Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC

Facility

$18,240.15

Service Code	MSDRG 714
Min. Negotiated Rate	$12,027.15
Max. Negotiated Rate	$18,240.15
Rate for Payer: AlohaCare Medicare	$12,027.15
Rate for Payer: Devoted Health Medicare	$13,229.86
Rate for Payer: Hawaii Medical Service Association Commercial	$14,341.21
Rate for Payer: Hawaii Medical Service Association Medicare	$12,027.15
Rate for Payer: Humana Medicare	$12,027.15
Rate for Payer: Kaiser Permanente Commercial	$18,240.15
Rate for Payer: Kaiser Permanente Medicare	$12,027.15
Rate for Payer: Ohana Health Plan Medicare	$12,027.15
Rate for Payer: UnitedHealthcare Medicare	$12,027.15

TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE)

Facility

$6,743.44

Service Code	CPT 52500
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22
Rate for Payer: University Health Alliance Commercial	$6,743.44

TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE

Facility

$5,509.00

Service Code	CPT 52640
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22
Rate for Payer: University Health Alliance Commercial	$5,160.40

TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION [167781]

Facility

$6,111.00

Service Code	HCPCS J9356
Hospital Revenue Code	636
Min. Negotiated Rate	$59.91
Max. Negotiated Rate	$5,927.67
Rate for Payer: AlohaCare Medicaid	$59.91
Rate for Payer: AlohaCare Medicare	$59.91
Rate for Payer: Cash Price	$3,666.60
Rate for Payer: Cash Price	$3,666.60
Rate for Payer: Devoted Health Medicare	$65.90
Rate for Payer: Hawaii Medical Service Association ABD	$62.97
Rate for Payer: Hawaii Medical Service Association Commercial	$74.89
Rate for Payer: Hawaii Medical Service Association Medicare	$59.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$62.97
Rate for Payer: Hawaii Western Management Group Commercial	$5,805.45
Rate for Payer: Health Management Network Commercial	$5,194.35
Rate for Payer: Humana Medicare	$59.91
Rate for Payer: Kaiser Permanente Commercial	$3,849.93
Rate for Payer: Kaiser Permanente Medicaid	$3,116.61
Rate for Payer: Kaiser Permanente Medicare	$59.91
Rate for Payer: MDX Hawaii PPO	$5,927.67
Rate for Payer: Ohana Health Plan Medicaid	$65.90
Rate for Payer: Ohana Health Plan Medicare	$59.91
Rate for Payer: UnitedHealthcare Medicaid	$3,666.60
Rate for Payer: UnitedHealthcare Medicare	$59.91
Rate for Payer: University Health Alliance Commercial	$4,454.31

TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION [167781]

Facility

$6,111.00

Service Code	HCPCS J9356
Hospital Revenue Code	250
Min. Negotiated Rate	$5,194.35
Max. Negotiated Rate	$5,927.67
Rate for Payer: Cash Price	$3,666.60
Rate for Payer: Health Management Network Commercial	$5,194.35
Rate for Payer: MDX Hawaii PPO	$5,927.67

TRASTUZUMAB-ANNS 150 MG/7.15ML IV (WET SOLR VIAL) [430170301]

Facility

$2,133.00

Service Code	HCPCS Q5117
Hospital Revenue Code	250
Min. Negotiated Rate	$1,813.05
Max. Negotiated Rate	$2,069.01
Rate for Payer: Cash Price	$1,279.80
Rate for Payer: Health Management Network Commercial	$1,813.05
Rate for Payer: MDX Hawaii PPO	$2,069.01

TRASTUZUMAB-ANNS 150 MG/7.15ML IV (WET SOLR VIAL) [430170301]

