Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION [27834]

Facility

$42.00

Service Code	NDC 00338001304
Hospital Revenue Code	258
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$26.46
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: University Health Alliance Commercial	$30.61

WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION [27834]

Facility

$21.00

Service Code	NDC 00264785000
Hospital Revenue Code	258
Min. Negotiated Rate	$17.85
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: MDX Hawaii PPO	$20.37

WATER FOR IRRIGATION, STERILE SOLUTION [7485]

Facility

$7.00

Service Code	NDC 00264210100
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$10.20
Rate for Payer: Cash Price	$10.80
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: MDX Hawaii PPO	$6.79

WATER FOR IRRIGATION, STERILE SOLUTION [7485]

Facility

$14.00

Service Code	NDC 00264210110
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: MDX Hawaii PPO	$13.58

WAYNE PNEUMOTHORAX SET

Facility

$779.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$662.15
Max. Negotiated Rate	$755.63
Rate for Payer: Cash Price	$467.40
Rate for Payer: Health Management Network Commercial	$662.15
Rate for Payer: MDX Hawaii PPO	$755.63

WAYNE PNEUMOTHORAX SET

Facility

$779.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$397.29
Max. Negotiated Rate	$755.63
Rate for Payer: Cash Price	$467.40
Rate for Payer: Hawaii Western Management Group Commercial	$740.05
Rate for Payer: Health Management Network Commercial	$662.15
Rate for Payer: Kaiser Permanente Commercial	$490.77
Rate for Payer: Kaiser Permanente Medicaid	$397.29
Rate for Payer: MDX Hawaii PPO	$755.63
Rate for Payer: University Health Alliance Commercial	$567.81

WAYNE PNEUMOTHORAX TRAY G56537

Facility

$868.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$442.68
Max. Negotiated Rate	$841.96
Rate for Payer: Cash Price	$520.80
Rate for Payer: Hawaii Western Management Group Commercial	$824.60
Rate for Payer: Health Management Network Commercial	$737.80
Rate for Payer: Kaiser Permanente Commercial	$546.84
Rate for Payer: Kaiser Permanente Medicaid	$442.68
Rate for Payer: MDX Hawaii PPO	$841.96
Rate for Payer: University Health Alliance Commercial	$632.69

WAYNE PNEUMOTHORAX TRAY G56537

Facility

$868.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$737.80
Max. Negotiated Rate	$841.96
Rate for Payer: Cash Price	$520.80
Rate for Payer: Health Management Network Commercial	$737.80
Rate for Payer: MDX Hawaii PPO	$841.96

WEDGE FULL BASE PLATE DWJ515

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,680.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

WEDGE FULL BASE PLATE DWJ515

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,530.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Kaiser Permanente Commercial	$1,890.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

WEDGE SUBTALAR 12MM PSBT-1206

Facility

$5,588.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,849.88
Max. Negotiated Rate	$5,420.36
Rate for Payer: Cash Price	$3,352.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,911.60
Rate for Payer: Health Management Network Commercial	$4,749.80
Rate for Payer: Kaiser Permanente Commercial	$3,520.44
Rate for Payer: Kaiser Permanente Medicaid	$2,849.88
Rate for Payer: MDX Hawaii PPO	$5,420.36
Rate for Payer: University Health Alliance Commercial	$3,129.28

WEDGE SUBTALAR 12MM PSBT-1206

Facility

$5,588.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,129.28
Max. Negotiated Rate	$5,420.36
Rate for Payer: Cash Price	$3,352.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,911.60
Rate for Payer: Health Management Network Commercial	$4,749.80
Rate for Payer: MDX Hawaii PPO	$5,420.36
Rate for Payer: University Health Alliance Commercial	$3,129.28

