Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CLOZAPINE 25 MG TABLET [9648]

Facility

$5.00

Service Code	NDC 60687040401
Hospital Revenue Code	637
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: University Health Alliance Commercial	$3.64

CLOZAPINE 25 MG TABLET [9648]

Facility

$5.00

Service Code	NDC 60687040411
Hospital Revenue Code	637
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: University Health Alliance Commercial	$3.64

CLSTERHLE SHELL48MM 702-04-48D

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,654.44
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Kaiser Permanente Commercial	$2,043.72
Rate for Payer: Kaiser Permanente Medicaid	$1,654.44
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

CLSTERHLE SHELL48MM 702-04-48D

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,816.64
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

CLSTERHLE SHELL50MM 702-04-50D

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,798.16
Max. Negotiated Rate	$3,114.67
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: University Health Alliance Commercial	$1,798.16

CLSTERHLE SHELL50MM 702-04-50D

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,637.61
Max. Negotiated Rate	$3,114.67
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Kaiser Permanente Commercial	$2,022.93
Rate for Payer: Kaiser Permanente Medicaid	$1,637.61
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: University Health Alliance Commercial	$1,798.16

CLSTR SHEL 50HH 00-8757-050-01

Facility

$4,684.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,623.04
Max. Negotiated Rate	$4,543.48
Rate for Payer: Cash Price	$2,810.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,278.80
Rate for Payer: Health Management Network Commercial	$3,981.40
Rate for Payer: MDX Hawaii PPO	$4,543.48
Rate for Payer: University Health Alliance Commercial	$2,623.04

CLSTR SHEL 50HH 00-8757-050-01

Facility

$4,684.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,388.84
Max. Negotiated Rate	$4,543.48
Rate for Payer: Cash Price	$2,810.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,278.80
Rate for Payer: Health Management Network Commercial	$3,981.40
Rate for Payer: Kaiser Permanente Commercial	$2,950.92
Rate for Payer: Kaiser Permanente Medicaid	$2,388.84
Rate for Payer: MDX Hawaii PPO	$4,543.48
Rate for Payer: University Health Alliance Commercial	$2,623.04

CLSTR SHEL 54JJ 00-8757-054-01

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 54JJ 00-8757-054-01

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,244.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$2,772.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 56KK 00-8757-056-01

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 56KK 00-8757-056-01

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,244.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$2,772.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 60MM 00-8757-060-01

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 60MM 00-8757-060-01

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,244.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$2,772.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 64OO 00-8757-064-01

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 64OO 00-8757-064-01

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,244.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$2,772.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CMC MINI TIGHTROPE IMPLANT SYS

Facility

$2,819.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,578.64
Max. Negotiated Rate	$2,734.43
Rate for Payer: Cash Price	$1,691.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,973.30
Rate for Payer: Health Management Network Commercial	$2,396.15
Rate for Payer: MDX Hawaii PPO	$2,734.43
Rate for Payer: University Health Alliance Commercial	$1,578.64

CMC MINI TIGHTROPE IMPLANT SYS

Facility

$2,819.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,437.69
Max. Negotiated Rate	$2,734.43
Rate for Payer: Cash Price	$1,691.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,973.30
Rate for Payer: Health Management Network Commercial	$2,396.15
Rate for Payer: Kaiser Permanente Commercial	$1,775.97
Rate for Payer: Kaiser Permanente Medicaid	$1,437.69
Rate for Payer: MDX Hawaii PPO	$2,734.43
Rate for Payer: University Health Alliance Commercial	$1,578.64

C/M HUMERAL 4" 32-8105-025-04

Facility

$10,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,508.00
Max. Negotiated Rate	$10,476.00
Rate for Payer: Cash Price	$6,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,560.00
Rate for Payer: Health Management Network Commercial	$9,180.00
Rate for Payer: Kaiser Permanente Commercial	$6,804.00
Rate for Payer: Kaiser Permanente Medicaid	$5,508.00
Rate for Payer: MDX Hawaii PPO	$10,476.00
Rate for Payer: University Health Alliance Commercial	$6,048.00

