Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

AGENT DCB 3.5X15

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: MDX Hawaii PPO	$11,979.50

AGENT DCB 3.5X15

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,298.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$7,780.50
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: University Health Alliance Commercial	$9,001.92

AGENT DCB 3X15

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,298.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$7,780.50
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: University Health Alliance Commercial	$9,001.92

AGENT DCB 3X15

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: MDX Hawaii PPO	$11,979.50

AICD GENERATOR PROCEDURES

Facility

$79,155.69

Service Code	MSDRG 245
Min. Negotiated Rate	$51,893.90
Max. Negotiated Rate	$79,155.69
Rate for Payer: AlohaCare Medicare	$51,893.90
Rate for Payer: Devoted Health Medicare	$57,083.29
Rate for Payer: Hawaii Medical Service Association Commercial	$79,155.69
Rate for Payer: Hawaii Medical Service Association Medicare	$51,893.90
Rate for Payer: Humana Medicare	$51,893.90
Rate for Payer: Kaiser Permanente Commercial	$78,701.40
Rate for Payer: Kaiser Permanente Medicare	$51,893.90
Rate for Payer: Ohana Health Plan Medicare	$51,893.90
Rate for Payer: UnitedHealthcare Medicare	$51,893.90

AICD LEAD PROCEDURES

Facility

$79,155.69

Service Code	MSDRG 265
Min. Negotiated Rate	$41,154.33
Max. Negotiated Rate	$79,155.69
Rate for Payer: AlohaCare Medicare	$41,154.33
Rate for Payer: Devoted Health Medicare	$45,269.76
Rate for Payer: Hawaii Medical Service Association Commercial	$79,155.69
Rate for Payer: Hawaii Medical Service Association Medicare	$41,154.33
Rate for Payer: Humana Medicare	$41,154.33
Rate for Payer: Kaiser Permanente Commercial	$62,413.95
Rate for Payer: Kaiser Permanente Medicare	$41,154.33
Rate for Payer: Ohana Health Plan Medicare	$41,154.33
Rate for Payer: UnitedHealthcare Medicare	$41,154.33

AIRSEAL ACCESS PORT 12X100MM

Facility

$374.00

Hospital Revenue Code	272
Min. Negotiated Rate	$317.90
Max. Negotiated Rate	$362.78
Rate for Payer: Cash Price	$224.40
Rate for Payer: Health Management Network Commercial	$317.90
Rate for Payer: MDX Hawaii PPO	$362.78

AIRSEAL ACCESS PORT 12X100MM

Facility

$374.00

Hospital Revenue Code	272
Min. Negotiated Rate	$190.74
Max. Negotiated Rate	$362.78
Rate for Payer: Cash Price	$224.40
Rate for Payer: Hawaii Western Management Group Commercial	$355.30
Rate for Payer: Health Management Network Commercial	$317.90
Rate for Payer: Kaiser Permanente Commercial	$235.62
Rate for Payer: Kaiser Permanente Medicaid	$190.74
Rate for Payer: MDX Hawaii PPO	$362.78
Rate for Payer: University Health Alliance Commercial	$272.61

AIRSEAL TUBE SET ASM-EVAC1

Facility

$386.00

Hospital Revenue Code	271
Min. Negotiated Rate	$328.10
Max. Negotiated Rate	$374.42
Rate for Payer: Cash Price	$231.60
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: MDX Hawaii PPO	$374.42

AIRSEAL TUBE SET ASM-EVAC1

Facility

$386.00

Hospital Revenue Code	271
Min. Negotiated Rate	$196.86
Max. Negotiated Rate	$374.42
Rate for Payer: Cash Price	$231.60
Rate for Payer: Hawaii Western Management Group Commercial	$366.70
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: Kaiser Permanente Commercial	$243.18
Rate for Payer: Kaiser Permanente Medicaid	$196.86
Rate for Payer: MDX Hawaii PPO	$374.42
Rate for Payer: University Health Alliance Commercial	$281.36

AIRTAP PREVALON GLIDE SHEET

Facility

$547.00

Hospital Revenue Code	272
Min. Negotiated Rate	$464.95
Max. Negotiated Rate	$530.59
Rate for Payer: Cash Price	$328.20
Rate for Payer: Health Management Network Commercial	$464.95
Rate for Payer: MDX Hawaii PPO	$530.59

AIRTAP PREVALON GLIDE SHEET

Facility

$547.00

Hospital Revenue Code	272
Min. Negotiated Rate	$278.97
Max. Negotiated Rate	$530.59
Rate for Payer: Cash Price	$328.20
Rate for Payer: Hawaii Western Management Group Commercial	$519.65
Rate for Payer: Health Management Network Commercial	$464.95
Rate for Payer: Kaiser Permanente Commercial	$344.61
Rate for Payer: Kaiser Permanente Medicaid	$278.97
Rate for Payer: MDX Hawaii PPO	$530.59
Rate for Payer: University Health Alliance Commercial	$398.71

