Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TIGHTROPE SYS AR-1288BTBIB-FC3

Facility

$2,384.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,215.84
Max. Negotiated Rate	$2,312.48
Rate for Payer: Cash Price	$1,430.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,668.80
Rate for Payer: Health Management Network Commercial	$2,026.40
Rate for Payer: Kaiser Permanente Commercial	$1,501.92
Rate for Payer: Kaiser Permanente Medicaid	$1,215.84
Rate for Payer: MDX Hawaii PPO	$2,312.48
Rate for Payer: University Health Alliance Commercial	$1,335.04

TIMOLOL MALEATE 0.25 % EYE DROPS [11561]

Facility

$53.00

Service Code	NDC 64980051305
Hospital Revenue Code	250
Min. Negotiated Rate	$45.05
Max. Negotiated Rate	$51.41
Rate for Payer: Cash Price	$31.80
Rate for Payer: Health Management Network Commercial	$45.05
Rate for Payer: MDX Hawaii PPO	$51.41

TIMOLOL MALEATE 0.25 % EYE DROPS [11561]

Facility

$53.00

Service Code	NDC 64980051305
Hospital Revenue Code	637
Min. Negotiated Rate	$27.03
Max. Negotiated Rate	$51.41
Rate for Payer: Cash Price	$31.80
Rate for Payer: Hawaii Western Management Group Commercial	$50.35
Rate for Payer: Health Management Network Commercial	$45.05
Rate for Payer: Kaiser Permanente Commercial	$33.39
Rate for Payer: Kaiser Permanente Medicaid	$27.03
Rate for Payer: MDX Hawaii PPO	$51.41
Rate for Payer: University Health Alliance Commercial	$38.63

TIMOLOL MALEATE 0.5 % EYE DROPS [11562]

Facility

$60.00

Service Code	NDC 61314022705
Hospital Revenue Code	250
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: MDX Hawaii PPO	$58.20

TIMOLOL MALEATE 0.5 % EYE DROPS [11562]

Facility

$60.00

Service Code	NDC 61314022705
Hospital Revenue Code	637
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: University Health Alliance Commercial	$43.73

TI NAIL 11X380/RT 04.003.456S

Facility

$3,806.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,941.06
Max. Negotiated Rate	$3,691.82
Rate for Payer: Cash Price	$2,283.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,664.20
Rate for Payer: Health Management Network Commercial	$3,235.10
Rate for Payer: Kaiser Permanente Commercial	$2,397.78
Rate for Payer: Kaiser Permanente Medicaid	$1,941.06
Rate for Payer: MDX Hawaii PPO	$3,691.82
Rate for Payer: University Health Alliance Commercial	$2,131.36

TI NAIL 11X380/RT 04.003.456S

Facility

$3,806.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,131.36
Max. Negotiated Rate	$3,691.82
Rate for Payer: Cash Price	$2,283.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,664.20
Rate for Payer: Health Management Network Commercial	$3,235.10
Rate for Payer: MDX Hawaii PPO	$3,691.82
Rate for Payer: University Health Alliance Commercial	$2,131.36

TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION [127331]

Facility

$225.00

Service Code	NDC 00597010051
Hospital Revenue Code	250
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: MDX Hawaii PPO	$218.25

TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION [127331]

Facility

$225.00

Service Code	NDC 00597010051
Hospital Revenue Code	637
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$141.75
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: University Health Alliance Commercial	$164.00

TIPS DISPOSABLE RENEW 3372

Facility

$226.00

Hospital Revenue Code	272
Min. Negotiated Rate	$115.26
Max. Negotiated Rate	$219.22
Rate for Payer: Cash Price	$135.60
Rate for Payer: Hawaii Western Management Group Commercial	$214.70
Rate for Payer: Health Management Network Commercial	$192.10
Rate for Payer: Kaiser Permanente Commercial	$142.38
Rate for Payer: Kaiser Permanente Medicaid	$115.26
Rate for Payer: MDX Hawaii PPO	$219.22
Rate for Payer: University Health Alliance Commercial	$164.73

