Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HEMOST PARTICLES 3G

Facility

$812.00

Hospital Revenue Code	272
Min. Negotiated Rate	$690.20
Max. Negotiated Rate	$787.64
Rate for Payer: Cash Price	$487.20
Rate for Payer: Health Management Network Commercial	$690.20
Rate for Payer: MDX Hawaii PPO	$787.64

HEMOST SPRAY 10

Facility

$5,000.00

Service Code	HCPCS C1052
Hospital Revenue Code	272
Min. Negotiated Rate	$4,250.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00

HEMOST SPRAY 10

Facility

$5,000.00

Service Code	HCPCS C1052
Hospital Revenue Code	272
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,750.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$3,150.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$3,644.50

HEMOST SPRAY 7

Facility

$5,000.00

Service Code	HCPCS C1052
Hospital Revenue Code	272
Min. Negotiated Rate	$4,250.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00

HEMOST SPRAY 7

Facility

$5,000.00

Service Code	HCPCS C1052
Hospital Revenue Code	272
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,750.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$3,150.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$3,644.50

HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION [10177]

Facility

$32.00

Service Code	HCPCS J1644
Hospital Revenue Code	250
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: MDX Hawaii PPO	$31.04

HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION [10177]

Facility

$32.00

Service Code	HCPCS J1644
Hospital Revenue Code	636
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$19.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Western Management Group Commercial	$30.40
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Kaiser Permanente Commercial	$20.16
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: UnitedHealthcare Medicaid	$19.20
Rate for Payer: University Health Alliance Commercial	$23.32

HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]

Facility

$17.00

Service Code	HCPCS J1644
Hospital Revenue Code	636
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$10.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Kaiser Permanente Commercial	$9.45
Rate for Payer: Kaiser Permanente Commercial	$10.71
Rate for Payer: Kaiser Permanente Commercial	$19.53
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: UnitedHealthcare Medicaid	$9.00
Rate for Payer: UnitedHealthcare Medicaid	$18.60
Rate for Payer: UnitedHealthcare Medicaid	$10.20
Rate for Payer: University Health Alliance Commercial	$22.60
Rate for Payer: University Health Alliance Commercial	$10.93
Rate for Payer: University Health Alliance Commercial	$12.39

HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]

Facility

$31.00

Service Code	HCPCS J1644
Hospital Revenue Code	250
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: MDX Hawaii PPO	$16.49

HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV [166269]

Facility

$51.00

Service Code	HCPCS J1644
Hospital Revenue Code	636
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cash Price	$30.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$32.13
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: UnitedHealthcare Medicaid	$30.60
Rate for Payer: University Health Alliance Commercial	$37.17

HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV [166269]

Facility

$51.00

Service Code	HCPCS J1644
Hospital Revenue Code	250
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: MDX Hawaii PPO	$49.47

HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]

Facility

$18.00

Service Code	HCPCS J1644
Hospital Revenue Code	250
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$17.46

HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]

Facility

$18.00

Service Code	HCPCS J1644
Hospital Revenue Code	636
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$10.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$11.34
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: University Health Alliance Commercial	$13.12

HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV [166266]

Facility

$27.00

Service Code	HCPCS J1644
Hospital Revenue Code	250
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: MDX Hawaii PPO	$26.19

HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV [166266]

Facility

$27.00

Service Code	HCPCS J1644
Hospital Revenue Code	636
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$16.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$17.01
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: UnitedHealthcare Medicaid	$16.20
Rate for Payer: University Health Alliance Commercial	$19.68

HEPARIN, PORCINE (PF) 1,000 UNIT/ML INJECTION SOLUTION [197315]

Facility

$50.00

Service Code	HCPCS J1644
Hospital Revenue Code	636
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$48.50
Rate for Payer: Cash Price	$30.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Western Management Group Commercial	$47.50
Rate for Payer: Health Management Network Commercial	$42.50
Rate for Payer: Kaiser Permanente Commercial	$31.50
Rate for Payer: Kaiser Permanente Medicaid	$25.50
Rate for Payer: MDX Hawaii PPO	$48.50
Rate for Payer: UnitedHealthcare Medicaid	$30.00
Rate for Payer: University Health Alliance Commercial	$36.45

HEPARIN, PORCINE (PF) 1,000 UNIT/ML INJECTION SOLUTION [197315]

