Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

EPINEPHRINE INFUSION 8 MCG/ML IN 250 ML NS-CNR (SIMPLE) [4080073]

Facility

$71.00

Service Code	NDC 00004080024
Hospital Revenue Code	250
Min. Negotiated Rate	$60.35
Max. Negotiated Rate	$68.87
Rate for Payer: Cash Price	$42.60
Rate for Payer: Health Management Network Commercial	$60.35
Rate for Payer: MDX Hawaii PPO	$68.87

EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR [124985]

Facility

$282.00

Service Code	HCPCS J0165
Hospital Revenue Code	250
Min. Negotiated Rate	$239.70
Max. Negotiated Rate	$273.54
Rate for Payer: Cash Price	$169.20
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: MDX Hawaii PPO	$273.54

EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR [124985]

Facility

$282.00

Service Code	HCPCS J0165
Hospital Revenue Code	636
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$273.54
Rate for Payer: Cash Price	$169.20
Rate for Payer: Cash Price	$169.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.58
Rate for Payer: Hawaii Western Management Group Commercial	$267.90
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Kaiser Permanente Commercial	$177.66
Rate for Payer: Kaiser Permanente Medicaid	$143.82
Rate for Payer: MDX Hawaii PPO	$273.54
Rate for Payer: UnitedHealthcare Medicaid	$169.20
Rate for Payer: University Health Alliance Commercial	$205.55

EPISTAXIS WITH MCC

Facility

$22,968.38

Service Code	MSDRG 150
Min. Negotiated Rate	$10,652.77
Max. Negotiated Rate	$22,968.38
Rate for Payer: AlohaCare Medicare	$15,144.83
Rate for Payer: Devoted Health Medicare	$16,659.31
Rate for Payer: Hawaii Medical Service Association Commercial	$10,652.77
Rate for Payer: Hawaii Medical Service Association Medicare	$15,144.83
Rate for Payer: Humana Medicare	$15,144.83
Rate for Payer: Kaiser Permanente Commercial	$22,968.38
Rate for Payer: Kaiser Permanente Medicare	$15,144.83
Rate for Payer: Ohana Health Plan Medicare	$15,144.83
Rate for Payer: UnitedHealthcare Medicare	$15,144.83

EPISTAXIS WITHOUT MCC

Facility

$12,661.50

Service Code	MSDRG 151
Min. Negotiated Rate	$8,348.70
Max. Negotiated Rate	$12,661.50
Rate for Payer: AlohaCare Medicare	$8,348.70
Rate for Payer: Devoted Health Medicare	$9,183.57
Rate for Payer: Hawaii Medical Service Association Commercial	$10,652.77
Rate for Payer: Hawaii Medical Service Association Medicare	$8,348.70
Rate for Payer: Humana Medicare	$8,348.70
Rate for Payer: Kaiser Permanente Commercial	$12,661.50
Rate for Payer: Kaiser Permanente Medicare	$8,348.70
Rate for Payer: Ohana Health Plan Medicare	$8,348.70
Rate for Payer: UnitedHealthcare Medicare	$8,348.70

EPIX LAPAROSCOPIC GRASPER 5MM

Facility

$360.00

Hospital Revenue Code	272
Min. Negotiated Rate	$183.60
Max. Negotiated Rate	$349.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Hawaii Western Management Group Commercial	$342.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: Kaiser Permanente Commercial	$226.80
Rate for Payer: Kaiser Permanente Medicaid	$183.60
Rate for Payer: MDX Hawaii PPO	$349.20
Rate for Payer: University Health Alliance Commercial	$262.40

EPIX LAPAROSCOPIC GRASPER 5MM

Facility

$360.00

Hospital Revenue Code	272
Min. Negotiated Rate	$306.00
Max. Negotiated Rate	$349.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: MDX Hawaii PPO	$349.20

EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION [14643]

Facility

$597.00

Service Code	HCPCS Q4081
Hospital Revenue Code	635
Min. Negotiated Rate	$507.45
Max. Negotiated Rate	$579.09
Rate for Payer: Cash Price	$358.20
Rate for Payer: Cash Price	$577.80
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Health Management Network Commercial	$507.45
Rate for Payer: MDX Hawaii PPO	$579.09
Rate for Payer: MDX Hawaii PPO	$934.11

EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION [14643]

Facility

$597.00

Service Code	HCPCS Q4081
Hospital Revenue Code	635
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$579.09
Rate for Payer: Cash Price	$358.20
Rate for Payer: Cash Price	$577.80
Rate for Payer: Cash Price	$358.20
Rate for Payer: Cash Price	$577.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.77
Rate for Payer: Hawaii Medical Service Association ABD	$0.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.77
Rate for Payer: Hawaii Western Management Group Commercial	$914.85
Rate for Payer: Hawaii Western Management Group Commercial	$567.15
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Health Management Network Commercial	$507.45
Rate for Payer: Kaiser Permanente Commercial	$376.11
Rate for Payer: Kaiser Permanente Commercial	$606.69
Rate for Payer: Kaiser Permanente Medicaid	$304.47
Rate for Payer: Kaiser Permanente Medicaid	$491.13
Rate for Payer: MDX Hawaii PPO	$934.11
Rate for Payer: MDX Hawaii PPO	$579.09
Rate for Payer: UnitedHealthcare Medicaid	$0.58
Rate for Payer: UnitedHealthcare Medicaid	$0.58
Rate for Payer: University Health Alliance Commercial	$435.15
Rate for Payer: University Health Alliance Commercial	$701.93

EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION [160716]

Facility

$199.00

Service Code	HCPCS Q5105
Hospital Revenue Code	635
Min. Negotiated Rate	$169.15
Max. Negotiated Rate	$193.03
Rate for Payer: Cash Price	$119.40
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: MDX Hawaii PPO	$193.03

EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION [160716]

Facility

$199.00

Service Code	HCPCS Q5105
Hospital Revenue Code	635
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$193.03
Rate for Payer: Cash Price	$119.40
Rate for Payer: Cash Price	$119.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.76
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.76
Rate for Payer: Hawaii Western Management Group Commercial	$189.05
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Kaiser Permanente Commercial	$125.37
Rate for Payer: Kaiser Permanente Medicaid	$101.49
Rate for Payer: MDX Hawaii PPO	$193.03
Rate for Payer: UnitedHealthcare Medicaid	$0.57
Rate for Payer: University Health Alliance Commercial	$145.05

EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION [176329]

Facility

$398.00

Service Code	HCPCS Q5105
Hospital Revenue Code	635
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$386.06
Rate for Payer: Cash Price	$238.80
Rate for Payer: Cash Price	$238.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.76
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.76
Rate for Payer: Hawaii Western Management Group Commercial	$378.10
Rate for Payer: Health Management Network Commercial	$338.30
Rate for Payer: Kaiser Permanente Commercial	$250.74
Rate for Payer: Kaiser Permanente Medicaid	$202.98
Rate for Payer: MDX Hawaii PPO	$386.06
Rate for Payer: UnitedHealthcare Medicaid	$0.57
Rate for Payer: University Health Alliance Commercial	$290.10

EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION [176329]

Facility

$398.00

Service Code	HCPCS Q5105
Hospital Revenue Code	635
Min. Negotiated Rate	$338.30
Max. Negotiated Rate	$386.06
Rate for Payer: Cash Price	$238.80
Rate for Payer: Health Management Network Commercial	$338.30
Rate for Payer: MDX Hawaii PPO	$386.06

EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION [160717]

Facility

$795.00

Service Code	HCPCS Q5105
Hospital Revenue Code	635
Min. Negotiated Rate	$675.75
Max. Negotiated Rate	$771.15
Rate for Payer: Cash Price	$477.00
Rate for Payer: Health Management Network Commercial	$675.75
Rate for Payer: MDX Hawaii PPO	$771.15

EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION [160717]

Facility

$795.00

Service Code	HCPCS Q5105
Hospital Revenue Code	635
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$771.15
Rate for Payer: Cash Price	$477.00
Rate for Payer: Cash Price	$477.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.76
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.76
Rate for Payer: Hawaii Western Management Group Commercial	$755.25
Rate for Payer: Health Management Network Commercial	$675.75
Rate for Payer: Kaiser Permanente Commercial	$500.85
Rate for Payer: Kaiser Permanente Medicaid	$405.45
Rate for Payer: MDX Hawaii PPO	$771.15
Rate for Payer: UnitedHealthcare Medicaid	$0.57
Rate for Payer: University Health Alliance Commercial	$579.48

EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION [160715]

Facility

$106.00

Service Code	HCPCS Q5105
Hospital Revenue Code	634
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Cash Price	$63.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.76
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.76
Rate for Payer: Hawaii Western Management Group Commercial	$100.70
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$66.78
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: UnitedHealthcare Medicaid	$0.57
Rate for Payer: University Health Alliance Commercial	$77.26

EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION [160715]

Facility

$106.00

Service Code	HCPCS Q5105
Hospital Revenue Code	634
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: MDX Hawaii PPO	$102.82

EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION [23123]

Facility

$2,055.00

Service Code	NDC 67457063110
Hospital Revenue Code	250
Min. Negotiated Rate	$1,746.75
Max. Negotiated Rate	$1,993.35
Rate for Payer: Cash Price	$1,233.00
Rate for Payer: Health Management Network Commercial	$1,746.75
Rate for Payer: MDX Hawaii PPO	$1,993.35

EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [131638]

Facility

$189.00

Service Code	NDC 55150021910
Hospital Revenue Code	250
Min. Negotiated Rate	$160.65
Max. Negotiated Rate	$183.33
Rate for Payer: Cash Price	$113.40
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: MDX Hawaii PPO	$183.33

EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [131638]

Facility

$469.00

Service Code	NDC 67457062910
Hospital Revenue Code	250
Min. Negotiated Rate	$398.65
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$281.40
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: MDX Hawaii PPO	$454.93

ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]

Facility

$7.00

Service Code	NDC 50268029711
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

ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]

Facility

$3.00

Service Code	NDC 69452015120
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]

Facility

$7.00

Service Code	NDC 50268029711
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

ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]

Facility

$3.00

Service Code	NDC 69452015120
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: University Health Alliance Commercial	$2.19

ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION [106773]

Facility

$2,538.00

Service Code	HCPCS J9179
Hospital Revenue Code	250
Min. Negotiated Rate	$2,157.30
Max. Negotiated Rate	$2,461.86
Rate for Payer: Cash Price	$1,522.80
Rate for Payer: Cash Price	$2,479.20
Rate for Payer: Health Management Network Commercial	$3,512.20
Rate for Payer: Health Management Network Commercial	$2,157.30
Rate for Payer: MDX Hawaii PPO	$2,461.86
Rate for Payer: MDX Hawaii PPO	$4,008.04

Know your out-of-pocket cost for care.

All Charges