TIPS DISPOSABLE RENEW 3372

Facility

$226.00

Hospital Revenue Code	272
Min. Negotiated Rate	$192.10
Max. Negotiated Rate	$219.22
Rate for Payer: Cash Price	$135.60
Rate for Payer: Health Management Network Commercial	$192.10
Rate for Payer: MDX Hawaii PPO	$219.22

TISOTUMAB VEDOTIN-TFTV 40 MG/4ML IV (WET SOLR VIAL) [430181289]

Facility

$9,381.00

Service Code	NDC 51144000301
Hospital Revenue Code	250
Min. Negotiated Rate	$7,973.85
Max. Negotiated Rate	$9,099.57
Rate for Payer: Cash Price	$5,628.60
Rate for Payer: Health Management Network Commercial	$7,973.85
Rate for Payer: MDX Hawaii PPO	$9,099.57

TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION [181289]

Facility

$19,595.00

Service Code	HCPCS J9273
Hospital Revenue Code	636
Min. Negotiated Rate	$188.65
Max. Negotiated Rate	$19,007.15
Rate for Payer: AlohaCare Medicaid	$196.12
Rate for Payer: AlohaCare Medicaid	$196.12
Rate for Payer: AlohaCare Medicare	$196.12
Rate for Payer: AlohaCare Medicare	$196.12
Rate for Payer: Cash Price	$11,757.00
Rate for Payer: Cash Price	$5,628.60
Rate for Payer: Cash Price	$5,628.60
Rate for Payer: Cash Price	$11,757.00
Rate for Payer: Devoted Health Medicare	$215.73
Rate for Payer: Devoted Health Medicare	$215.73
Rate for Payer: Hawaii Medical Service Association ABD	$188.65
Rate for Payer: Hawaii Medical Service Association ABD	$188.65
Rate for Payer: Hawaii Medical Service Association Commercial	$245.15
Rate for Payer: Hawaii Medical Service Association Commercial	$245.15
Rate for Payer: Hawaii Medical Service Association Medicare	$196.12
Rate for Payer: Hawaii Medical Service Association Medicare	$196.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$188.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$188.65
Rate for Payer: Hawaii Western Management Group Commercial	$8,911.95
Rate for Payer: Hawaii Western Management Group Commercial	$18,615.25
Rate for Payer: Health Management Network Commercial	$16,655.75
Rate for Payer: Health Management Network Commercial	$7,973.85
Rate for Payer: Humana Medicare	$196.12
Rate for Payer: Humana Medicare	$196.12
Rate for Payer: Kaiser Permanente Commercial	$12,344.85
Rate for Payer: Kaiser Permanente Commercial	$5,910.03
Rate for Payer: Kaiser Permanente Medicaid	$4,784.31
Rate for Payer: Kaiser Permanente Medicaid	$9,993.45
Rate for Payer: Kaiser Permanente Medicare	$196.12
Rate for Payer: Kaiser Permanente Medicare	$196.12
Rate for Payer: MDX Hawaii PPO	$19,007.15
Rate for Payer: MDX Hawaii PPO	$9,099.57
Rate for Payer: Ohana Health Plan Medicaid	$215.73
Rate for Payer: Ohana Health Plan Medicaid	$215.73
Rate for Payer: Ohana Health Plan Medicare	$196.12
Rate for Payer: Ohana Health Plan Medicare	$196.12
Rate for Payer: UnitedHealthcare Medicaid	$11,757.00
Rate for Payer: UnitedHealthcare Medicaid	$5,628.60
Rate for Payer: UnitedHealthcare Medicare	$196.12
Rate for Payer: UnitedHealthcare Medicare	$196.12
Rate for Payer: University Health Alliance Commercial	$14,282.80
Rate for Payer: University Health Alliance Commercial	$6,837.81

TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION [181289]

