Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

BRA POST SURGICAL 2X M5001-XXL

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

BRA POST SURGICAL 2X M5001-XXL

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

BREAST AUGMENTATION WITH IMPLANT

Facility

$24,500.00

Service Code	CPT 19325
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$9,655.59
Rate for Payer: AlohaCare Medicare	$9,655.59
Rate for Payer: Devoted Health Medicare	$10,621.15
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$9,655.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$9,655.59
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$9,655.59
Rate for Payer: Ohana Health Plan Medicaid	$10,621.15
Rate for Payer: Ohana Health Plan Medicare	$9,655.59
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$9,655.59
Rate for Payer: University Health Alliance Commercial	$24,500.00

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC

Facility

$36,927.07

Service Code	MSDRG 584
Min. Negotiated Rate	$24,348.88
Max. Negotiated Rate	$36,927.07
Rate for Payer: AlohaCare Medicare	$24,348.88
Rate for Payer: Devoted Health Medicare	$26,783.77
Rate for Payer: Hawaii Medical Service Association Commercial	$25,770.49
Rate for Payer: Hawaii Medical Service Association Medicare	$24,348.88
Rate for Payer: Humana Medicare	$24,348.88
Rate for Payer: Kaiser Permanente Commercial	$36,927.07
Rate for Payer: Kaiser Permanente Medicare	$24,348.88
Rate for Payer: Ohana Health Plan Medicare	$24,348.88
Rate for Payer: UnitedHealthcare Medicare	$24,348.88

BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC

Facility

$33,276.97

Service Code	MSDRG 585
Min. Negotiated Rate	$21,942.07
Max. Negotiated Rate	$33,276.97
Rate for Payer: AlohaCare Medicare	$21,942.07
Rate for Payer: Devoted Health Medicare	$24,136.28
Rate for Payer: Hawaii Medical Service Association Commercial	$24,945.45
Rate for Payer: Hawaii Medical Service Association Medicare	$21,942.07
Rate for Payer: Humana Medicare	$21,942.07
Rate for Payer: Kaiser Permanente Commercial	$33,276.97
Rate for Payer: Kaiser Permanente Medicare	$21,942.07
Rate for Payer: Ohana Health Plan Medicare	$21,942.07
Rate for Payer: UnitedHealthcare Medicare	$21,942.07

BREAST HSC+ 10721-195MP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,453.50
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$1,795.50
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

BREAST HSC+ 10721-195MP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

BREAST HSC+ 10721-215MP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,453.50
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$1,795.50
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

BREAST HSC+ 10721-215MP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

BREAST IMPLANT SZ10621-305MP

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

BREAST IMPLANT SZ10621-305MP

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$110.25
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$13,481.26

Service Code	APR-DRG 3634
Min. Negotiated Rate	$13,481.26
Max. Negotiated Rate	$13,481.26
Rate for Payer: AlohaCare Medicaid	$13,481.26
Rate for Payer: Hawaii Medical Service Association ABD	$13,481.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,481.26
Rate for Payer: Kaiser Permanente Medicaid	$13,481.26
Rate for Payer: Ohana Health Plan Medicaid	$13,481.26
Rate for Payer: UnitedHealthcare Medicaid	$13,481.26

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$9,257.77

Service Code	APR-DRG 3632
Min. Negotiated Rate	$9,257.77
Max. Negotiated Rate	$9,257.77
Rate for Payer: AlohaCare Medicaid	$9,257.77
Rate for Payer: Hawaii Medical Service Association ABD	$9,257.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,257.77
Rate for Payer: Kaiser Permanente Medicaid	$9,257.77
Rate for Payer: Ohana Health Plan Medicaid	$9,257.77
Rate for Payer: UnitedHealthcare Medicaid	$9,257.77

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$11,861.00

Service Code	APR-DRG 3633
Min. Negotiated Rate	$11,861.00
Max. Negotiated Rate	$11,861.00
Rate for Payer: AlohaCare Medicaid	$11,861.00
Rate for Payer: Hawaii Medical Service Association ABD	$11,861.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,861.00
Rate for Payer: Kaiser Permanente Medicaid	$11,861.00
Rate for Payer: Ohana Health Plan Medicaid	$11,861.00
Rate for Payer: UnitedHealthcare Medicaid	$11,861.00