Facility

$2,133.00

Service Code	HCPCS Q5117
Hospital Revenue Code	636
Min. Negotiated Rate	$43.28
Max. Negotiated Rate	$2,069.01
Rate for Payer: AlohaCare Medicaid	$56.38
Rate for Payer: AlohaCare Medicare	$56.38
Rate for Payer: Cash Price	$1,279.80
Rate for Payer: Cash Price	$1,279.80
Rate for Payer: Devoted Health Medicare	$62.02
Rate for Payer: Hawaii Medical Service Association ABD	$43.28
Rate for Payer: Hawaii Medical Service Association Commercial	$70.47
Rate for Payer: Hawaii Medical Service Association Medicare	$56.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$43.28
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.35
Rate for Payer: Health Management Network Commercial	$1,813.05
Rate for Payer: Humana Medicare	$56.38
Rate for Payer: Kaiser Permanente Commercial	$1,343.79
Rate for Payer: Kaiser Permanente Medicaid	$1,087.83
Rate for Payer: Kaiser Permanente Medicare	$56.38
Rate for Payer: MDX Hawaii PPO	$2,069.01
Rate for Payer: Ohana Health Plan Medicaid	$62.02
Rate for Payer: Ohana Health Plan Medicare	$56.38
Rate for Payer: UnitedHealthcare Medicaid	$1,279.80
Rate for Payer: UnitedHealthcare Medicare	$56.38
Rate for Payer: University Health Alliance Commercial	$1,554.74

TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION [168930]

Facility

$5,070.00

Service Code	HCPCS Q5117
Hospital Revenue Code	636
Min. Negotiated Rate	$43.28
Max. Negotiated Rate	$4,917.90
Rate for Payer: AlohaCare Medicaid	$56.38
Rate for Payer: AlohaCare Medicare	$56.38
Rate for Payer: Cash Price	$3,042.00
Rate for Payer: Cash Price	$3,042.00
Rate for Payer: Devoted Health Medicare	$62.02
Rate for Payer: Hawaii Medical Service Association ABD	$43.28
Rate for Payer: Hawaii Medical Service Association Commercial	$70.47
Rate for Payer: Hawaii Medical Service Association Medicare	$56.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$43.28
Rate for Payer: Hawaii Western Management Group Commercial	$4,816.50
Rate for Payer: Health Management Network Commercial	$4,309.50
Rate for Payer: Humana Medicare	$56.38
Rate for Payer: Kaiser Permanente Commercial	$3,194.10
Rate for Payer: Kaiser Permanente Medicaid	$2,585.70
Rate for Payer: Kaiser Permanente Medicare	$56.38
Rate for Payer: MDX Hawaii PPO	$4,917.90
Rate for Payer: Ohana Health Plan Medicaid	$62.02
Rate for Payer: Ohana Health Plan Medicare	$56.38
Rate for Payer: UnitedHealthcare Medicaid	$3,042.00
Rate for Payer: UnitedHealthcare Medicare	$56.38
Rate for Payer: University Health Alliance Commercial	$3,695.52

TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION [168930]

Facility

$5,070.00

Service Code	HCPCS Q5117
Hospital Revenue Code	250
Min. Negotiated Rate	$4,309.50
Max. Negotiated Rate	$4,917.90
Rate for Payer: Cash Price	$3,042.00
Rate for Payer: Health Management Network Commercial	$4,309.50
Rate for Payer: MDX Hawaii PPO	$4,917.90

TRASTUZUMAB-DKST 150 MG/7.15ML IV (WET SOLR VIAL) [430170123]

Facility

$1,148.00

Service Code	HCPCS Q5114
Hospital Revenue Code	250
Min. Negotiated Rate	$975.80
Max. Negotiated Rate	$1,113.56
Rate for Payer: Cash Price	$688.80
Rate for Payer: Cash Price	$977.40
Rate for Payer: Health Management Network Commercial	$975.80
Rate for Payer: Health Management Network Commercial	$1,384.65
Rate for Payer: MDX Hawaii PPO	$1,113.56
Rate for Payer: MDX Hawaii PPO	$1,580.13

TRASTUZUMAB-DKST 150 MG/7.15ML IV (WET SOLR VIAL) [430170123]