Facility

$19,595.00

Service Code	HCPCS J9273
Hospital Revenue Code	250
Min. Negotiated Rate	$16,655.75
Max. Negotiated Rate	$19,007.15
Rate for Payer: Cash Price	$11,757.00
Rate for Payer: Cash Price	$5,628.60
Rate for Payer: Health Management Network Commercial	$16,655.75
Rate for Payer: Health Management Network Commercial	$7,973.85
Rate for Payer: MDX Hawaii PPO	$19,007.15
Rate for Payer: MDX Hawaii PPO	$9,099.57

TISSEEL DUPLOSPRAY 060-1130

Facility

$436.00

Hospital Revenue Code	272
Min. Negotiated Rate	$370.60
Max. Negotiated Rate	$422.92
Rate for Payer: Cash Price	$261.60
Rate for Payer: Health Management Network Commercial	$370.60
Rate for Payer: MDX Hawaii PPO	$422.92

TISSEEL DUPLOSPRAY 060-1130

Facility

$436.00

Hospital Revenue Code	272
Min. Negotiated Rate	$222.36
Max. Negotiated Rate	$422.92
Rate for Payer: Cash Price	$261.60
Rate for Payer: Hawaii Western Management Group Commercial	$414.20
Rate for Payer: Health Management Network Commercial	$370.60
Rate for Payer: Kaiser Permanente Commercial	$274.68
Rate for Payer: Kaiser Permanente Medicaid	$222.36
Rate for Payer: MDX Hawaii PPO	$422.92
Rate for Payer: University Health Alliance Commercial	$317.80

TISSEEL FROZEN 10ML KT 1506080

Facility

$2,115.00

Service Code	HCPCS C9250
Hospital Revenue Code	636
Min. Negotiated Rate	$1,797.75
Max. Negotiated Rate	$2,051.55
Rate for Payer: Cash Price	$1,269.00
Rate for Payer: Health Management Network Commercial	$1,797.75
Rate for Payer: MDX Hawaii PPO	$2,051.55

TISSEEL FROZEN 10ML KT 1506080

Facility

$2,115.00

Service Code	HCPCS C9250
Hospital Revenue Code	636
Min. Negotiated Rate	$143.70
Max. Negotiated Rate	$2,051.55
Rate for Payer: AlohaCare Medicaid	$143.70
Rate for Payer: AlohaCare Medicare	$143.70
Rate for Payer: Cash Price	$1,269.00
Rate for Payer: Cash Price	$1,269.00
Rate for Payer: Devoted Health Medicare	$158.07
Rate for Payer: Hawaii Medical Service Association Commercial	$179.62
Rate for Payer: Hawaii Medical Service Association Medicare	$143.70
Rate for Payer: Hawaii Western Management Group Commercial	$2,009.25
Rate for Payer: Health Management Network Commercial	$1,797.75
Rate for Payer: Humana Medicare	$143.70
Rate for Payer: Kaiser Permanente Commercial	$1,332.45
Rate for Payer: Kaiser Permanente Medicaid	$1,078.65
Rate for Payer: Kaiser Permanente Medicare	$143.70
Rate for Payer: MDX Hawaii PPO	$2,051.55
Rate for Payer: Ohana Health Plan Medicaid	$158.07
Rate for Payer: Ohana Health Plan Medicare	$143.70
Rate for Payer: UnitedHealthcare Medicaid	$1,269.00
Rate for Payer: UnitedHealthcare Medicare	$143.70
Rate for Payer: University Health Alliance Commercial	$1,541.62

TISSEEL VHSD FROZEN 4ML KIT

Facility

$929.00

Service Code	HCPCS C9250
Hospital Revenue Code	636
Min. Negotiated Rate	$789.65
Max. Negotiated Rate	$901.13
Rate for Payer: Cash Price	$557.40
Rate for Payer: Health Management Network Commercial	$789.65
Rate for Payer: MDX Hawaii PPO	$901.13

