Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$40.00

Service Code	NDC 00143978601
Hospital Revenue Code	250
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: MDX Hawaii PPO	$38.80

ENALAPRIL MALEATE 10 MG TABLET [9924]

Facility

$7.00

Service Code	NDC 43547054710
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

ENALAPRIL MALEATE 10 MG TABLET [9924]

Facility

$7.00

Service Code	NDC 43547054710
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

ENALAPRIL MALEATE 5 MG TABLET [9927]

Facility

$7.00

Service Code	NDC 43547054610
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

ENALAPRIL MALEATE 5 MG TABLET [9927]

Facility

$7.00

Service Code	NDC 51672403801
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

ENALAPRIL MALEATE 5 MG TABLET [9927]

Facility

$7.00

Service Code	NDC 43547054610
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

ENALAPRIL MALEATE 5 MG TABLET [9927]

Facility

$7.00

Service Code	NDC 51672403801
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

END CAP 0MM TI 04.013.000S

Facility

$894.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$500.64
Max. Negotiated Rate	$867.18
Rate for Payer: Cash Price	$536.40
Rate for Payer: Hawaii Western Management Group Commercial	$625.80
Rate for Payer: Health Management Network Commercial	$759.90
Rate for Payer: MDX Hawaii PPO	$867.18
Rate for Payer: University Health Alliance Commercial	$500.64

END CAP 0MM TI 04.013.000S

Facility

$894.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$455.94
Max. Negotiated Rate	$867.18
Rate for Payer: Cash Price	$536.40
Rate for Payer: Hawaii Western Management Group Commercial	$625.80
Rate for Payer: Health Management Network Commercial	$759.90
Rate for Payer: Kaiser Permanente Commercial	$563.22
Rate for Payer: Kaiser Permanente Medicaid	$455.94
Rate for Payer: MDX Hawaii PPO	$867.18
Rate for Payer: University Health Alliance Commercial	$500.64

END CAP 12X5MM 04.004.009S

Facility

$1,130.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$576.30
Max. Negotiated Rate	$1,096.10
Rate for Payer: Cash Price	$678.00
Rate for Payer: Hawaii Western Management Group Commercial	$791.00
Rate for Payer: Health Management Network Commercial	$960.50
Rate for Payer: Kaiser Permanente Commercial	$711.90
Rate for Payer: Kaiser Permanente Medicaid	$576.30
Rate for Payer: MDX Hawaii PPO	$1,096.10
Rate for Payer: University Health Alliance Commercial	$632.80

END CAP 12X5MM 04.004.009S

Facility

$1,130.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$632.80
Max. Negotiated Rate	$1,096.10
Rate for Payer: Cash Price	$678.00
Rate for Payer: Hawaii Western Management Group Commercial	$791.00
Rate for Payer: Health Management Network Commercial	$960.50
Rate for Payer: MDX Hawaii PPO	$1,096.10
Rate for Payer: University Health Alliance Commercial	$632.80

END CAP TI 0MM T40 04.003.000S

Facility

$925.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$471.75
Max. Negotiated Rate	$897.25
Rate for Payer: Cash Price	$555.00
Rate for Payer: Hawaii Western Management Group Commercial	$647.50
Rate for Payer: Health Management Network Commercial	$786.25
Rate for Payer: Kaiser Permanente Commercial	$582.75
Rate for Payer: Kaiser Permanente Medicaid	$471.75
Rate for Payer: MDX Hawaii PPO	$897.25
Rate for Payer: University Health Alliance Commercial	$518.00

END CAP TI 0MM T40 04.003.000S

Facility

$925.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$518.00
Max. Negotiated Rate	$897.25
Rate for Payer: Cash Price	$555.00
Rate for Payer: Hawaii Western Management Group Commercial	$647.50
Rate for Payer: Health Management Network Commercial	$786.25
Rate for Payer: MDX Hawaii PPO	$897.25
Rate for Payer: University Health Alliance Commercial	$518.00

ENDOCRINE DISORDERS WITH CC

Facility

$19,849.59

Service Code	MSDRG 644
Min. Negotiated Rate	$11,658.61
Max. Negotiated Rate	$19,849.59
Rate for Payer: AlohaCare Medicare	$11,658.61
Rate for Payer: Devoted Health Medicare	$12,824.47
Rate for Payer: Hawaii Medical Service Association Commercial	$19,849.59
Rate for Payer: Hawaii Medical Service Association Medicare	$11,658.61
Rate for Payer: Humana Medicare	$11,658.61
Rate for Payer: Kaiser Permanente Commercial	$17,681.25
Rate for Payer: Kaiser Permanente Medicare	$11,658.61
Rate for Payer: Ohana Health Plan Medicare	$11,658.61
Rate for Payer: UnitedHealthcare Medicare	$11,658.61

ENDOCRINE DISORDERS WITH MCC

Facility

$28,395.22

Service Code	MSDRG 643
Min. Negotiated Rate	$18,723.16
Max. Negotiated Rate	$28,395.22
Rate for Payer: AlohaCare Medicare	$18,723.16
Rate for Payer: Devoted Health Medicare	$20,595.48
Rate for Payer: Hawaii Medical Service Association Commercial	$19,849.59
Rate for Payer: Hawaii Medical Service Association Medicare	$18,723.16
Rate for Payer: Humana Medicare	$18,723.16
Rate for Payer: Kaiser Permanente Commercial	$28,395.22
Rate for Payer: Kaiser Permanente Medicare	$18,723.16
Rate for Payer: Ohana Health Plan Medicare	$18,723.16
Rate for Payer: UnitedHealthcare Medicare	$18,723.16

