Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

ESOPH BALLN 5.5FRX10-20MM

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$420.75
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Hawaii Western Management Group Commercial	$783.75
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: Kaiser Permanente Commercial	$519.75
Rate for Payer: Kaiser Permanente Medicaid	$420.75
Rate for Payer: MDX Hawaii PPO	$800.25
Rate for Payer: University Health Alliance Commercial	$601.34

ESTRADIOL CYPIONATE 5 MG/ML INTRAMUSCULAR OIL [2929]

Facility

$590.00

Service Code	HCPCS J1000
Hospital Revenue Code	250
Min. Negotiated Rate	$501.50
Max. Negotiated Rate	$572.30
Rate for Payer: Cash Price	$354.00
Rate for Payer: Health Management Network Commercial	$501.50
Rate for Payer: MDX Hawaii PPO	$572.30

ESTRADIOL CYPIONATE 5 MG/ML INTRAMUSCULAR OIL [2929]

Facility

$590.00

Service Code	HCPCS J1000
Hospital Revenue Code	636
Min. Negotiated Rate	$46.91
Max. Negotiated Rate	$572.30
Rate for Payer: Cash Price	$354.00
Rate for Payer: Cash Price	$354.00
Rate for Payer: Hawaii Medical Service Association ABD	$46.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$46.91
Rate for Payer: Hawaii Western Management Group Commercial	$560.50
Rate for Payer: Health Management Network Commercial	$501.50
Rate for Payer: Kaiser Permanente Commercial	$371.70
Rate for Payer: Kaiser Permanente Medicaid	$300.90
Rate for Payer: MDX Hawaii PPO	$572.30
Rate for Payer: UnitedHealthcare Medicaid	$354.00
Rate for Payer: University Health Alliance Commercial	$430.05

ETHAMBUTOL 100 MG TABLET [9982]

Facility

$3.00

Service Code	NDC 68180028001
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

ETHAMBUTOL 100 MG TABLET [9982]

Facility

$3.00

Service Code	NDC 68180028001
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

ETHAMBUTOL 400 MG TABLET [9983]

Facility

$6.00

Service Code	NDC 68084028001
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

ETHAMBUTOL 400 MG TABLET [9983]

Facility

$6.00

Service Code	NDC 68084028001
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

ETHAMBUTOL 400 MG TABLET [9983]

Facility

$7.00

Service Code	NDC 68180028101
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

ETHAMBUTOL 400 MG TABLET [9983]

Facility

$7.00

Service Code	NDC 68180028101
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

ETHICON PROLENE HERNIA PHSE

Facility

$2,016.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$1,028.16
Max. Negotiated Rate	$1,955.52
Rate for Payer: Cash Price	$1,209.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,411.20
Rate for Payer: Health Management Network Commercial	$1,713.60
Rate for Payer: Kaiser Permanente Commercial	$1,270.08
Rate for Payer: Kaiser Permanente Medicaid	$1,028.16
Rate for Payer: MDX Hawaii PPO	$1,955.52
Rate for Payer: University Health Alliance Commercial	$1,128.96

ETHICON PROLENE HERNIA PHSE

Facility

$2,016.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$1,128.96
Max. Negotiated Rate	$1,955.52
Rate for Payer: Cash Price	$1,209.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,411.20
Rate for Payer: Health Management Network Commercial	$1,713.60
Rate for Payer: MDX Hawaii PPO	$1,955.52
Rate for Payer: University Health Alliance Commercial	$1,128.96

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

$17.00

Service Code	NDC 00143950610
Hospital Revenue Code	250
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: MDX Hawaii PPO	$16.49

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

$17.00

Service Code	NDC 00143950601
Hospital Revenue Code	250
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: MDX Hawaii PPO	$16.49

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

$19.00

Service Code	NDC 72266014610
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

ETONOGESTREL 68 MG SUBDERMAL IMPLANT [77012]

Facility

$1,958.00

Service Code	HCPCS J7307
Hospital Revenue Code	250
Min. Negotiated Rate	$1,664.30
Max. Negotiated Rate	$1,899.26
Rate for Payer: Cash Price	$1,174.80
Rate for Payer: Health Management Network Commercial	$1,664.30
Rate for Payer: MDX Hawaii PPO	$1,899.26

ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION [122196]

Facility

$40.00

Service Code	HCPCS J9181
Hospital Revenue Code	636
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cash Price	$119.40
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cash Price	$238.80
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$238.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cash Price	$119.40
Rate for Payer: Cash Price	$96.00
Rate for Payer: Hawaii Medical Service Association ABD	$1.30
Rate for Payer: Hawaii Medical Service Association ABD	$1.30
Rate for Payer: Hawaii Medical Service Association ABD	$1.30
Rate for Payer: Hawaii Medical Service Association ABD	$1.30
Rate for Payer: Hawaii Medical Service Association ABD	$1.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.30
Rate for Payer: Hawaii Western Management Group Commercial	$189.05
Rate for Payer: Hawaii Western Management Group Commercial	$152.00
Rate for Payer: Hawaii Western Management Group Commercial	$378.10
Rate for Payer: Hawaii Western Management Group Commercial	$38.00
Rate for Payer: Hawaii Western Management Group Commercial	$28.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Health Management Network Commercial	$338.30
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Commercial	$125.37
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Commercial	$250.74
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$81.60
Rate for Payer: Kaiser Permanente Medicaid	$20.40
Rate for Payer: Kaiser Permanente Medicaid	$202.98
Rate for Payer: Kaiser Permanente Medicaid	$101.49
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: MDX Hawaii PPO	$193.03
Rate for Payer: MDX Hawaii PPO	$386.06
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: MDX Hawaii PPO	$38.80
Rate for Payer: UnitedHealthcare Medicaid	$96.00
Rate for Payer: UnitedHealthcare Medicaid	$238.80
Rate for Payer: UnitedHealthcare Medicaid	$24.00
Rate for Payer: UnitedHealthcare Medicaid	$119.40
Rate for Payer: UnitedHealthcare Medicaid	$18.00
Rate for Payer: University Health Alliance Commercial	$290.10
Rate for Payer: University Health Alliance Commercial	$21.87
Rate for Payer: University Health Alliance Commercial	$145.05
Rate for Payer: University Health Alliance Commercial	$116.62
Rate for Payer: University Health Alliance Commercial	$29.16

ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION [122196]

Facility

$398.00

Service Code	HCPCS J9181
Hospital Revenue Code	250
Min. Negotiated Rate	$338.30
Max. Negotiated Rate	$386.06
Rate for Payer: Cash Price	$238.80
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cash Price	$119.40
Rate for Payer: Cash Price	$96.00
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Health Management Network Commercial	$338.30
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: MDX Hawaii PPO	$38.80
Rate for Payer: MDX Hawaii PPO	$386.06
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: MDX Hawaii PPO	$193.03

EXCALIBUR 5.5MM AR-8550EX

Facility

$236.00

Hospital Revenue Code	272
Min. Negotiated Rate	$120.36
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$148.68
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: University Health Alliance Commercial	$172.02

EXCALIBUR 5.5MM AR-8550EX

Facility

$236.00

Hospital Revenue Code	272
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: MDX Hawaii PPO	$228.92

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM

Facility

$4,035.20

Service Code	CPT 11421
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$836.55
Rate for Payer: AlohaCare Medicare	$836.55
Rate for Payer: Devoted Health Medicare	$920.21
Rate for Payer: Hawaii Medical Service Association Commercial	$1,045.69
Rate for Payer: Hawaii Medical Service Association Medicare	$836.55
Rate for Payer: Humana Medicare	$836.55
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$836.55
Rate for Payer: Ohana Health Plan Medicaid	$920.21
Rate for Payer: Ohana Health Plan Medicare	$836.55
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$836.55
Rate for Payer: University Health Alliance Commercial	$4,035.20

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM

Facility

$4,035.20

Service Code	CPT 11422
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,951.11
Rate for Payer: AlohaCare Medicare	$1,951.11
Rate for Payer: Devoted Health Medicare	$2,146.22
Rate for Payer: Hawaii Medical Service Association Commercial	$2,438.89
Rate for Payer: Hawaii Medical Service Association Medicare	$1,951.11
Rate for Payer: Humana Medicare	$1,951.11
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,951.11
Rate for Payer: Ohana Health Plan Medicaid	$2,146.22
Rate for Payer: Ohana Health Plan Medicare	$1,951.11
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,951.11
Rate for Payer: University Health Alliance Commercial	$4,035.20

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM

Facility

$5,160.40

Service Code	CPT 11423
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$1,951.11
Rate for Payer: AlohaCare Medicare	$1,951.11
Rate for Payer: Devoted Health Medicare	$2,146.22
Rate for Payer: Hawaii Medical Service Association Commercial	$2,438.89
Rate for Payer: Hawaii Medical Service Association Medicare	$1,951.11
Rate for Payer: Humana Medicare	$1,951.11
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,951.11
Rate for Payer: Ohana Health Plan Medicaid	$2,146.22
Rate for Payer: Ohana Health Plan Medicare	$1,951.11
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,951.11
Rate for Payer: University Health Alliance Commercial	$5,160.40

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM

Facility

$5,160.40

Service Code	CPT 11424
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$1,951.11
Rate for Payer: AlohaCare Medicare	$1,951.11
Rate for Payer: Devoted Health Medicare	$2,146.22
Rate for Payer: Hawaii Medical Service Association Commercial	$2,438.89
Rate for Payer: Hawaii Medical Service Association Medicare	$1,951.11
Rate for Payer: Humana Medicare	$1,951.11
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,951.11
Rate for Payer: Ohana Health Plan Medicaid	$2,146.22
Rate for Payer: Ohana Health Plan Medicare	$1,951.11
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,951.11
Rate for Payer: University Health Alliance Commercial	$5,160.40

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM

Facility

$5,509.00

Service Code	CPT 11426
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$3,431.47
Rate for Payer: AlohaCare Medicare	$3,431.47
Rate for Payer: Devoted Health Medicare	$3,774.62
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	$3,431.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,431.47
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,431.47
Rate for Payer: Ohana Health Plan Medicaid	$3,774.62
Rate for Payer: Ohana Health Plan Medicare	$3,431.47
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,431.47
Rate for Payer: University Health Alliance Commercial	$5,160.40

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM

Facility

$4,035.20

Service Code	CPT 11401
Hospital Revenue Code	360
Min. Negotiated Rate	$56.58
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Devoted Health Medicare	$528.25
Rate for Payer: Hawaii Medical Service Association Commercial	$600.29
Rate for Payer: Hawaii Medical Service Association Medicare	$480.23
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicaid	$56.58
Rate for Payer: UnitedHealthcare Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$4,035.20

Know your out-of-pocket cost for care.

All Charges