Facility

$50.00

Service Code	HCPCS J1644
Hospital Revenue Code	250
Min. Negotiated Rate	$42.50
Max. Negotiated Rate	$48.50
Rate for Payer: Cash Price	$30.00
Rate for Payer: Health Management Network Commercial	$42.50
Rate for Payer: MDX Hawaii PPO	$48.50

HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV [166267]

Facility

$35.00

Service Code	HCPCS J1644
Hospital Revenue Code	250
Min. Negotiated Rate	$29.75
Max. Negotiated Rate	$33.95
Rate for Payer: Cash Price	$21.00
Rate for Payer: Cash Price	$16.80
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: MDX Hawaii PPO	$33.95
Rate for Payer: MDX Hawaii PPO	$27.16

HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV [166267]

Facility

$28.00

Service Code	HCPCS J1644
Hospital Revenue Code	636
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$21.00
Rate for Payer: Cash Price	$21.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Hawaii Western Management Group Commercial	$33.25
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: Kaiser Permanente Commercial	$17.64
Rate for Payer: Kaiser Permanente Commercial	$22.05
Rate for Payer: Kaiser Permanente Medicaid	$17.85
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: MDX Hawaii PPO	$33.95
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: UnitedHealthcare Medicaid	$16.80
Rate for Payer: UnitedHealthcare Medicaid	$21.00
Rate for Payer: University Health Alliance Commercial	$20.41
Rate for Payer: University Health Alliance Commercial	$25.51

HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS

Facility

$2,539.97

Service Code	APR-DRG 2791
Min. Negotiated Rate	$2,539.97
Max. Negotiated Rate	$2,539.97
Rate for Payer: AlohaCare Medicaid	$2,539.97
Rate for Payer: Hawaii Medical Service Association ABD	$2,539.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,539.97
Rate for Payer: Kaiser Permanente Medicaid	$2,539.97
Rate for Payer: Ohana Health Plan Medicaid	$2,539.97
Rate for Payer: UnitedHealthcare Medicaid	$2,539.97

HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS

Facility

$3,283.56

Service Code	APR-DRG 2792
Min. Negotiated Rate	$3,283.56
Max. Negotiated Rate	$3,283.56
Rate for Payer: AlohaCare Medicaid	$3,283.56
Rate for Payer: Hawaii Medical Service Association ABD	$3,283.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,283.56
Rate for Payer: Kaiser Permanente Medicaid	$3,283.56
Rate for Payer: Ohana Health Plan Medicaid	$3,283.56
Rate for Payer: UnitedHealthcare Medicaid	$3,283.56

HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS

Facility

$10,121.38

Service Code	APR-DRG 2794
Min. Negotiated Rate	$10,121.38
Max. Negotiated Rate	$10,121.38
Rate for Payer: AlohaCare Medicaid	$10,121.38
Rate for Payer: Hawaii Medical Service Association ABD	$10,121.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,121.38
Rate for Payer: Kaiser Permanente Medicaid	$10,121.38
Rate for Payer: Ohana Health Plan Medicaid	$10,121.38
Rate for Payer: UnitedHealthcare Medicaid	$10,121.38

HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS

Facility

$4,858.81

Service Code	APR-DRG 2793
Min. Negotiated Rate	$4,858.81
Max. Negotiated Rate	$4,858.81
Rate for Payer: AlohaCare Medicaid	$4,858.81
Rate for Payer: Hawaii Medical Service Association ABD	$4,858.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,858.81
Rate for Payer: Kaiser Permanente Medicaid	$4,858.81
Rate for Payer: Ohana Health Plan Medicaid	$4,858.81
Rate for Payer: UnitedHealthcare Medicaid	$4,858.81

HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE [203251]

Facility

$155.00

Service Code	HCPCS 90632
Hospital Revenue Code	636
Min. Negotiated Rate	$71.61
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$93.00
Rate for Payer: Cash Price	$93.00
Rate for Payer: Hawaii Medical Service Association ABD	$71.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$71.61
Rate for Payer: Hawaii Western Management Group Commercial	$147.25
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Kaiser Permanente Commercial	$97.65
Rate for Payer: Kaiser Permanente Medicaid	$79.05
Rate for Payer: MDX Hawaii PPO	$150.35
Rate for Payer: UnitedHealthcare Medicaid	$93.00
Rate for Payer: University Health Alliance Commercial	$112.98

HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE [203251]

Facility

$155.00

Service Code	HCPCS 90632
Hospital Revenue Code	250
Min. Negotiated Rate	$131.75
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$93.00
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: MDX Hawaii PPO	$150.35

Know your out-of-pocket cost for care.

All Charges