Facility

$1,629.00

Service Code	HCPCS Q5114
Hospital Revenue Code	636
Min. Negotiated Rate	$35.78
Max. Negotiated Rate	$1,580.13
Rate for Payer: AlohaCare Medicaid	$35.78
Rate for Payer: AlohaCare Medicaid	$35.78
Rate for Payer: AlohaCare Medicare	$35.78
Rate for Payer: AlohaCare Medicare	$35.78
Rate for Payer: Cash Price	$977.40
Rate for Payer: Cash Price	$977.40
Rate for Payer: Cash Price	$688.80
Rate for Payer: Cash Price	$688.80
Rate for Payer: Devoted Health Medicare	$39.36
Rate for Payer: Devoted Health Medicare	$39.36
Rate for Payer: Hawaii Medical Service Association ABD	$44.59
Rate for Payer: Hawaii Medical Service Association ABD	$44.59
Rate for Payer: Hawaii Medical Service Association Commercial	$44.73
Rate for Payer: Hawaii Medical Service Association Commercial	$44.73
Rate for Payer: Hawaii Medical Service Association Medicare	$35.78
Rate for Payer: Hawaii Medical Service Association Medicare	$35.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$44.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$44.59
Rate for Payer: Hawaii Western Management Group Commercial	$1,090.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,547.55
Rate for Payer: Health Management Network Commercial	$975.80
Rate for Payer: Health Management Network Commercial	$1,384.65
Rate for Payer: Humana Medicare	$35.78
Rate for Payer: Humana Medicare	$35.78
Rate for Payer: Kaiser Permanente Commercial	$723.24
Rate for Payer: Kaiser Permanente Commercial	$1,026.27
Rate for Payer: Kaiser Permanente Medicaid	$830.79
Rate for Payer: Kaiser Permanente Medicaid	$585.48
Rate for Payer: Kaiser Permanente Medicare	$35.78
Rate for Payer: Kaiser Permanente Medicare	$35.78
Rate for Payer: MDX Hawaii PPO	$1,580.13
Rate for Payer: MDX Hawaii PPO	$1,113.56
Rate for Payer: Ohana Health Plan Medicaid	$39.36
Rate for Payer: Ohana Health Plan Medicaid	$39.36
Rate for Payer: Ohana Health Plan Medicare	$35.78
Rate for Payer: Ohana Health Plan Medicare	$35.78
Rate for Payer: UnitedHealthcare Medicaid	$977.40
Rate for Payer: UnitedHealthcare Medicaid	$688.80
Rate for Payer: UnitedHealthcare Medicare	$35.78
Rate for Payer: UnitedHealthcare Medicare	$35.78
Rate for Payer: University Health Alliance Commercial	$1,187.38
Rate for Payer: University Health Alliance Commercial	$836.78

TRASTUZUMAB-DTTB 420 MG INTRAVENOUS SOLUTION [173239]

Facility

$4,951.00

Service Code	HCPCS Q5112
Hospital Revenue Code	636
Min. Negotiated Rate	$21.99
Max. Negotiated Rate	$4,802.47
Rate for Payer: AlohaCare Medicaid	$29.81
Rate for Payer: AlohaCare Medicare	$29.81
Rate for Payer: Cash Price	$2,970.60
Rate for Payer: Cash Price	$2,970.60
Rate for Payer: Devoted Health Medicare	$32.79
Rate for Payer: Hawaii Medical Service Association ABD	$21.99
Rate for Payer: Hawaii Medical Service Association Commercial	$37.26
Rate for Payer: Hawaii Medical Service Association Medicare	$29.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.99
Rate for Payer: Hawaii Western Management Group Commercial	$4,703.45
Rate for Payer: Health Management Network Commercial	$4,208.35
Rate for Payer: Humana Medicare	$29.81
Rate for Payer: Kaiser Permanente Commercial	$3,119.13
Rate for Payer: Kaiser Permanente Medicaid	$2,525.01
Rate for Payer: Kaiser Permanente Medicare	$29.81
Rate for Payer: MDX Hawaii PPO	$4,802.47
Rate for Payer: Ohana Health Plan Medicaid	$32.79
Rate for Payer: Ohana Health Plan Medicare	$29.81
Rate for Payer: UnitedHealthcare Medicaid	$2,970.60
Rate for Payer: UnitedHealthcare Medicare	$29.81
Rate for Payer: University Health Alliance Commercial	$3,608.78

TRASTUZUMAB-DTTB 420 MG INTRAVENOUS SOLUTION [173239]

Facility

$4,951.00

Service Code	HCPCS Q5112
Hospital Revenue Code	250
Min. Negotiated Rate	$4,208.35
Max. Negotiated Rate	$4,802.47
Rate for Payer: Cash Price	$2,970.60
Rate for Payer: Health Management Network Commercial	$4,208.35
Rate for Payer: MDX Hawaii PPO	$4,802.47