WEDGE SUBTALAR 18MM PSBT-1818

Facility

$5,476.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,066.56
Max. Negotiated Rate	$5,311.72
Rate for Payer: Cash Price	$3,285.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,833.20
Rate for Payer: Health Management Network Commercial	$4,654.60
Rate for Payer: MDX Hawaii PPO	$5,311.72
Rate for Payer: University Health Alliance Commercial	$3,066.56

WEDGE SUBTALAR 18MM PSBT-1818

Facility

$5,476.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,792.76
Max. Negotiated Rate	$5,311.72
Rate for Payer: Cash Price	$3,285.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,833.20
Rate for Payer: Health Management Network Commercial	$4,654.60
Rate for Payer: Kaiser Permanente Commercial	$3,449.88
Rate for Payer: Kaiser Permanente Medicaid	$2,792.76
Rate for Payer: MDX Hawaii PPO	$5,311.72
Rate for Payer: University Health Alliance Commercial	$3,066.56

WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT [139325]

Facility

$27.00

Service Code	NDC 00065051801
Hospital Revenue Code	637
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$17.01
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: University Health Alliance Commercial	$19.68

WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT [139325]

Facility

$27.00

Service Code	NDC 00065051801
Hospital Revenue Code	250
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: MDX Hawaii PPO	$26.19

WILLIAMS CYSTO INJ NEEDLE

Facility

$144.00

Hospital Revenue Code	272
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: MDX Hawaii PPO	$139.68

WILLIAMS CYSTO INJ NEEDLE

Facility

$144.00

Hospital Revenue Code	272
Min. Negotiated Rate	$73.44
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$86.40
Rate for Payer: Hawaii Western Management Group Commercial	$136.80
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Kaiser Permanente Commercial	$90.72
Rate for Payer: Kaiser Permanente Medicaid	$73.44
Rate for Payer: MDX Hawaii PPO	$139.68
Rate for Payer: University Health Alliance Commercial	$104.96

WIRE 2.0 KIRSCHNER 390192

Facility

$145.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$87.00
Rate for Payer: Hawaii Western Management Group Commercial	$137.75
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$91.35
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: University Health Alliance Commercial	$105.69

WIRE 2.0 KIRSCHNER 390192

Facility

$145.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$87.00
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: MDX Hawaii PPO	$140.65

WIRE 260 GLIDEWIRE ADVANTAGE

Facility

$675.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$573.75
Max. Negotiated Rate	$654.75
Rate for Payer: Cash Price	$405.00
Rate for Payer: Health Management Network Commercial	$573.75
Rate for Payer: MDX Hawaii PPO	$654.75

WIRE 260 GLIDEWIRE ADVANTAGE

Facility

$675.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$344.25
Max. Negotiated Rate	$654.75
Rate for Payer: Cash Price	$405.00
Rate for Payer: Hawaii Western Management Group Commercial	$641.25
Rate for Payer: Health Management Network Commercial	$573.75
Rate for Payer: Kaiser Permanente Commercial	$425.25
Rate for Payer: Kaiser Permanente Medicaid	$344.25
Rate for Payer: MDX Hawaii PPO	$654.75
Rate for Payer: University Health Alliance Commercial	$492.01

WIRE BAYONET 54-1216

Facility

$825.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$701.25
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: MDX Hawaii PPO	$800.25

WIRE BAYONET 54-1216

Facility

$825.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$420.75
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Hawaii Western Management Group Commercial	$783.75
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: Kaiser Permanente Commercial	$519.75
Rate for Payer: Kaiser Permanente Medicaid	$420.75
Rate for Payer: MDX Hawaii PPO	$800.25
Rate for Payer: University Health Alliance Commercial	$601.34

WIRE COMP 2.8X10MM 03.118.010

Facility

$279.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$237.15
Max. Negotiated Rate	$270.63
Rate for Payer: Cash Price	$167.40
Rate for Payer: Health Management Network Commercial	$237.15
Rate for Payer: MDX Hawaii PPO	$270.63

Know your out-of-pocket cost for care.

All Charges