Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

ATORVASTATIN 80 MG TABLET [28645]

Facility

$7.00

Service Code	NDC 68084059025
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

ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [14953]

Facility

$1,879.00

Service Code	NDC 65162069388
Hospital Revenue Code	250
Min. Negotiated Rate	$1,597.15
Max. Negotiated Rate	$1,822.63
Rate for Payer: Cash Price	$1,127.40
Rate for Payer: Health Management Network Commercial	$1,597.15
Rate for Payer: MDX Hawaii PPO	$1,822.63

ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [14953]

Facility

$1,879.00

Service Code	NDC 65162069388
Hospital Revenue Code	637
Min. Negotiated Rate	$958.29
Max. Negotiated Rate	$1,822.63
Rate for Payer: Cash Price	$1,127.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,785.05
Rate for Payer: Health Management Network Commercial	$1,597.15
Rate for Payer: Kaiser Permanente Commercial	$1,183.77
Rate for Payer: Kaiser Permanente Medicaid	$958.29
Rate for Payer: MDX Hawaii PPO	$1,822.63
Rate for Payer: University Health Alliance Commercial	$1,369.60

ATROPINE 0.1 MG/ML INJECTION SYRINGE [137071]

Facility

$49.00

Service Code	HCPCS J0461
Hospital Revenue Code	250
Min. Negotiated Rate	$41.65
Max. Negotiated Rate	$47.53
Rate for Payer: Cash Price	$29.40
Rate for Payer: Cash Price	$26.40
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: MDX Hawaii PPO	$47.53
Rate for Payer: MDX Hawaii PPO	$42.68

ATROPINE 0.1 MG/ML INJECTION SYRINGE [137071]

Facility

$44.00

Service Code	HCPCS J0461
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$42.68
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cash Price	$29.40
Rate for Payer: Cash Price	$29.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.07
Rate for Payer: Hawaii Medical Service Association ABD	$0.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.07
Rate for Payer: Hawaii Western Management Group Commercial	$41.80
Rate for Payer: Hawaii Western Management Group Commercial	$46.55
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: Kaiser Permanente Commercial	$30.87
Rate for Payer: Kaiser Permanente Commercial	$27.72
Rate for Payer: Kaiser Permanente Medicaid	$22.44
Rate for Payer: Kaiser Permanente Medicaid	$24.99
Rate for Payer: MDX Hawaii PPO	$47.53
Rate for Payer: MDX Hawaii PPO	$42.68
Rate for Payer: UnitedHealthcare Medicaid	$26.40
Rate for Payer: UnitedHealthcare Medicaid	$29.40
Rate for Payer: University Health Alliance Commercial	$35.72
Rate for Payer: University Health Alliance Commercial	$32.07

ATROPINE 0.4 MG/ML INTRAVENOUS SOLUTION [177367]

Facility

$34.00

Service Code	HCPCS J0461
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$20.40
Rate for Payer: Cash Price	$20.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.07
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$21.42
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: University Health Alliance Commercial	$24.78

ATROPINE 0.4 MG/ML INTRAVENOUS SOLUTION [177367]

Facility

$34.00

Service Code	HCPCS J0461
Hospital Revenue Code	250
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$20.40
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: MDX Hawaii PPO	$32.98

ATROPINE 1 % EYE DROPS [736]

Facility

$120.00

Service Code	NDC 60219174802
Hospital Revenue Code	250
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: MDX Hawaii PPO	$116.40

ATROPINE 1 % EYE DROPS [736]

Facility

$120.00

Service Code	NDC 60219174802
Hospital Revenue Code	637
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Hawaii Western Management Group Commercial	$114.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: University Health Alliance Commercial	$87.47

ATROPINE 1 % EYE OINTMENT [735]

Facility

$65.00

Service Code	NDC 24208082555
Hospital Revenue Code	250
Min. Negotiated Rate	$55.25
Max. Negotiated Rate	$63.05
Rate for Payer: Cash Price	$39.00
Rate for Payer: Health Management Network Commercial	$55.25
Rate for Payer: MDX Hawaii PPO	$63.05

ATROPINE 1 % EYE OINTMENT [735]

Facility

$65.00

Service Code	NDC 24208082555
Hospital Revenue Code	637
Min. Negotiated Rate	$33.15
Max. Negotiated Rate	$63.05
Rate for Payer: Cash Price	$39.00
Rate for Payer: Hawaii Western Management Group Commercial	$61.75
Rate for Payer: Health Management Network Commercial	$55.25
Rate for Payer: Kaiser Permanente Commercial	$40.95
Rate for Payer: Kaiser Permanente Medicaid	$33.15
Rate for Payer: MDX Hawaii PPO	$63.05
Rate for Payer: University Health Alliance Commercial	$47.38

