Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

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

BRACE HUMERAL OVER SHOULDER LG

Facility

$245.00

Service Code	HCPCS L3980
Hospital Revenue Code	274
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$237.65
Rate for Payer: Cash Price	$147.00
Rate for Payer: Hawaii Western Management Group Commercial	$171.50
Rate for Payer: Health Management Network Commercial	$208.25
Rate for Payer: MDX Hawaii PPO	$237.65
Rate for Payer: University Health Alliance Commercial	$137.20

BRACE HUMERAL OVER SHOULDER LG

Facility

$245.00

Service Code	HCPCS L3980
Hospital Revenue Code	274
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$237.65
Rate for Payer: Cash Price	$147.00
Rate for Payer: Cash Price	$147.00
Rate for Payer: Hawaii Western Management Group Commercial	$171.50
Rate for Payer: Health Management Network Commercial	$208.25
Rate for Payer: Kaiser Permanente Commercial	$154.35
Rate for Payer: Kaiser Permanente Medicaid	$124.95
Rate for Payer: MDX Hawaii PPO	$237.65
Rate for Payer: UnitedHealthcare Medicaid	$232.34
Rate for Payer: University Health Alliance Commercial	$137.20

BRACE HUMERAL OVER SHOULDER SM

Facility

$237.00

Service Code	HCPCS L3980
Hospital Revenue Code	274
Min. Negotiated Rate	$120.87
Max. Negotiated Rate	$232.34
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cash Price	$142.20
Rate for Payer: Hawaii Western Management Group Commercial	$165.90
Rate for Payer: Health Management Network Commercial	$201.45
Rate for Payer: Kaiser Permanente Commercial	$149.31
Rate for Payer: Kaiser Permanente Medicaid	$120.87
Rate for Payer: MDX Hawaii PPO	$229.89
Rate for Payer: UnitedHealthcare Medicaid	$232.34
Rate for Payer: University Health Alliance Commercial	$132.72

BRACE HUMERAL OVER SHOULDER SM

Facility

$237.00

Service Code	HCPCS L3980
Hospital Revenue Code	274
Min. Negotiated Rate	$132.72
Max. Negotiated Rate	$229.89
Rate for Payer: Cash Price	$142.20
Rate for Payer: Hawaii Western Management Group Commercial	$165.90
Rate for Payer: Health Management Network Commercial	$201.45
Rate for Payer: MDX Hawaii PPO	$229.89
Rate for Payer: University Health Alliance Commercial	$132.72

BRACE HUMERAL SHOULDER MED

Facility

$243.00

Service Code	HCPCS L3980
Hospital Revenue Code	274
Min. Negotiated Rate	$136.08
Max. Negotiated Rate	$235.71
Rate for Payer: Cash Price	$145.80
Rate for Payer: Hawaii Western Management Group Commercial	$170.10
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: MDX Hawaii PPO	$235.71
Rate for Payer: University Health Alliance Commercial	$136.08

BRACE HUMERAL SHOULDER MED

Facility

$243.00

Service Code	HCPCS L3980
Hospital Revenue Code	274
Min. Negotiated Rate	$123.93
Max. Negotiated Rate	$235.71
Rate for Payer: Cash Price	$145.80
Rate for Payer: Cash Price	$145.80
Rate for Payer: Hawaii Western Management Group Commercial	$170.10
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: Kaiser Permanente Commercial	$153.09
Rate for Payer: Kaiser Permanente Medicaid	$123.93
Rate for Payer: MDX Hawaii PPO	$235.71
Rate for Payer: UnitedHealthcare Medicaid	$232.34
Rate for Payer: University Health Alliance Commercial	$136.08

BRACE THUMB RIGHT LG

Facility

$96.00

Service Code	HCPCS L6624
Hospital Revenue Code	274
Min. Negotiated Rate	$53.76
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$57.60
Rate for Payer: Hawaii Western Management Group Commercial	$67.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: University Health Alliance Commercial	$53.76

BRACE THUMB RIGHT LG

Facility

$96.00

Service Code	HCPCS L6624
Hospital Revenue Code	274
Min. Negotiated Rate	$48.96
Max. Negotiated Rate	$278.32
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cash Price	$57.60
Rate for Payer: Hawaii Western Management Group Commercial	$67.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$60.48
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: UnitedHealthcare Medicaid	$278.32
Rate for Payer: University Health Alliance Commercial	$53.76

BRACE THUMB RIGHT MED

Facility

$96.00

Service Code	HCPCS L6624
Hospital Revenue Code	274
Min. Negotiated Rate	$53.76
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$57.60
Rate for Payer: Hawaii Western Management Group Commercial	$67.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: University Health Alliance Commercial	$53.76

BRACE THUMB RIGHT MED

Facility

$96.00

Service Code	HCPCS L6624
Hospital Revenue Code	274
Min. Negotiated Rate	$48.96
Max. Negotiated Rate	$278.32
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cash Price	$57.60
Rate for Payer: Hawaii Western Management Group Commercial	$67.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$60.48
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: UnitedHealthcare Medicaid	$278.32
Rate for Payer: University Health Alliance Commercial	$53.76

BRACE WALKING SKIBOOT AIR LG

Facility

$220.00

Service Code	HCPCS L4360
Hospital Revenue Code	274
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Hawaii Western Management Group Commercial	$154.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$138.60
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: UnitedHealthcare Medicaid	$157.58
Rate for Payer: University Health Alliance Commercial	$123.20

