Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CLARITHROMYCIN 125 MG/5 ML ORAL SUSPENSION [12885]

Facility

$225.00

Service Code	NDC 00781602246
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

CLARITHROMYCIN 125 MG/5 ML ORAL SUSPENSION [12885]

Facility

$225.00

Service Code	NDC 00781602246
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

CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION [12886]

Facility

$328.00

Service Code	NDC 00781602346
Hospital Revenue Code	250
Min. Negotiated Rate	$278.80
Max. Negotiated Rate	$318.16
Rate for Payer: Cash Price	$196.80
Rate for Payer: Health Management Network Commercial	$278.80
Rate for Payer: MDX Hawaii PPO	$318.16

CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION [12886]

Facility

$328.00

Service Code	NDC 00781602346
Hospital Revenue Code	637
Min. Negotiated Rate	$167.28
Max. Negotiated Rate	$318.16
Rate for Payer: Cash Price	$196.80
Rate for Payer: Hawaii Western Management Group Commercial	$311.60
Rate for Payer: Health Management Network Commercial	$278.80
Rate for Payer: Kaiser Permanente Commercial	$206.64
Rate for Payer: Kaiser Permanente Medicaid	$167.28
Rate for Payer: MDX Hawaii PPO	$318.16
Rate for Payer: University Health Alliance Commercial	$239.08

CLARITHROMYCIN 250 MG TABLET [9616]

Facility

$19.00

Service Code	NDC 00781196160
Hospital Revenue Code	637
Min. Negotiated Rate	$9.69
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$11.97
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: University Health Alliance Commercial	$13.85

CLARITHROMYCIN 250 MG TABLET [9616]

Facility

$19.00

Service Code	NDC 00527193106
Hospital Revenue Code	637
Min. Negotiated Rate	$9.69
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$11.97
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: University Health Alliance Commercial	$13.85

CLARITHROMYCIN 250 MG TABLET [9616]

Facility

$19.00

Service Code	NDC 00527193106
Hospital Revenue Code	250
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: MDX Hawaii PPO	$18.43

CLARITHROMYCIN 250 MG TABLET [9616]

Facility

$19.00

Service Code	NDC 00781196160
Hospital Revenue Code	250
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: MDX Hawaii PPO	$18.43

CLARITHROMYCIN 500 MG TABLET [9617]

Facility

$19.00

Service Code	NDC 00781196260
Hospital Revenue Code	250
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: MDX Hawaii PPO	$18.43

CLARITHROMYCIN 500 MG TABLET [9617]

Facility

$19.00

Service Code	NDC 00781196260
Hospital Revenue Code	637
Min. Negotiated Rate	$9.69
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$11.97
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: University Health Alliance Commercial	$13.85

CLAVICLE PIN ASSEMBLY 2.5MM

Facility

$3,474.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,771.74
Max. Negotiated Rate	$3,369.78
Rate for Payer: Cash Price	$2,084.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,431.80
Rate for Payer: Health Management Network Commercial	$2,952.90
Rate for Payer: Kaiser Permanente Commercial	$2,188.62
Rate for Payer: Kaiser Permanente Medicaid	$1,771.74
Rate for Payer: MDX Hawaii PPO	$3,369.78
Rate for Payer: University Health Alliance Commercial	$1,945.44

CLAVICLE PIN ASSEMBLY 2.5MM

Facility

$3,474.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,945.44
Max. Negotiated Rate	$3,369.78
Rate for Payer: Cash Price	$2,084.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,431.80
Rate for Payer: Health Management Network Commercial	$2,952.90
Rate for Payer: MDX Hawaii PPO	$3,369.78
Rate for Payer: University Health Alliance Commercial	$1,945.44

CLAVICULECTOMY; PARTIAL

Facility

$13,778.00

Service Code	CPT 23120
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$11,157.19

CLEARIFY VISUAL SYSTEM 21-345

Facility

$312.00

Hospital Revenue Code	272
Min. Negotiated Rate	$265.20
Max. Negotiated Rate	$302.64
Rate for Payer: Cash Price	$187.20
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: MDX Hawaii PPO	$302.64

CLEARIFY VISUAL SYSTEM 21-345

Facility

$312.00

Hospital Revenue Code	272
Min. Negotiated Rate	$159.12
Max. Negotiated Rate	$302.64
Rate for Payer: Cash Price	$187.20
Rate for Payer: Hawaii Western Management Group Commercial	$296.40
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Kaiser Permanente Commercial	$196.56
Rate for Payer: Kaiser Permanente Medicaid	$159.12
Rate for Payer: MDX Hawaii PPO	$302.64
Rate for Payer: University Health Alliance Commercial	$227.42

