Max. Negotiated Rate	$159.08
Rate for Payer: Cash Price	$98.40
Rate for Payer: Hawaii Western Management Group Commercial	$114.80
Rate for Payer: Health Management Network Commercial	$139.40
Rate for Payer: MDX Hawaii PPO	$159.08
Rate for Payer: University Health Alliance Commercial	$91.84

BOOT MULTI PODUS XLG

Facility

$164.00

Service Code	HCPCS L4398
Hospital Revenue Code	274
Min. Negotiated Rate	$91.84
Max. Negotiated Rate	$159.08
Rate for Payer: Cash Price	$98.40
Rate for Payer: Hawaii Western Management Group Commercial	$114.80
Rate for Payer: Health Management Network Commercial	$139.40
Rate for Payer: MDX Hawaii PPO	$159.08
Rate for Payer: University Health Alliance Commercial	$91.84

BOOT MULTI PODUS XLG

Facility

$164.00

Service Code	HCPCS L4398
Hospital Revenue Code	274
Min. Negotiated Rate	$35.81
Max. Negotiated Rate	$159.08
Rate for Payer: Cash Price	$98.40
Rate for Payer: Cash Price	$98.40
Rate for Payer: Hawaii Western Management Group Commercial	$114.80
Rate for Payer: Health Management Network Commercial	$139.40
Rate for Payer: Kaiser Permanente Commercial	$103.32
Rate for Payer: Kaiser Permanente Medicaid	$83.64
Rate for Payer: MDX Hawaii PPO	$159.08
Rate for Payer: UnitedHealthcare Medicaid	$35.81
Rate for Payer: University Health Alliance Commercial	$91.84

BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [123070]

Facility

$450.00

Service Code	HCPCS J9041
Hospital Revenue Code	250
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$148.80
Rate for Payer: Cash Price	$114.60
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Health Management Network Commercial	$162.35
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: MDX Hawaii PPO	$185.27

BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [123070]

Facility

$248.00

Service Code	HCPCS J9041
Hospital Revenue Code	636
Min. Negotiated Rate	$1.59
Max. Negotiated Rate	$240.56
Rate for Payer: Cash Price	$148.80
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$114.60
Rate for Payer: Cash Price	$114.60
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$148.80
Rate for Payer: Hawaii Medical Service Association ABD	$1.59
Rate for Payer: Hawaii Medical Service Association ABD	$1.59
Rate for Payer: Hawaii Medical Service Association ABD	$1.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.59
Rate for Payer: Hawaii Western Management Group Commercial	$181.45
Rate for Payer: Hawaii Western Management Group Commercial	$235.60
Rate for Payer: Hawaii Western Management Group Commercial	$427.50
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Health Management Network Commercial	$162.35
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Kaiser Permanente Commercial	$283.50
Rate for Payer: Kaiser Permanente Commercial	$156.24
Rate for Payer: Kaiser Permanente Commercial	$120.33
Rate for Payer: Kaiser Permanente Medicaid	$97.41
Rate for Payer: Kaiser Permanente Medicaid	$126.48
Rate for Payer: Kaiser Permanente Medicaid	$229.50
Rate for Payer: MDX Hawaii PPO	$185.27
Rate for Payer: MDX Hawaii PPO	$240.56
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: UnitedHealthcare Medicaid	$148.80
Rate for Payer: UnitedHealthcare Medicaid	$270.00
Rate for Payer: UnitedHealthcare Medicaid	$114.60
Rate for Payer: University Health Alliance Commercial	$139.22
Rate for Payer: University Health Alliance Commercial	$180.77
Rate for Payer: University Health Alliance Commercial	$328.00

BOSS REAMER 6543-4-517

Facility

$2,026.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,722.10
Max. Negotiated Rate	$1,965.22
Rate for Payer: Cash Price	$1,215.60
Rate for Payer: Health Management Network Commercial	$1,722.10
Rate for Payer: MDX Hawaii PPO	$1,965.22

BOSS REAMER 6543-4-517

Facility

$2,026.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,033.26
Max. Negotiated Rate	$1,965.22
Rate for Payer: Cash Price	$1,215.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,924.70
Rate for Payer: Health Management Network Commercial	$1,722.10
Rate for Payer: Kaiser Permanente Commercial	$1,276.38
Rate for Payer: Kaiser Permanente Medicaid	$1,033.26
Rate for Payer: MDX Hawaii PPO	$1,965.22
Rate for Payer: University Health Alliance Commercial	$1,476.75

