Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

IFOSFAMIDE 3 G/60ML IV (WET SOLR VIAL) [43010249]

Facility

$194.00

Service Code	HCPCS J9208
Hospital Revenue Code	636
Min. Negotiated Rate	$23.50
Max. Negotiated Rate	$188.18
Rate for Payer: Cash Price	$116.40
Rate for Payer: Cash Price	$69.00
Rate for Payer: Cash Price	$69.00
Rate for Payer: Cash Price	$116.40
Rate for Payer: Hawaii Medical Service Association ABD	$23.50
Rate for Payer: Hawaii Medical Service Association ABD	$23.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.50
Rate for Payer: Hawaii Western Management Group Commercial	$109.25
Rate for Payer: Hawaii Western Management Group Commercial	$184.30
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Kaiser Permanente Commercial	$122.22
Rate for Payer: Kaiser Permanente Commercial	$72.45
Rate for Payer: Kaiser Permanente Medicaid	$58.65
Rate for Payer: Kaiser Permanente Medicaid	$98.94
Rate for Payer: MDX Hawaii PPO	$111.55
Rate for Payer: MDX Hawaii PPO	$188.18
Rate for Payer: UnitedHealthcare Medicaid	$116.40
Rate for Payer: UnitedHealthcare Medicaid	$69.00
Rate for Payer: University Health Alliance Commercial	$141.41
Rate for Payer: University Health Alliance Commercial	$83.82

IFOSFAMIDE 3 G/60ML IV (WET SOLR VIAL) [43010249]

Facility

$115.00

Service Code	HCPCS J9208
Hospital Revenue Code	250
Min. Negotiated Rate	$97.75
Max. Negotiated Rate	$111.55
Rate for Payer: Cash Price	$69.00
Rate for Payer: Cash Price	$116.40
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: MDX Hawaii PPO	$111.55
Rate for Payer: MDX Hawaii PPO	$188.18

IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION [10249]

Facility

$194.00

Service Code	HCPCS J9208
Hospital Revenue Code	250
Min. Negotiated Rate	$164.90
Max. Negotiated Rate	$188.18
Rate for Payer: Cash Price	$116.40
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: MDX Hawaii PPO	$188.18

IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION [10249]

Facility

$194.00

Service Code	HCPCS J9208
Hospital Revenue Code	636
Min. Negotiated Rate	$23.50
Max. Negotiated Rate	$188.18
Rate for Payer: Cash Price	$116.40
Rate for Payer: Cash Price	$116.40
Rate for Payer: Hawaii Medical Service Association ABD	$23.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.50
Rate for Payer: Hawaii Western Management Group Commercial	$184.30
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: Kaiser Permanente Commercial	$122.22
Rate for Payer: Kaiser Permanente Medicaid	$98.94
Rate for Payer: MDX Hawaii PPO	$188.18
Rate for Payer: UnitedHealthcare Medicaid	$116.40
Rate for Payer: University Health Alliance Commercial	$141.41

ILIAC EXTENDER ENDOPROSTHESIS

Facility

$6,200.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,162.00
Max. Negotiated Rate	$6,014.00
Rate for Payer: Cash Price	$3,720.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,340.00
Rate for Payer: Health Management Network Commercial	$5,270.00
Rate for Payer: Kaiser Permanente Commercial	$3,906.00
Rate for Payer: Kaiser Permanente Medicaid	$3,162.00
Rate for Payer: MDX Hawaii PPO	$6,014.00
Rate for Payer: University Health Alliance Commercial	$3,472.00

ILIAC EXTENDER ENDOPROSTHESIS

Facility

$6,200.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,472.00
Max. Negotiated Rate	$6,014.00
Rate for Payer: Cash Price	$3,720.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,340.00
Rate for Payer: Health Management Network Commercial	$5,270.00
Rate for Payer: MDX Hawaii PPO	$6,014.00
Rate for Payer: University Health Alliance Commercial	$3,472.00

ILIVIA 7 DEFIBRILLATOR 404625

Facility

$33,900.00

Service Code	HCPCS C1722
Hospital Revenue Code	275
Min. Negotiated Rate	$17,289.00
Max. Negotiated Rate	$32,883.00
Rate for Payer: Cash Price	$20,340.00
Rate for Payer: Hawaii Western Management Group Commercial	$23,730.00
Rate for Payer: Health Management Network Commercial	$28,815.00
Rate for Payer: Kaiser Permanente Commercial	$21,357.00
Rate for Payer: Kaiser Permanente Medicaid	$17,289.00
Rate for Payer: MDX Hawaii PPO	$32,883.00
Rate for Payer: University Health Alliance Commercial	$18,984.00

ILIVIA 7 DEFIBRILLATOR 404625

Facility

$33,900.00

Service Code	HCPCS C1722
Hospital Revenue Code	275
Min. Negotiated Rate	$18,984.00
Max. Negotiated Rate	$32,883.00
Rate for Payer: Cash Price	$20,340.00
Rate for Payer: Hawaii Western Management Group Commercial	$23,730.00
Rate for Payer: Health Management Network Commercial	$28,815.00
Rate for Payer: MDX Hawaii PPO	$32,883.00
Rate for Payer: University Health Alliance Commercial	$18,984.00