TRASTUZUMAB-PKRB 150 MG/7.15ML IV (WET SOLR VIAL) [430171650]

Facility

$1,809.00

Service Code	HCPCS Q5113
Hospital Revenue Code	250
Min. Negotiated Rate	$1,537.65
Max. Negotiated Rate	$1,754.73
Rate for Payer: Cash Price	$1,085.40
Rate for Payer: Health Management Network Commercial	$1,537.65
Rate for Payer: MDX Hawaii PPO	$1,754.73

TRASTUZUMAB-PKRB 150 MG/7.15ML IV (WET SOLR VIAL) [430171650]

Facility

$1,809.00

Service Code	HCPCS Q5113
Hospital Revenue Code	636
Min. Negotiated Rate	$56.02
Max. Negotiated Rate	$1,754.73
Rate for Payer: AlohaCare Medicaid	$56.02
Rate for Payer: AlohaCare Medicare	$56.02
Rate for Payer: Cash Price	$1,085.40
Rate for Payer: Cash Price	$1,085.40
Rate for Payer: Devoted Health Medicare	$61.62
Rate for Payer: Hawaii Medical Service Association ABD	$77.49
Rate for Payer: Hawaii Medical Service Association Commercial	$70.03
Rate for Payer: Hawaii Medical Service Association Medicare	$56.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$77.49
Rate for Payer: Hawaii Western Management Group Commercial	$1,718.55
Rate for Payer: Health Management Network Commercial	$1,537.65
Rate for Payer: Humana Medicare	$56.02
Rate for Payer: Kaiser Permanente Commercial	$1,139.67
Rate for Payer: Kaiser Permanente Medicaid	$922.59
Rate for Payer: Kaiser Permanente Medicare	$56.02
Rate for Payer: MDX Hawaii PPO	$1,754.73
Rate for Payer: Ohana Health Plan Medicaid	$61.62
Rate for Payer: Ohana Health Plan Medicare	$56.02
Rate for Payer: UnitedHealthcare Medicaid	$1,085.40
Rate for Payer: UnitedHealthcare Medicare	$56.02
Rate for Payer: University Health Alliance Commercial	$1,318.58

TRAUMACEM V CEMENT 07.702.040S

Facility

$1,598.00

Hospital Revenue Code	278
Min. Negotiated Rate	$894.88
Max. Negotiated Rate	$1,550.06
Rate for Payer: Cash Price	$958.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,118.60
Rate for Payer: Health Management Network Commercial	$1,358.30
Rate for Payer: MDX Hawaii PPO	$1,550.06
Rate for Payer: University Health Alliance Commercial	$894.88

TRAUMACEM V CEMENT 07.702.040S

Facility

$1,598.00

Hospital Revenue Code	278
Min. Negotiated Rate	$814.98
Max. Negotiated Rate	$1,550.06
Rate for Payer: Cash Price	$958.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,118.60
Rate for Payer: Health Management Network Commercial	$1,358.30
Rate for Payer: Kaiser Permanente Commercial	$1,006.74
Rate for Payer: Kaiser Permanente Medicaid	$814.98
Rate for Payer: MDX Hawaii PPO	$1,550.06
Rate for Payer: University Health Alliance Commercial	$894.88

TRAUMACEM V INJECT 03.702.121S

Facility

$1,684.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,431.40
Max. Negotiated Rate	$1,633.48
Rate for Payer: Cash Price	$1,010.40
Rate for Payer: Health Management Network Commercial	$1,431.40
Rate for Payer: MDX Hawaii PPO	$1,633.48

TRAUMACEM V INJECT 03.702.121S

Facility

$1,684.00

Hospital Revenue Code	272
Min. Negotiated Rate	$858.84
Max. Negotiated Rate	$1,633.48
Rate for Payer: Cash Price	$1,010.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,599.80
Rate for Payer: Health Management Network Commercial	$1,431.40
Rate for Payer: Kaiser Permanente Commercial	$1,060.92
Rate for Payer: Kaiser Permanente Medicaid	$858.84
Rate for Payer: MDX Hawaii PPO	$1,633.48
Rate for Payer: University Health Alliance Commercial	$1,227.47