BRACE WALKING SKIBOOT AIR LG

Facility

$220.00

Service Code	HCPCS L4360
Hospital Revenue Code	274
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$132.00
Rate for Payer: Hawaii Western Management Group Commercial	$154.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: University Health Alliance Commercial	$123.20

BRACE WALKING SKIBOOT AIR MED

Facility

$220.00

Service Code	HCPCS L4360
Hospital Revenue Code	274
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$132.00
Rate for Payer: Hawaii Western Management Group Commercial	$154.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: University Health Alliance Commercial	$123.20

BRACE WALKING SKIBOOT AIR MED

Facility

$220.00

Service Code	HCPCS L4360
Hospital Revenue Code	274
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Hawaii Western Management Group Commercial	$154.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$138.60
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: UnitedHealthcare Medicaid	$157.58
Rate for Payer: University Health Alliance Commercial	$123.20

BRACE WRIST ABDUCT THUMB L XLG

Facility

$90.00

Service Code	HCPCS L3908
Hospital Revenue Code	274
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Hawaii Western Management Group Commercial	$63.00
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$45.90
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: UnitedHealthcare Medicaid	$49.46
Rate for Payer: University Health Alliance Commercial	$50.40

BRACE WRIST ABDUCT THUMB L XLG

Facility

$90.00

Service Code	HCPCS L3908
Hospital Revenue Code	274
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$54.00
Rate for Payer: Hawaii Western Management Group Commercial	$63.00
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: University Health Alliance Commercial	$50.40

BRACKET TL ASSM STUD 51-10462

Facility

$365.00

Hospital Revenue Code	272
Min. Negotiated Rate	$186.15
Max. Negotiated Rate	$354.05
Rate for Payer: Cash Price	$219.00
Rate for Payer: Hawaii Western Management Group Commercial	$346.75
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: Kaiser Permanente Commercial	$229.95
Rate for Payer: Kaiser Permanente Medicaid	$186.15
Rate for Payer: MDX Hawaii PPO	$354.05
Rate for Payer: University Health Alliance Commercial	$266.05

BRACKET TL ASSM STUD 51-10462

Facility

$365.00

Hospital Revenue Code	272
Min. Negotiated Rate	$310.25
Max. Negotiated Rate	$354.05
Rate for Payer: Cash Price	$219.00
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: MDX Hawaii PPO	$354.05

BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA

Facility

$4,340.90

Service Code	APR-DRG 0562
Min. Negotiated Rate	$4,340.90
Max. Negotiated Rate	$4,340.90
Rate for Payer: AlohaCare Medicaid	$4,340.90
Rate for Payer: Hawaii Medical Service Association ABD	$4,340.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,340.90
Rate for Payer: Kaiser Permanente Medicaid	$4,340.90
Rate for Payer: Ohana Health Plan Medicaid	$4,340.90
Rate for Payer: UnitedHealthcare Medicaid	$4,340.90

BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA

Facility

$6,237.72

Service Code	APR-DRG 0563
Min. Negotiated Rate	$6,237.72
Max. Negotiated Rate	$6,237.72
Rate for Payer: AlohaCare Medicaid	$6,237.72
Rate for Payer: Hawaii Medical Service Association ABD	$6,237.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,237.72
Rate for Payer: Kaiser Permanente Medicaid	$6,237.72
Rate for Payer: Ohana Health Plan Medicaid	$6,237.72
Rate for Payer: UnitedHealthcare Medicaid	$6,237.72

BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA

Facility

$3,063.09

Service Code	APR-DRG 0561
Min. Negotiated Rate	$3,063.09
Max. Negotiated Rate	$3,063.09
Rate for Payer: AlohaCare Medicaid	$3,063.09
Rate for Payer: Hawaii Medical Service Association ABD	$3,063.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,063.09
Rate for Payer: Kaiser Permanente Medicaid	$3,063.09
Rate for Payer: Ohana Health Plan Medicaid	$3,063.09
Rate for Payer: UnitedHealthcare Medicaid	$3,063.09

BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA

Facility

$11,749.47

Service Code	APR-DRG 0564
Min. Negotiated Rate	$11,749.47
Max. Negotiated Rate	$11,749.47
Rate for Payer: AlohaCare Medicaid	$11,749.47
Rate for Payer: Hawaii Medical Service Association ABD	$11,749.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,749.47
Rate for Payer: Kaiser Permanente Medicaid	$11,749.47
Rate for Payer: Ohana Health Plan Medicaid	$11,749.47
Rate for Payer: UnitedHealthcare Medicaid	$11,749.47

BRA POST SURGI 3X M5001-XXXL

Facility

$135.00

Hospital Revenue Code	272
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$130.95
Rate for Payer: Cash Price	$81.00
Rate for Payer: Hawaii Western Management Group Commercial	$128.25
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Kaiser Permanente Commercial	$85.05
Rate for Payer: Kaiser Permanente Medicaid	$68.85
Rate for Payer: MDX Hawaii PPO	$130.95
Rate for Payer: University Health Alliance Commercial	$98.40

BRA POST SURGI 3X M5001-XXXL

Facility

$135.00

Hospital Revenue Code	272
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$130.95
Rate for Payer: Cash Price	$81.00
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: MDX Hawaii PPO	$130.95

Know your out-of-pocket cost for care.

All Charges