Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CHO PLATE 20MM 00-1012-220

Facility

$2,643.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,480.08
Max. Negotiated Rate	$2,563.71
Rate for Payer: Cash Price	$1,585.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,850.10
Rate for Payer: Health Management Network Commercial	$2,246.55
Rate for Payer: MDX Hawaii PPO	$2,563.71
Rate for Payer: University Health Alliance Commercial	$1,480.08

CHO PLATE 20MM 00-1012-220

Facility

$2,643.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,347.93
Max. Negotiated Rate	$2,563.71
Rate for Payer: Cash Price	$1,585.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,850.10
Rate for Payer: Health Management Network Commercial	$2,246.55
Rate for Payer: Kaiser Permanente Commercial	$1,665.09
Rate for Payer: Kaiser Permanente Medicaid	$1,347.93
Rate for Payer: MDX Hawaii PPO	$2,563.71
Rate for Payer: University Health Alliance Commercial	$1,480.08

CHO PLATE 24MM 00-1012-224

Facility

$2,643.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,347.93
Max. Negotiated Rate	$2,563.71
Rate for Payer: Cash Price	$1,585.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,850.10
Rate for Payer: Health Management Network Commercial	$2,246.55
Rate for Payer: Kaiser Permanente Commercial	$1,665.09
Rate for Payer: Kaiser Permanente Medicaid	$1,347.93
Rate for Payer: MDX Hawaii PPO	$2,563.71
Rate for Payer: University Health Alliance Commercial	$1,480.08

CHO PLATE 24MM 00-1012-224

Facility

$2,643.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,480.08
Max. Negotiated Rate	$2,563.71
Rate for Payer: Cash Price	$1,585.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,850.10
Rate for Payer: Health Management Network Commercial	$2,246.55
Rate for Payer: MDX Hawaii PPO	$2,563.71
Rate for Payer: University Health Alliance Commercial	$1,480.08

CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS

Facility

$8,270.00

Service Code	CPT 58350
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$5,909.62
Rate for Payer: AlohaCare Medicare	$5,909.62
Rate for Payer: Devoted Health Medicare	$6,500.58
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$5,909.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$5,909.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$5,909.62
Rate for Payer: Ohana Health Plan Medicaid	$6,500.58
Rate for Payer: Ohana Health Plan Medicare	$5,909.62
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$5,909.62
Rate for Payer: University Health Alliance Commercial	$6,743.44

CHRONIC KIDNEY DISEASE

Facility

$7,611.42

Service Code	APR-DRG 4704
Min. Negotiated Rate	$7,611.42
Max. Negotiated Rate	$7,611.42
Rate for Payer: AlohaCare Medicaid	$7,611.42
Rate for Payer: Hawaii Medical Service Association ABD	$7,611.42
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,611.42
Rate for Payer: Kaiser Permanente Medicaid	$7,611.42
Rate for Payer: Ohana Health Plan Medicaid	$7,611.42
Rate for Payer: UnitedHealthcare Medicaid	$7,611.42

CHRONIC KIDNEY DISEASE

Facility

$3,115.27

Service Code	APR-DRG 4702
Min. Negotiated Rate	$3,115.27
Max. Negotiated Rate	$3,115.27
Rate for Payer: AlohaCare Medicaid	$3,115.27
Rate for Payer: Hawaii Medical Service Association ABD	$3,115.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,115.27
Rate for Payer: Kaiser Permanente Medicaid	$3,115.27
Rate for Payer: Ohana Health Plan Medicaid	$3,115.27
Rate for Payer: UnitedHealthcare Medicaid	$3,115.27

CHRONIC KIDNEY DISEASE

Facility

$4,462.88

Service Code	APR-DRG 4703
Min. Negotiated Rate	$4,462.88
Max. Negotiated Rate	$4,462.88
Rate for Payer: AlohaCare Medicaid	$4,462.88
Rate for Payer: Hawaii Medical Service Association ABD	$4,462.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,462.88
Rate for Payer: Kaiser Permanente Medicaid	$4,462.88
Rate for Payer: Ohana Health Plan Medicaid	$4,462.88
Rate for Payer: UnitedHealthcare Medicaid	$4,462.88

CHRONIC KIDNEY DISEASE

Facility

$2,560.19

Service Code	APR-DRG 4701
Min. Negotiated Rate	$2,560.19
Max. Negotiated Rate	$2,560.19
Rate for Payer: AlohaCare Medicaid	$2,560.19
Rate for Payer: Hawaii Medical Service Association ABD	$2,560.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,560.19
Rate for Payer: Kaiser Permanente Medicaid	$2,560.19
Rate for Payer: Ohana Health Plan Medicaid	$2,560.19
Rate for Payer: UnitedHealthcare Medicaid	$2,560.19