TRAUMACEM V SYRING 03.702.150S

Facility

$666.00

Hospital Revenue Code	272
Min. Negotiated Rate	$566.10
Max. Negotiated Rate	$646.02
Rate for Payer: Cash Price	$399.60
Rate for Payer: Health Management Network Commercial	$566.10
Rate for Payer: MDX Hawaii PPO	$646.02

TRAUMACEM V SYRING 03.702.150S

Facility

$666.00

Hospital Revenue Code	272
Min. Negotiated Rate	$339.66
Max. Negotiated Rate	$646.02
Rate for Payer: Cash Price	$399.60
Rate for Payer: Hawaii Western Management Group Commercial	$632.70
Rate for Payer: Health Management Network Commercial	$566.10
Rate for Payer: Kaiser Permanente Commercial	$419.58
Rate for Payer: Kaiser Permanente Medicaid	$339.66
Rate for Payer: MDX Hawaii PPO	$646.02
Rate for Payer: University Health Alliance Commercial	$485.45

TRAUMATIC INJURY WITH MCC

Facility

$28,196.85

Service Code	MSDRG 913
Min. Negotiated Rate	$15,214.78
Max. Negotiated Rate	$28,196.85
Rate for Payer: AlohaCare Medicare	$18,592.36
Rate for Payer: Devoted Health Medicare	$20,451.60
Rate for Payer: Hawaii Medical Service Association Commercial	$15,214.78
Rate for Payer: Hawaii Medical Service Association Medicare	$18,592.36
Rate for Payer: Humana Medicare	$18,592.36
Rate for Payer: Kaiser Permanente Commercial	$28,196.85
Rate for Payer: Kaiser Permanente Medicare	$18,592.36
Rate for Payer: Ohana Health Plan Medicare	$18,592.36
Rate for Payer: UnitedHealthcare Medicare	$18,592.36

TRAUMATIC INJURY WITHOUT MCC

Facility

$15,274.88

Service Code	MSDRG 914
Min. Negotiated Rate	$10,071.90
Max. Negotiated Rate	$15,274.88
Rate for Payer: AlohaCare Medicare	$10,071.90
Rate for Payer: Devoted Health Medicare	$11,079.09
Rate for Payer: Hawaii Medical Service Association Commercial	$15,214.78
Rate for Payer: Hawaii Medical Service Association Medicare	$10,071.90
Rate for Payer: Humana Medicare	$10,071.90
Rate for Payer: Kaiser Permanente Commercial	$15,274.88
Rate for Payer: Kaiser Permanente Medicare	$10,071.90
Rate for Payer: Ohana Health Plan Medicare	$10,071.90
Rate for Payer: UnitedHealthcare Medicare	$10,071.90

TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC

Facility

$22,471.58

Service Code	MSDRG 086
Min. Negotiated Rate	$14,817.24
Max. Negotiated Rate	$22,471.58
Rate for Payer: AlohaCare Medicare	$14,817.24
Rate for Payer: Devoted Health Medicare	$16,298.96
Rate for Payer: Hawaii Medical Service Association Commercial	$17,107.53
Rate for Payer: Hawaii Medical Service Association Medicare	$14,817.24
Rate for Payer: Humana Medicare	$14,817.24
Rate for Payer: Kaiser Permanente Commercial	$22,471.58
Rate for Payer: Kaiser Permanente Medicare	$14,817.24
Rate for Payer: Ohana Health Plan Medicare	$14,817.24
Rate for Payer: UnitedHealthcare Medicare	$14,817.24

TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC

Facility

$38,655.74

Service Code	MSDRG 083
Min. Negotiated Rate	$15,876.19
Max. Negotiated Rate	$38,655.74
Rate for Payer: AlohaCare Medicare	$15,876.19
Rate for Payer: Devoted Health Medicare	$17,463.81
Rate for Payer: Hawaii Medical Service Association Commercial	$38,655.74
Rate for Payer: Hawaii Medical Service Association Medicare	$15,876.19
Rate for Payer: Humana Medicare	$15,876.19
Rate for Payer: Kaiser Permanente Commercial	$24,077.55
Rate for Payer: Kaiser Permanente Medicare	$15,876.19
Rate for Payer: Ohana Health Plan Medicare	$15,876.19
Rate for Payer: UnitedHealthcare Medicare	$15,876.19

Know your out-of-pocket cost for care.

All Charges