ENDOCRINE DISORDERS WITHOUT CC/MCC

Facility

$17,180.33

Service Code	MSDRG 645
Min. Negotiated Rate	$8,738.83
Max. Negotiated Rate	$17,180.33
Rate for Payer: AlohaCare Medicare	$8,738.83
Rate for Payer: Devoted Health Medicare	$9,612.71
Rate for Payer: Hawaii Medical Service Association Commercial	$17,180.33
Rate for Payer: Hawaii Medical Service Association Medicare	$8,738.83
Rate for Payer: Humana Medicare	$8,738.83
Rate for Payer: Kaiser Permanente Commercial	$13,253.17
Rate for Payer: Kaiser Permanente Medicare	$8,738.83
Rate for Payer: Ohana Health Plan Medicare	$8,738.83
Rate for Payer: UnitedHealthcare Medicare	$8,738.83

ENDO GIA 30 LOADING UNIT

Facility

$676.00

Hospital Revenue Code	272
Min. Negotiated Rate	$344.76
Max. Negotiated Rate	$655.72
Rate for Payer: Cash Price	$405.60
Rate for Payer: Hawaii Western Management Group Commercial	$642.20
Rate for Payer: Health Management Network Commercial	$574.60
Rate for Payer: Kaiser Permanente Commercial	$425.88
Rate for Payer: Kaiser Permanente Medicaid	$344.76
Rate for Payer: MDX Hawaii PPO	$655.72
Rate for Payer: University Health Alliance Commercial	$492.74

ENDO GIA 30 LOADING UNIT

Facility

$676.00

Hospital Revenue Code	272
Min. Negotiated Rate	$574.60
Max. Negotiated Rate	$655.72
Rate for Payer: Cash Price	$405.60
Rate for Payer: Health Management Network Commercial	$574.60
Rate for Payer: MDX Hawaii PPO	$655.72

ENDO GIA 45M CURVD SIG45CTAVM

Facility

$726.00

Hospital Revenue Code	272
Min. Negotiated Rate	$617.10
Max. Negotiated Rate	$704.22
Rate for Payer: Cash Price	$435.60
Rate for Payer: Health Management Network Commercial	$617.10
Rate for Payer: MDX Hawaii PPO	$704.22

ENDO GIA 45M CURVD SIG45CTAVM

Facility

$726.00

Hospital Revenue Code	272
Min. Negotiated Rate	$370.26
Max. Negotiated Rate	$704.22
Rate for Payer: Cash Price	$435.60
Rate for Payer: Hawaii Western Management Group Commercial	$689.70
Rate for Payer: Health Management Network Commercial	$617.10
Rate for Payer: Kaiser Permanente Commercial	$457.38
Rate for Payer: Kaiser Permanente Medicaid	$370.26
Rate for Payer: MDX Hawaii PPO	$704.22
Rate for Payer: University Health Alliance Commercial	$529.18

ENDO GIA ROTICULATOR 45-2.0

Facility

$776.00

Hospital Revenue Code	272
Min. Negotiated Rate	$659.60
Max. Negotiated Rate	$752.72
Rate for Payer: Cash Price	$465.60
Rate for Payer: Health Management Network Commercial	$659.60
Rate for Payer: MDX Hawaii PPO	$752.72

ENDO GIA ROTICULATOR 45-2.0

Facility

$776.00

Hospital Revenue Code	272
Min. Negotiated Rate	$395.76
Max. Negotiated Rate	$752.72
Rate for Payer: Cash Price	$465.60
Rate for Payer: Hawaii Western Management Group Commercial	$737.20
Rate for Payer: Health Management Network Commercial	$659.60
Rate for Payer: Kaiser Permanente Commercial	$488.88
Rate for Payer: Kaiser Permanente Medicaid	$395.76
Rate for Payer: MDX Hawaii PPO	$752.72
Rate for Payer: University Health Alliance Commercial	$565.63

ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE

Facility

$16,700.00

Service Code	CPT 58353
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$16,700.00
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	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$5,909.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
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	$16,700.00

ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)

Facility

$2,837.00

Service Code	CPT 58100
Hospital Revenue Code	360
Min. Negotiated Rate	$56.43
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$238.83
Rate for Payer: AlohaCare Medicare	$238.83
Rate for Payer: Devoted Health Medicare	$262.71
Rate for Payer: Hawaii Medical Service Association Commercial	$298.54
Rate for Payer: Hawaii Medical Service Association Medicare	$238.83
Rate for Payer: Humana Medicare	$238.83
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$238.83
Rate for Payer: Ohana Health Plan Medicaid	$262.71
Rate for Payer: Ohana Health Plan Medicare	$238.83
Rate for Payer: UnitedHealthcare Medicaid	$56.43
Rate for Payer: UnitedHealthcare Medicare	$238.83

ENDOPATH BLUNT DISSECTOR

Facility

$257.00

Hospital Revenue Code	272
Min. Negotiated Rate	$131.07
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$154.20
Rate for Payer: Hawaii Western Management Group Commercial	$244.15
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$161.91
Rate for Payer: Kaiser Permanente Medicaid	$131.07
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: University Health Alliance Commercial	$187.33

Know your out-of-pocket cost for care.

All Charges