C/M HUMERAL 4" 32-8105-025-04

Facility

$10,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,048.00
Max. Negotiated Rate	$10,476.00
Rate for Payer: Cash Price	$6,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,560.00
Rate for Payer: Health Management Network Commercial	$9,180.00
Rate for Payer: MDX Hawaii PPO	$10,476.00
Rate for Payer: University Health Alliance Commercial	$6,048.00

C/M ULNA 3" 32-8105-043-01

Facility

$9,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,998.00
Max. Negotiated Rate	$9,506.00
Rate for Payer: Cash Price	$5,880.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,860.00
Rate for Payer: Health Management Network Commercial	$8,330.00
Rate for Payer: Kaiser Permanente Commercial	$6,174.00
Rate for Payer: Kaiser Permanente Medicaid	$4,998.00
Rate for Payer: MDX Hawaii PPO	$9,506.00
Rate for Payer: University Health Alliance Commercial	$5,488.00

C/M ULNA 3" 32-8105-043-01

Facility

$9,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,488.00
Max. Negotiated Rate	$9,506.00
Rate for Payer: Cash Price	$5,880.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,860.00
Rate for Payer: Health Management Network Commercial	$8,330.00
Rate for Payer: MDX Hawaii PPO	$9,506.00
Rate for Payer: University Health Alliance Commercial	$5,488.00

COAGULATION DISORDERS

Facility

$33,026.03

Service Code	MSDRG 813
Min. Negotiated Rate	$17,349.14
Max. Negotiated Rate	$33,026.03
Rate for Payer: AlohaCare Medicare	$17,349.14
Rate for Payer: Devoted Health Medicare	$19,084.05
Rate for Payer: Hawaii Medical Service Association Commercial	$33,026.03
Rate for Payer: Hawaii Medical Service Association Medicare	$17,349.14
Rate for Payer: Humana Medicare	$17,349.14
Rate for Payer: Kaiser Permanente Commercial	$26,311.42
Rate for Payer: Kaiser Permanente Medicare	$17,349.14
Rate for Payer: Ohana Health Plan Medicare	$17,349.14
Rate for Payer: UnitedHealthcare Medicare	$17,349.14

COAGULATION FACTOR IX (RECOMB) 1,000 UNIT INTRAVENOUS SOLUTION [134078]

Facility

$2,779.00

Service Code	HCPCS J7195
Hospital Revenue Code	636
Min. Negotiated Rate	$2,362.15
Max. Negotiated Rate	$2,695.63
Rate for Payer: Cash Price	$1,667.40
Rate for Payer: Health Management Network Commercial	$2,362.15
Rate for Payer: MDX Hawaii PPO	$2,695.63

COAGULATION FACTOR IX (RECOMB) 1,000 UNIT INTRAVENOUS SOLUTION [134078]

Facility

$2,779.00

Service Code	HCPCS J7195
Hospital Revenue Code	636
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$2,695.63
Rate for Payer: AlohaCare Medicaid	$1.84
Rate for Payer: AlohaCare Medicare	$1.84
Rate for Payer: Cash Price	$1,667.40
Rate for Payer: Cash Price	$1,667.40
Rate for Payer: Devoted Health Medicare	$2.02
Rate for Payer: Hawaii Medical Service Association Commercial	$2.30
Rate for Payer: Hawaii Medical Service Association Medicare	$1.84
Rate for Payer: Hawaii Western Management Group Commercial	$2,640.05
Rate for Payer: Health Management Network Commercial	$2,362.15
Rate for Payer: Humana Medicare	$1.84
Rate for Payer: Kaiser Permanente Commercial	$1,750.77
Rate for Payer: Kaiser Permanente Medicaid	$1,417.29
Rate for Payer: Kaiser Permanente Medicare	$1.84
Rate for Payer: MDX Hawaii PPO	$2,695.63
Rate for Payer: Ohana Health Plan Medicaid	$2.02
Rate for Payer: Ohana Health Plan Medicare	$1.84
Rate for Payer: UnitedHealthcare Medicaid	$1,667.40
Rate for Payer: UnitedHealthcare Medicare	$1.84
Rate for Payer: University Health Alliance Commercial	$2,025.61

Know your out-of-pocket cost for care.

All Charges