TISSEEL VHSD FROZEN 4ML KIT

Facility

$929.00

Service Code	HCPCS C9250
Hospital Revenue Code	636
Min. Negotiated Rate	$143.70
Max. Negotiated Rate	$901.13
Rate for Payer: AlohaCare Medicaid	$143.70
Rate for Payer: AlohaCare Medicare	$143.70
Rate for Payer: Cash Price	$557.40
Rate for Payer: Cash Price	$557.40
Rate for Payer: Devoted Health Medicare	$158.07
Rate for Payer: Hawaii Medical Service Association Commercial	$179.62
Rate for Payer: Hawaii Medical Service Association Medicare	$143.70
Rate for Payer: Hawaii Western Management Group Commercial	$882.55
Rate for Payer: Health Management Network Commercial	$789.65
Rate for Payer: Humana Medicare	$143.70
Rate for Payer: Kaiser Permanente Commercial	$585.27
Rate for Payer: Kaiser Permanente Medicaid	$473.79
Rate for Payer: Kaiser Permanente Medicare	$143.70
Rate for Payer: MDX Hawaii PPO	$901.13
Rate for Payer: Ohana Health Plan Medicaid	$158.07
Rate for Payer: Ohana Health Plan Medicare	$143.70
Rate for Payer: UnitedHealthcare Medicaid	$557.40
Rate for Payer: UnitedHealthcare Medicare	$143.70
Rate for Payer: University Health Alliance Commercial	$677.15

TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)

Facility

$17,908.07

Service Code	CPT 19357
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$17,908.07
Rate for Payer: AlohaCare Medicaid	$16,280.06
Rate for Payer: AlohaCare Medicare	$16,280.06
Rate for Payer: Devoted Health Medicare	$17,908.07
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	$16,280.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$16,280.06
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$16,280.06
Rate for Payer: Ohana Health Plan Medicaid	$17,908.07
Rate for Payer: Ohana Health Plan Medicare	$16,280.06
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$16,280.06
Rate for Payer: University Health Alliance Commercial	$11,157.19

TISSUE MICROMATRIX MM1000

Facility

$5,436.00

Service Code	HCPCS Q4118
Hospital Revenue Code	636
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$5,272.92
Rate for Payer: Cash Price	$3,261.60
Rate for Payer: Cash Price	$3,261.60
Rate for Payer: Hawaii Medical Service Association ABD	$2.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.56
Rate for Payer: Hawaii Western Management Group Commercial	$5,164.20
Rate for Payer: Health Management Network Commercial	$4,620.60
Rate for Payer: Kaiser Permanente Commercial	$3,424.68
Rate for Payer: Kaiser Permanente Medicaid	$2,772.36
Rate for Payer: MDX Hawaii PPO	$5,272.92
Rate for Payer: UnitedHealthcare Medicaid	$3,261.60
Rate for Payer: University Health Alliance Commercial	$3,962.30

TISSUE MICROMATRIX MM1000

Facility

$5,436.00

Service Code	HCPCS Q4118
Hospital Revenue Code	636
Min. Negotiated Rate	$4,620.60
Max. Negotiated Rate	$5,272.92
Rate for Payer: Cash Price	$3,261.60
Rate for Payer: Health Management Network Commercial	$4,620.60
Rate for Payer: MDX Hawaii PPO	$5,272.92

TISSUE RETRIEVAL TRS-ROBO-8

Facility

$450.00

Hospital Revenue Code	272
Min. Negotiated Rate	$229.50
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$270.00
Rate for Payer: Hawaii Western Management Group Commercial	$427.50
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Kaiser Permanente Commercial	$283.50
Rate for Payer: Kaiser Permanente Medicaid	$229.50
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: University Health Alliance Commercial	$328.00

TISSUE RETRIEVAL TRS-ROBO-8

Facility

$450.00

Hospital Revenue Code	272
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$270.00
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: MDX Hawaii PPO	$436.50

Know your out-of-pocket cost for care.

All Charges