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$2,871.32

Service Code	APR-DRG 1401
Min. Negotiated Rate	$2,871.32
Max. Negotiated Rate	$2,871.32
Rate for Payer: AlohaCare Medicaid	$2,871.32
Rate for Payer: Hawaii Medical Service Association ABD	$2,871.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,871.32
Rate for Payer: Kaiser Permanente Medicaid	$2,871.32
Rate for Payer: Ohana Health Plan Medicaid	$2,871.32
Rate for Payer: UnitedHealthcare Medicaid	$2,871.32

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$3,522.30

Service Code	APR-DRG 1402
Min. Negotiated Rate	$3,522.30
Max. Negotiated Rate	$3,522.30
Rate for Payer: AlohaCare Medicaid	$3,522.30
Rate for Payer: Hawaii Medical Service Association ABD	$3,522.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,522.30
Rate for Payer: Kaiser Permanente Medicaid	$3,522.30
Rate for Payer: Ohana Health Plan Medicaid	$3,522.30
Rate for Payer: UnitedHealthcare Medicaid	$3,522.30

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$6,464.72

Service Code	APR-DRG 1404
Min. Negotiated Rate	$6,464.72
Max. Negotiated Rate	$6,464.72
Rate for Payer: AlohaCare Medicaid	$6,464.72
Rate for Payer: Hawaii Medical Service Association ABD	$6,464.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,464.72
Rate for Payer: Kaiser Permanente Medicaid	$6,464.72
Rate for Payer: Ohana Health Plan Medicaid	$6,464.72
Rate for Payer: UnitedHealthcare Medicaid	$6,464.72

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$4,375.47

Service Code	APR-DRG 1403
Min. Negotiated Rate	$4,375.47
Max. Negotiated Rate	$4,375.47
Rate for Payer: AlohaCare Medicaid	$4,375.47
Rate for Payer: Hawaii Medical Service Association ABD	$4,375.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,375.47
Rate for Payer: Kaiser Permanente Medicaid	$4,375.47
Rate for Payer: Ohana Health Plan Medicaid	$4,375.47
Rate for Payer: UnitedHealthcare Medicaid	$4,375.47

CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC

Facility

$18,927.48

Service Code	MSDRG 191
Min. Negotiated Rate	$9,588.51
Max. Negotiated Rate	$18,927.48
Rate for Payer: AlohaCare Medicare	$9,588.51
Rate for Payer: Devoted Health Medicare	$10,547.36
Rate for Payer: Hawaii Medical Service Association Commercial	$18,927.48
Rate for Payer: Hawaii Medical Service Association Medicare	$9,588.51
Rate for Payer: Humana Medicare	$9,588.51
Rate for Payer: Kaiser Permanente Commercial	$14,541.75
Rate for Payer: Kaiser Permanente Medicare	$9,588.51
Rate for Payer: Ohana Health Plan Medicare	$9,588.51
Rate for Payer: UnitedHealthcare Medicare	$9,588.51

CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC

Facility

$19,107.83

Service Code	MSDRG 190
Min. Negotiated Rate	$12,599.25
Max. Negotiated Rate	$19,107.83
Rate for Payer: AlohaCare Medicare	$12,599.25
Rate for Payer: Devoted Health Medicare	$13,859.17
Rate for Payer: Hawaii Medical Service Association Commercial	$18,927.48
Rate for Payer: Hawaii Medical Service Association Medicare	$12,599.25
Rate for Payer: Humana Medicare	$12,599.25
Rate for Payer: Kaiser Permanente Commercial	$19,107.83
Rate for Payer: Kaiser Permanente Medicare	$12,599.25
Rate for Payer: Ohana Health Plan Medicare	$12,599.25
Rate for Payer: UnitedHealthcare Medicare	$12,599.25

CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC

Facility

$18,927.48

Service Code	MSDRG 192
Min. Negotiated Rate	$7,302.26
Max. Negotiated Rate	$18,927.48
Rate for Payer: AlohaCare Medicare	$7,302.26
Rate for Payer: Devoted Health Medicare	$8,032.49
Rate for Payer: Hawaii Medical Service Association Commercial	$18,927.48
Rate for Payer: Hawaii Medical Service Association Medicare	$7,302.26
Rate for Payer: Humana Medicare	$7,302.26
Rate for Payer: Kaiser Permanente Commercial	$11,074.50
Rate for Payer: Kaiser Permanente Medicare	$7,302.26
Rate for Payer: Ohana Health Plan Medicare	$7,302.26
Rate for Payer: UnitedHealthcare Medicare	$7,302.26

CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION [17378]

Facility

$1,332.00

Service Code	HCPCS J0740
Hospital Revenue Code	250
Min. Negotiated Rate	$1,132.20
Max. Negotiated Rate	$1,292.04
Rate for Payer: Cash Price	$799.20
Rate for Payer: Health Management Network Commercial	$1,132.20
Rate for Payer: MDX Hawaii PPO	$1,292.04

CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION [17378]

Facility

$1,332.00

Service Code	HCPCS J0740
Hospital Revenue Code	636
Min. Negotiated Rate	$529.38
Max. Negotiated Rate	$1,292.04
Rate for Payer: AlohaCare Medicaid	$560.79
Rate for Payer: AlohaCare Medicare	$560.79
Rate for Payer: Cash Price	$799.20
Rate for Payer: Cash Price	$799.20
Rate for Payer: Devoted Health Medicare	$616.87
Rate for Payer: Hawaii Medical Service Association ABD	$529.38
Rate for Payer: Hawaii Medical Service Association Commercial	$700.99
Rate for Payer: Hawaii Medical Service Association Medicare	$560.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$529.38
Rate for Payer: Hawaii Western Management Group Commercial	$1,265.40
Rate for Payer: Health Management Network Commercial	$1,132.20
Rate for Payer: Humana Medicare	$560.79
Rate for Payer: Kaiser Permanente Commercial	$839.16
Rate for Payer: Kaiser Permanente Medicaid	$679.32
Rate for Payer: Kaiser Permanente Medicare	$560.79
Rate for Payer: MDX Hawaii PPO	$1,292.04
Rate for Payer: Ohana Health Plan Medicaid	$616.87
Rate for Payer: Ohana Health Plan Medicare	$560.79
Rate for Payer: UnitedHealthcare Medicaid	$799.20
Rate for Payer: UnitedHealthcare Medicare	$560.79
Rate for Payer: University Health Alliance Commercial	$970.89

CILOSTAZOL 50 MG TABLET [24473]

Facility

$8.00

Service Code	NDC 50268017615
Hospital Revenue Code	637
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: University Health Alliance Commercial	$5.83

CILOSTAZOL 50 MG TABLET [24473]

Facility

$7.00

Service Code	NDC 00093206506
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: MDX Hawaii PPO	$6.79

CILOSTAZOL 50 MG TABLET [24473]

Facility

$8.00

Service Code	NDC 50268017615
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$7.76

CILOSTAZOL 50 MG TABLET [24473]

Facility

$7.00

Service Code	NDC 00093206506
Hospital Revenue Code	637
Min. Negotiated Rate	$3.57
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$4.41
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: University Health Alliance Commercial	$5.10

CINACALCET 30 MG TABLET [38100]

Facility

$77.00

Service Code	NDC 69097041002
Hospital Revenue Code	250
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$74.69
Rate for Payer: Cash Price	$46.20
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: MDX Hawaii PPO	$74.69

CINACALCET 30 MG TABLET [38100]

Facility

$77.00

Service Code	NDC 69097041002
Hospital Revenue Code	637
Min. Negotiated Rate	$39.27
Max. Negotiated Rate	$74.69
Rate for Payer: Cash Price	$46.20
Rate for Payer: Hawaii Western Management Group Commercial	$73.15
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Kaiser Permanente Commercial	$48.51
Rate for Payer: Kaiser Permanente Medicaid	$39.27
Rate for Payer: MDX Hawaii PPO	$74.69
Rate for Payer: University Health Alliance Commercial	$56.13

CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION [36576]

Facility

$701.00

Service Code	NDC 00781618667
Hospital Revenue Code	637
Min. Negotiated Rate	$357.51
Max. Negotiated Rate	$679.97
Rate for Payer: Cash Price	$420.60
Rate for Payer: Hawaii Western Management Group Commercial	$665.95
Rate for Payer: Health Management Network Commercial	$595.85
Rate for Payer: Kaiser Permanente Commercial	$441.63
Rate for Payer: Kaiser Permanente Medicaid	$357.51
Rate for Payer: MDX Hawaii PPO	$679.97
Rate for Payer: University Health Alliance Commercial	$510.96

Know your out-of-pocket cost for care.

All Charges