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility

$5,773.30

Service Code	APR-DRG 3631
Min. Negotiated Rate	$5,773.30
Max. Negotiated Rate	$5,773.30
Rate for Payer: AlohaCare Medicaid	$5,773.30
Rate for Payer: Hawaii Medical Service Association ABD	$5,773.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,773.30
Rate for Payer: Kaiser Permanente Medicaid	$5,773.30
Rate for Payer: Ohana Health Plan Medicaid	$5,773.30
Rate for Payer: UnitedHealthcare Medicaid	$5,773.30

BREAST REDUCTION

Facility

$14,395.00

Service Code	CPT 19318
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$14,395.00
Rate for Payer: AlohaCare Medicaid	$7,844.33
Rate for Payer: AlohaCare Medicare	$7,844.33
Rate for Payer: Devoted Health Medicare	$8,628.76
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,395.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,844.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$7,844.33
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,844.33
Rate for Payer: Ohana Health Plan Medicaid	$8,628.76
Rate for Payer: Ohana Health Plan Medicare	$7,844.33
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,844.33
Rate for Payer: University Health Alliance Commercial	$10,679.55

BREAST SILICONE GS10610-190LP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

BREAST SILICONE GS10610-190LP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$430.44
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$531.72
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

BREAST TISSUE ALLOX2-FH14SE

Facility

$3,750.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$2,100.00
Max. Negotiated Rate	$3,637.50
Rate for Payer: Cash Price	$2,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,625.00
Rate for Payer: Health Management Network Commercial	$3,187.50
Rate for Payer: MDX Hawaii PPO	$3,637.50
Rate for Payer: University Health Alliance Commercial	$2,100.00

BREAST TISSUE ALLOX2-FH14SE

Facility

$3,750.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,912.50
Max. Negotiated Rate	$3,637.50
Rate for Payer: Cash Price	$2,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,625.00
Rate for Payer: Health Management Network Commercial	$3,187.50
Rate for Payer: Kaiser Permanente Commercial	$2,362.50
Rate for Payer: Kaiser Permanente Medicaid	$1,912.50
Rate for Payer: MDX Hawaii PPO	$3,637.50
Rate for Payer: University Health Alliance Commercial	$2,100.00

BRENTUXIMAB VEDOTIN 50 MG/10ML IV (WET SOLR VIAL) [430111348]

Facility

$15,711.00

Service Code	HCPCS J9042
Hospital Revenue Code	250
Min. Negotiated Rate	$13,354.35
Max. Negotiated Rate	$15,239.67
Rate for Payer: Cash Price	$9,426.60
Rate for Payer: Health Management Network Commercial	$13,354.35
Rate for Payer: MDX Hawaii PPO	$15,239.67

BRENTUXIMAB VEDOTIN 50 MG/10ML IV (WET SOLR VIAL) [430111348]

Facility

$15,711.00

Service Code	HCPCS J9042
Hospital Revenue Code	636
Min. Negotiated Rate	$258.52
Max. Negotiated Rate	$15,239.67
Rate for Payer: AlohaCare Medicaid	$268.73
Rate for Payer: AlohaCare Medicare	$268.73
Rate for Payer: Cash Price	$9,426.60
Rate for Payer: Cash Price	$9,426.60
Rate for Payer: Devoted Health Medicare	$295.60
Rate for Payer: Hawaii Medical Service Association ABD	$258.52
Rate for Payer: Hawaii Medical Service Association Commercial	$335.91
Rate for Payer: Hawaii Medical Service Association Medicare	$268.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$258.52
Rate for Payer: Hawaii Western Management Group Commercial	$14,925.45
Rate for Payer: Health Management Network Commercial	$13,354.35
Rate for Payer: Humana Medicare	$268.73
Rate for Payer: Kaiser Permanente Commercial	$9,897.93
Rate for Payer: Kaiser Permanente Medicaid	$8,012.61
Rate for Payer: Kaiser Permanente Medicare	$268.73
Rate for Payer: MDX Hawaii PPO	$15,239.67
Rate for Payer: Ohana Health Plan Medicaid	$295.60
Rate for Payer: Ohana Health Plan Medicare	$268.73
Rate for Payer: UnitedHealthcare Medicaid	$9,426.60
Rate for Payer: UnitedHealthcare Medicare	$268.73
Rate for Payer: University Health Alliance Commercial	$11,451.75

BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [111348]

Facility

$15,711.00

Service Code	HCPCS J9042
Hospital Revenue Code	250
Min. Negotiated Rate	$13,354.35
Max. Negotiated Rate	$15,239.67
Rate for Payer: Cash Price	$9,426.60
Rate for Payer: Cash Price	$9,718.80
Rate for Payer: Health Management Network Commercial	$13,768.30
Rate for Payer: Health Management Network Commercial	$13,354.35
Rate for Payer: MDX Hawaii PPO	$15,239.67
Rate for Payer: MDX Hawaii PPO	$15,712.06

BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [111348]

Facility

$15,711.00

Service Code	HCPCS J9042
Hospital Revenue Code	636
Min. Negotiated Rate	$258.52
Max. Negotiated Rate	$15,239.67
Rate for Payer: AlohaCare Medicaid	$268.73
Rate for Payer: AlohaCare Medicaid	$268.73
Rate for Payer: AlohaCare Medicare	$268.73
Rate for Payer: AlohaCare Medicare	$268.73
Rate for Payer: Cash Price	$9,718.80
Rate for Payer: Cash Price	$9,426.60
Rate for Payer: Cash Price	$9,426.60
Rate for Payer: Cash Price	$9,718.80
Rate for Payer: Devoted Health Medicare	$295.60
Rate for Payer: Devoted Health Medicare	$295.60
Rate for Payer: Hawaii Medical Service Association ABD	$258.52
Rate for Payer: Hawaii Medical Service Association ABD	$258.52
Rate for Payer: Hawaii Medical Service Association Commercial	$335.91
Rate for Payer: Hawaii Medical Service Association Commercial	$335.91
Rate for Payer: Hawaii Medical Service Association Medicare	$268.73
Rate for Payer: Hawaii Medical Service Association Medicare	$268.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$258.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$258.52
Rate for Payer: Hawaii Western Management Group Commercial	$14,925.45
Rate for Payer: Hawaii Western Management Group Commercial	$15,388.10
Rate for Payer: Health Management Network Commercial	$13,768.30
Rate for Payer: Health Management Network Commercial	$13,354.35
Rate for Payer: Humana Medicare	$268.73
Rate for Payer: Humana Medicare	$268.73
Rate for Payer: Kaiser Permanente Commercial	$10,204.74
Rate for Payer: Kaiser Permanente Commercial	$9,897.93
Rate for Payer: Kaiser Permanente Medicaid	$8,012.61
Rate for Payer: Kaiser Permanente Medicaid	$8,260.98
Rate for Payer: Kaiser Permanente Medicare	$268.73
Rate for Payer: Kaiser Permanente Medicare	$268.73
Rate for Payer: MDX Hawaii PPO	$15,712.06
Rate for Payer: MDX Hawaii PPO	$15,239.67
Rate for Payer: Ohana Health Plan Medicaid	$295.60
Rate for Payer: Ohana Health Plan Medicaid	$295.60
Rate for Payer: Ohana Health Plan Medicare	$268.73
Rate for Payer: Ohana Health Plan Medicare	$268.73
Rate for Payer: UnitedHealthcare Medicaid	$9,426.60
Rate for Payer: UnitedHealthcare Medicaid	$9,718.80
Rate for Payer: UnitedHealthcare Medicare	$268.73
Rate for Payer: UnitedHealthcare Medicare	$268.73
Rate for Payer: University Health Alliance Commercial	$11,806.72
Rate for Payer: University Health Alliance Commercial	$11,451.75

BRIDGE PLATE BRGP

Facility

$3,720.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,083.20
Max. Negotiated Rate	$3,608.40
Rate for Payer: Cash Price	$2,232.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,604.00
Rate for Payer: Health Management Network Commercial	$3,162.00
Rate for Payer: MDX Hawaii PPO	$3,608.40
Rate for Payer: University Health Alliance Commercial	$2,083.20

Know your out-of-pocket cost for care.

All Charges