AIRTAP WEDGES ONLY

Facility

$200.00

Hospital Revenue Code	271
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: MDX Hawaii PPO	$194.00

AIRTAP WEDGES ONLY

Facility

$200.00

Hospital Revenue Code	271
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: University Health Alliance Commercial	$145.78

ALBENDAZOLE 200 MG TABLET [8979]

Facility

$172.00

Service Code	NDC 43598045202
Hospital Revenue Code	637
Min. Negotiated Rate	$87.72
Max. Negotiated Rate	$166.84
Rate for Payer: Cash Price	$103.20
Rate for Payer: Hawaii Western Management Group Commercial	$163.40
Rate for Payer: Health Management Network Commercial	$146.20
Rate for Payer: Kaiser Permanente Commercial	$108.36
Rate for Payer: Kaiser Permanente Medicaid	$87.72
Rate for Payer: MDX Hawaii PPO	$166.84
Rate for Payer: University Health Alliance Commercial	$125.37

ALBENDAZOLE 200 MG TABLET [8979]

Facility

$393.00

Service Code	NDC 31722093502
Hospital Revenue Code	250
Min. Negotiated Rate	$334.05
Max. Negotiated Rate	$381.21
Rate for Payer: Cash Price	$235.80
Rate for Payer: Health Management Network Commercial	$334.05
Rate for Payer: MDX Hawaii PPO	$381.21

ALBENDAZOLE 200 MG TABLET [8979]

Facility

$172.00

Service Code	NDC 43598045202
Hospital Revenue Code	250
Min. Negotiated Rate	$146.20
Max. Negotiated Rate	$166.84
Rate for Payer: Cash Price	$103.20
Rate for Payer: Health Management Network Commercial	$146.20
Rate for Payer: MDX Hawaii PPO	$166.84

ALBENDAZOLE 200 MG TABLET [8979]

Facility

$393.00

Service Code	NDC 31722093502
Hospital Revenue Code	637
Min. Negotiated Rate	$200.43
Max. Negotiated Rate	$381.21
Rate for Payer: Cash Price	$235.80
Rate for Payer: Hawaii Western Management Group Commercial	$373.35
Rate for Payer: Health Management Network Commercial	$334.05
Rate for Payer: Kaiser Permanente Commercial	$247.59
Rate for Payer: Kaiser Permanente Medicaid	$200.43
Rate for Payer: MDX Hawaii PPO	$381.21
Rate for Payer: University Health Alliance Commercial	$286.46

ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION [8981]

Facility

$244.00

Service Code	HCPCS P9046
Hospital Revenue Code	250
Min. Negotiated Rate	$207.40
Max. Negotiated Rate	$236.68
Rate for Payer: Cash Price	$146.40
Rate for Payer: Cash Price	$292.20
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Health Management Network Commercial	$413.95
Rate for Payer: MDX Hawaii PPO	$236.68
Rate for Payer: MDX Hawaii PPO	$472.39

ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION [8981]

Facility

$391.00

Service Code	HCPCS P9047
Hospital Revenue Code	250
Min. Negotiated Rate	$332.35
Max. Negotiated Rate	$379.27
Rate for Payer: Cash Price	$234.60
Rate for Payer: Cash Price	$117.60
Rate for Payer: Cash Price	$146.40
Rate for Payer: Health Management Network Commercial	$166.60
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Health Management Network Commercial	$332.35
Rate for Payer: MDX Hawaii PPO	$190.12
Rate for Payer: MDX Hawaii PPO	$379.27
Rate for Payer: MDX Hawaii PPO	$236.68

ALBUTEROL HFA INHALER (PROVENTIL) (TAKE HOME) [4080330]

Facility

$15.00

Service Code	NDC 00004080118
Hospital Revenue Code	253
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$9.45
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: University Health Alliance Commercial	$10.93

ALBUTEROL HFA INHALER (PROVENTIL) (TAKE HOME) [4080330]

Facility

$15.00

Service Code	NDC 00004080118
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: MDX Hawaii PPO	$14.55

ALBUTEROL NEBULES (PROVENTIL) 2.5 MG (TAKE HOME) [4080331]

Facility

$15.00

Service Code	HCPCS J7611
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: MDX Hawaii PPO	$14.55

ALBUTEROL NEBULES (PROVENTIL) 2.5 MG (TAKE HOME) [4080331]

Facility

$15.00

Service Code	HCPCS J7611
Hospital Revenue Code	253
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$9.45
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: UnitedHealthcare Medicaid	$0.12
Rate for Payer: University Health Alliance Commercial	$10.93

ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION [31577]

Facility

$6.00

Service Code	HCPCS J7613
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

Know your out-of-pocket cost for care.

All Charges