CLEAR-TRAC 6.5X72 #72200427

Facility

$185.00

Hospital Revenue Code	272
Min. Negotiated Rate	$157.25
Max. Negotiated Rate	$179.45
Rate for Payer: Cash Price	$111.00
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: MDX Hawaii PPO	$179.45

CLEAR-TRAC 6.5X72 #72200427

Facility

$185.00

Hospital Revenue Code	272
Min. Negotiated Rate	$94.35
Max. Negotiated Rate	$179.45
Rate for Payer: Cash Price	$111.00
Rate for Payer: Hawaii Western Management Group Commercial	$175.75
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Kaiser Permanente Commercial	$116.55
Rate for Payer: Kaiser Permanente Medicaid	$94.35
Rate for Payer: MDX Hawaii PPO	$179.45
Rate for Payer: University Health Alliance Commercial	$134.85

CLEAR-TRAC SMOOTH 72201634

Facility

$133.00

Hospital Revenue Code	272
Min. Negotiated Rate	$67.83
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$79.80
Rate for Payer: Hawaii Western Management Group Commercial	$126.35
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$83.79
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: University Health Alliance Commercial	$96.94

CLEAR-TRAC SMOOTH 72201634

Facility

$133.00

Hospital Revenue Code	272
Min. Negotiated Rate	$113.05
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$79.80
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: MDX Hawaii PPO	$129.01

CLEFT LIP & PALATE REPAIR

Facility

$4,466.14

Service Code	APR-DRG 0951
Min. Negotiated Rate	$4,466.14
Max. Negotiated Rate	$4,466.14
Rate for Payer: AlohaCare Medicaid	$4,466.14
Rate for Payer: Hawaii Medical Service Association ABD	$4,466.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,466.14
Rate for Payer: Kaiser Permanente Medicaid	$4,466.14
Rate for Payer: Ohana Health Plan Medicaid	$4,466.14
Rate for Payer: UnitedHealthcare Medicaid	$4,466.14

CLEFT LIP & PALATE REPAIR

Facility

$5,083.19

Service Code	APR-DRG 0952
Min. Negotiated Rate	$5,083.19
Max. Negotiated Rate	$5,083.19
Rate for Payer: AlohaCare Medicaid	$5,083.19
Rate for Payer: Hawaii Medical Service Association ABD	$5,083.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,083.19
Rate for Payer: Kaiser Permanente Medicaid	$5,083.19
Rate for Payer: Ohana Health Plan Medicaid	$5,083.19
Rate for Payer: UnitedHealthcare Medicaid	$5,083.19

CLEFT LIP & PALATE REPAIR

Facility

$13,250.35

Service Code	APR-DRG 0954
Min. Negotiated Rate	$13,250.35
Max. Negotiated Rate	$13,250.35
Rate for Payer: AlohaCare Medicaid	$13,250.35
Rate for Payer: Hawaii Medical Service Association ABD	$13,250.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,250.35
Rate for Payer: Kaiser Permanente Medicaid	$13,250.35
Rate for Payer: Ohana Health Plan Medicaid	$13,250.35
Rate for Payer: UnitedHealthcare Medicaid	$13,250.35

CLEFT LIP & PALATE REPAIR

Facility

$7,608.81

Service Code	APR-DRG 0953
Min. Negotiated Rate	$7,608.81
Max. Negotiated Rate	$7,608.81
Rate for Payer: AlohaCare Medicaid	$7,608.81
Rate for Payer: Hawaii Medical Service Association ABD	$7,608.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,608.81
Rate for Payer: Kaiser Permanente Medicaid	$7,608.81
Rate for Payer: Ohana Health Plan Medicaid	$7,608.81
Rate for Payer: UnitedHealthcare Medicaid	$7,608.81

CLEVIDIPINE 50 MG/100 ML INTRAVENOUS EMULSION [160211]

Facility

$741.00

Service Code	HCPCS J0759
Hospital Revenue Code	250
Min. Negotiated Rate	$629.85
Max. Negotiated Rate	$718.77
Rate for Payer: Cash Price	$444.60
Rate for Payer: Health Management Network Commercial	$629.85
Rate for Payer: MDX Hawaii PPO	$718.77

CLINDAMYCIN 150 MG/ML INJECTION SOLUTION [82301]

Facility

$23.00

Service Code	HCPCS J0736
Hospital Revenue Code	250
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: MDX Hawaii PPO	$7.76

Know your out-of-pocket cost for care.

All Charges