BOWL SET X/55ML 04350

Facility

$471.00

Hospital Revenue Code	272
Min. Negotiated Rate	$400.35
Max. Negotiated Rate	$456.87
Rate for Payer: Cash Price	$282.60
Rate for Payer: Health Management Network Commercial	$400.35
Rate for Payer: MDX Hawaii PPO	$456.87

BOWL SET X/55ML 04350

Facility

$471.00

Hospital Revenue Code	272
Min. Negotiated Rate	$240.21
Max. Negotiated Rate	$456.87
Rate for Payer: Cash Price	$282.60
Rate for Payer: Hawaii Western Management Group Commercial	$447.45
Rate for Payer: Health Management Network Commercial	$400.35
Rate for Payer: Kaiser Permanente Commercial	$296.73
Rate for Payer: Kaiser Permanente Medicaid	$240.21
Rate for Payer: MDX Hawaii PPO	$456.87
Rate for Payer: University Health Alliance Commercial	$343.31

BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD

Facility

$8,300.88

Service Code	APR-DRG 1324
Min. Negotiated Rate	$8,300.88
Max. Negotiated Rate	$8,300.88
Rate for Payer: AlohaCare Medicaid	$8,300.88
Rate for Payer: Hawaii Medical Service Association ABD	$8,300.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,300.88
Rate for Payer: Kaiser Permanente Medicaid	$8,300.88
Rate for Payer: Ohana Health Plan Medicaid	$8,300.88
Rate for Payer: UnitedHealthcare Medicaid	$8,300.88

BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD

Facility

$5,377.37

Service Code	APR-DRG 1323
Min. Negotiated Rate	$5,377.37
Max. Negotiated Rate	$5,377.37
Rate for Payer: AlohaCare Medicaid	$5,377.37
Rate for Payer: Hawaii Medical Service Association ABD	$5,377.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,377.37
Rate for Payer: Kaiser Permanente Medicaid	$5,377.37
Rate for Payer: Ohana Health Plan Medicaid	$5,377.37
Rate for Payer: UnitedHealthcare Medicaid	$5,377.37

BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD

Facility

$2,411.47

Service Code	APR-DRG 1321
Min. Negotiated Rate	$2,411.47
Max. Negotiated Rate	$2,411.47
Rate for Payer: AlohaCare Medicaid	$2,411.47
Rate for Payer: Hawaii Medical Service Association ABD	$2,411.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,411.47
Rate for Payer: Kaiser Permanente Medicaid	$2,411.47
Rate for Payer: Ohana Health Plan Medicaid	$2,411.47
Rate for Payer: UnitedHealthcare Medicaid	$2,411.47

BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD

Facility

$3,235.95

Service Code	APR-DRG 1322
Min. Negotiated Rate	$3,235.95
Max. Negotiated Rate	$3,235.95
Rate for Payer: AlohaCare Medicaid	$3,235.95
Rate for Payer: Hawaii Medical Service Association ABD	$3,235.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,235.95
Rate for Payer: Kaiser Permanente Medicaid	$3,235.95
Rate for Payer: Ohana Health Plan Medicaid	$3,235.95
Rate for Payer: UnitedHealthcare Medicaid	$3,235.95

BPLR LINR 58X28 00-5001-057-28

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$551.25
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BPLR LINR 58X28 00-5001-057-28

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BPLR SHELL 57MM 00-5001-057-00

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

BPLR SHELL 57MM 00-5001-057-00

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

BRACE BACK L/XL 48-60IN

Facility

$918.00

Service Code	HCPCS L0456
Hospital Revenue Code	274
Min. Negotiated Rate	$514.08
Max. Negotiated Rate	$890.46
Rate for Payer: Cash Price	$550.80
Rate for Payer: Hawaii Western Management Group Commercial	$642.60
Rate for Payer: Health Management Network Commercial	$780.30
Rate for Payer: MDX Hawaii PPO	$890.46
Rate for Payer: University Health Alliance Commercial	$514.08

Know your out-of-pocket cost for care.

All Charges