AT X65 SIMPLICITY SET (BT2000)

Facility

$424.00

Hospital Revenue Code	272
Min. Negotiated Rate	$360.40
Max. Negotiated Rate	$411.28
Rate for Payer: Cash Price	$254.40
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: MDX Hawaii PPO	$411.28

AT X65 SIMPLICITY SET (BT2000)

Facility

$424.00

Hospital Revenue Code	272
Min. Negotiated Rate	$216.24
Max. Negotiated Rate	$411.28
Rate for Payer: Cash Price	$254.40
Rate for Payer: Hawaii Western Management Group Commercial	$402.80
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: Kaiser Permanente Commercial	$267.12
Rate for Payer: Kaiser Permanente Medicaid	$216.24
Rate for Payer: MDX Hawaii PPO	$411.28
Rate for Payer: University Health Alliance Commercial	$309.05

AUGMENT HALF BLOCK 5545-A-101

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,188.88
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

AUGMENT HALF BLOCK 5545-A-101

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,082.73
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Kaiser Permanente Commercial	$1,337.49
Rate for Payer: Kaiser Permanente Medicaid	$1,082.73
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

AUTOLOGOUS BONE MARROW TRANSPLANT OR T-CELL IMMUNOTHERAPY

Facility

$20,278.64

Service Code	APR-DRG 0081
Min. Negotiated Rate	$20,278.64
Max. Negotiated Rate	$20,278.64
Rate for Payer: AlohaCare Medicaid	$20,278.64
Rate for Payer: Hawaii Medical Service Association ABD	$20,278.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20,278.64
Rate for Payer: Kaiser Permanente Medicaid	$20,278.64
Rate for Payer: Ohana Health Plan Medicaid	$20,278.64
Rate for Payer: UnitedHealthcare Medicaid	$20,278.64

AUTOLOGOUS BONE MARROW TRANSPLANT OR T-CELL IMMUNOTHERAPY

Facility

$33,307.87

Service Code	APR-DRG 0083
Min. Negotiated Rate	$33,307.87
Max. Negotiated Rate	$33,307.87
Rate for Payer: AlohaCare Medicaid	$33,307.87
Rate for Payer: Hawaii Medical Service Association ABD	$33,307.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$33,307.87
Rate for Payer: Kaiser Permanente Medicaid	$33,307.87
Rate for Payer: Ohana Health Plan Medicaid	$33,307.87
Rate for Payer: UnitedHealthcare Medicaid	$33,307.87

AUTOLOGOUS BONE MARROW TRANSPLANT OR T-CELL IMMUNOTHERAPY

Facility

$50,340.78

Service Code	APR-DRG 0084
Min. Negotiated Rate	$50,340.78
Max. Negotiated Rate	$50,340.78
Rate for Payer: AlohaCare Medicaid	$50,340.78
Rate for Payer: Hawaii Medical Service Association ABD	$50,340.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50,340.78
Rate for Payer: Kaiser Permanente Medicaid	$50,340.78
Rate for Payer: Ohana Health Plan Medicaid	$50,340.78
Rate for Payer: UnitedHealthcare Medicaid	$50,340.78

AUTOLOGOUS BONE MARROW TRANSPLANT OR T-CELL IMMUNOTHERAPY

Facility

$25,478.59

Service Code	APR-DRG 0082
Min. Negotiated Rate	$25,478.59
Max. Negotiated Rate	$25,478.59
Rate for Payer: AlohaCare Medicaid	$25,478.59
Rate for Payer: Hawaii Medical Service Association ABD	$25,478.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$25,478.59
Rate for Payer: Kaiser Permanente Medicaid	$25,478.59
Rate for Payer: Ohana Health Plan Medicaid	$25,478.59
Rate for Payer: UnitedHealthcare Medicaid	$25,478.59

AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC

Facility

$234,409.56

Service Code	MSDRG 016
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$234,409.56
Rate for Payer: AlohaCare Medicare	$67,445.92
Rate for Payer: Devoted Health Medicare	$74,190.51
Rate for Payer: Hawaii Medical Service Association Commercial	$234,409.56
Rate for Payer: Hawaii Medical Service Association Medicare	$67,445.92
Rate for Payer: Humana Medicare	$67,445.92
Rate for Payer: Kaiser Permanente Commercial	$102,287.32
Rate for Payer: Kaiser Permanente Medicare	$67,445.92
Rate for Payer: Ohana Health Plan Medicare	$67,445.92
Rate for Payer: UnitedHealthcare Medicare	$67,445.92
Rate for Payer: University Health Alliance Commercial	$10,400.00

AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC

Facility

$234,409.56

Service Code	MSDRG 017
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$234,409.56
Rate for Payer: AlohaCare Medicare	$61,788.37
Rate for Payer: Devoted Health Medicare	$67,967.21
Rate for Payer: Hawaii Medical Service Association Commercial	$234,409.56
Rate for Payer: Hawaii Medical Service Association Medicare	$61,788.37
Rate for Payer: Humana Medicare	$61,788.37
Rate for Payer: Kaiser Permanente Commercial	$83,460.68
Rate for Payer: Kaiser Permanente Medicare	$61,788.37
Rate for Payer: Ohana Health Plan Medicare	$61,788.37
Rate for Payer: UnitedHealthcare Medicare	$61,788.37
Rate for Payer: University Health Alliance Commercial	$10,400.00

AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION [137797]

Facility

$3,770.00

Service Code	HCPCS J9023
Hospital Revenue Code	250
Min. Negotiated Rate	$3,204.50
Max. Negotiated Rate	$3,656.90
Rate for Payer: Cash Price	$2,262.00
Rate for Payer: Cash Price	$4,862.40
Rate for Payer: Health Management Network Commercial	$3,204.50
Rate for Payer: Health Management Network Commercial	$6,888.40
Rate for Payer: MDX Hawaii PPO	$3,656.90
Rate for Payer: MDX Hawaii PPO	$7,860.88

AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION [137797]

Facility

$8,104.00

Service Code	HCPCS J9023
Hospital Revenue Code	636
Min. Negotiated Rate	$100.30
Max. Negotiated Rate	$7,860.88
Rate for Payer: Devoted Health Medicare	$116.11
Rate for Payer: AlohaCare Medicaid	$105.55
Rate for Payer: AlohaCare Medicaid	$105.55
Rate for Payer: AlohaCare Medicare	$105.55
Rate for Payer: AlohaCare Medicare	$105.55
Rate for Payer: Cash Price	$4,862.40
Rate for Payer: Cash Price	$4,862.40
Rate for Payer: Cash Price	$2,262.00
Rate for Payer: Cash Price	$2,262.00
Rate for Payer: Devoted Health Medicare	$116.11
Rate for Payer: Hawaii Medical Service Association ABD	$100.30
Rate for Payer: Hawaii Medical Service Association ABD	$100.30
Rate for Payer: Hawaii Medical Service Association Commercial	$131.94
Rate for Payer: Hawaii Medical Service Association Commercial	$131.94
Rate for Payer: Hawaii Medical Service Association Medicare	$105.55
Rate for Payer: Hawaii Medical Service Association Medicare	$105.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$100.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$100.30
Rate for Payer: Hawaii Western Management Group Commercial	$3,581.50
Rate for Payer: Hawaii Western Management Group Commercial	$7,698.80
Rate for Payer: Health Management Network Commercial	$3,204.50
Rate for Payer: Health Management Network Commercial	$6,888.40
Rate for Payer: Humana Medicare	$105.55
Rate for Payer: Humana Medicare	$105.55
Rate for Payer: Kaiser Permanente Commercial	$2,375.10
Rate for Payer: Kaiser Permanente Commercial	$5,105.52
Rate for Payer: Kaiser Permanente Medicaid	$4,133.04
Rate for Payer: Kaiser Permanente Medicaid	$1,922.70
Rate for Payer: Kaiser Permanente Medicare	$105.55
Rate for Payer: Kaiser Permanente Medicare	$105.55
Rate for Payer: MDX Hawaii PPO	$7,860.88
Rate for Payer: MDX Hawaii PPO	$3,656.90
Rate for Payer: Ohana Health Plan Medicaid	$116.11
Rate for Payer: Ohana Health Plan Medicaid	$116.11
Rate for Payer: Ohana Health Plan Medicare	$105.55
Rate for Payer: Ohana Health Plan Medicare	$105.55
Rate for Payer: UnitedHealthcare Medicaid	$4,862.40
Rate for Payer: UnitedHealthcare Medicaid	$2,262.00
Rate for Payer: UnitedHealthcare Medicare	$105.55
Rate for Payer: UnitedHealthcare Medicare	$105.55
Rate for Payer: University Health Alliance Commercial	$5,907.01
Rate for Payer: University Health Alliance Commercial	$2,747.95

AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 11732
Hospital Revenue Code	360
Min. Negotiated Rate	$21.92
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$21.92

AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE

Facility

$4,035.20

Service Code	CPT 11730
Hospital Revenue Code	360
Min. Negotiated Rate	$42.41
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Devoted Health Medicare	$260.72
Rate for Payer: Hawaii Medical Service Association Commercial	$296.27
Rate for Payer: Hawaii Medical Service Association Medicare	$237.02
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicaid	$42.41
Rate for Payer: UnitedHealthcare Medicare	$237.02
Rate for Payer: University Health Alliance Commercial	$4,035.20

Know your out-of-pocket cost for care.

All Charges