IMIPENEM-CILASTATIN 500 MG/10ML IV (WET SOLR VIAL) [4309603]

Facility

$42.00

Service Code	HCPCS J0743
Hospital Revenue Code	250
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cash Price	$63.60
Rate for Payer: Cash Price	$49.80
Rate for Payer: Cash Price	$54.00
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: MDX Hawaii PPO	$80.51
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: MDX Hawaii PPO	$102.82

IMIPENEM-CILASTATIN 500 MG/10ML IV (WET SOLR VIAL) [4309603]

Facility

$90.00

Service Code	HCPCS J0743
Hospital Revenue Code	636
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cash Price	$63.60
Rate for Payer: Cash Price	$49.80
Rate for Payer: Cash Price	$49.80
Rate for Payer: Cash Price	$63.60
Rate for Payer: Cash Price	$54.00
Rate for Payer: Hawaii Medical Service Association ABD	$6.97
Rate for Payer: Hawaii Medical Service Association ABD	$6.97
Rate for Payer: Hawaii Medical Service Association ABD	$6.97
Rate for Payer: Hawaii Medical Service Association ABD	$6.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.97
Rate for Payer: Hawaii Western Management Group Commercial	$100.70
Rate for Payer: Hawaii Western Management Group Commercial	$85.50
Rate for Payer: Hawaii Western Management Group Commercial	$78.85
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Kaiser Permanente Commercial	$52.29
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Commercial	$66.78
Rate for Payer: Kaiser Permanente Commercial	$26.46
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: Kaiser Permanente Medicaid	$42.33
Rate for Payer: Kaiser Permanente Medicaid	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: MDX Hawaii PPO	$80.51
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: UnitedHealthcare Medicaid	$49.80
Rate for Payer: UnitedHealthcare Medicaid	$25.20
Rate for Payer: UnitedHealthcare Medicaid	$63.60
Rate for Payer: UnitedHealthcare Medicaid	$54.00
Rate for Payer: University Health Alliance Commercial	$30.61
Rate for Payer: University Health Alliance Commercial	$65.60
Rate for Payer: University Health Alliance Commercial	$60.50
Rate for Payer: University Health Alliance Commercial	$77.26

IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]

Facility

$83.00

Service Code	HCPCS J0743
Hospital Revenue Code	636
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$49.80
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$49.80
Rate for Payer: Hawaii Medical Service Association ABD	$6.97
Rate for Payer: Hawaii Medical Service Association ABD	$6.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.97
Rate for Payer: Hawaii Western Management Group Commercial	$85.50
Rate for Payer: Hawaii Western Management Group Commercial	$78.85
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$52.29
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$42.33
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: MDX Hawaii PPO	$80.51
Rate for Payer: UnitedHealthcare Medicaid	$49.80
Rate for Payer: UnitedHealthcare Medicaid	$54.00
Rate for Payer: University Health Alliance Commercial	$60.50
Rate for Payer: University Health Alliance Commercial	$65.60

IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]

Facility

$83.00

Service Code	HCPCS J0743
Hospital Revenue Code	250
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$49.80
Rate for Payer: Cash Price	$54.00
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: MDX Hawaii PPO	$80.51

IMMOBILIZER KNEE 16

Facility

$141.00

Service Code	HCPCS L1830
Hospital Revenue Code	274
Min. Negotiated Rate	$71.91
Max. Negotiated Rate	$136.77
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cash Price	$84.60
Rate for Payer: Hawaii Western Management Group Commercial	$98.70
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: Kaiser Permanente Commercial	$88.83
Rate for Payer: Kaiser Permanente Medicaid	$71.91
Rate for Payer: MDX Hawaii PPO	$136.77
Rate for Payer: UnitedHealthcare Medicaid	$87.51
Rate for Payer: University Health Alliance Commercial	$78.96

IMMOBILIZER KNEE 16

Facility

$141.00

Service Code	HCPCS L1830
Hospital Revenue Code	274
Min. Negotiated Rate	$78.96
Max. Negotiated Rate	$136.77
Rate for Payer: Cash Price	$84.60
Rate for Payer: Hawaii Western Management Group Commercial	$98.70
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: MDX Hawaii PPO	$136.77
Rate for Payer: University Health Alliance Commercial	$78.96

IMMOBILIZER KNEE 20

Facility

$87.00

Service Code	HCPCS L1830
Hospital Revenue Code	274
Min. Negotiated Rate	$44.37
Max. Negotiated Rate	$87.51
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cash Price	$52.20
Rate for Payer: Hawaii Western Management Group Commercial	$60.90
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$54.81
Rate for Payer: Kaiser Permanente Medicaid	$44.37
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: UnitedHealthcare Medicaid	$87.51
Rate for Payer: University Health Alliance Commercial	$48.72

IMMOBILIZER KNEE 20

Facility

$87.00

Service Code	HCPCS L1830
Hospital Revenue Code	274
Min. Negotiated Rate	$48.72
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Hawaii Western Management Group Commercial	$60.90
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: University Health Alliance Commercial	$48.72

IMMOBILIZER KNEE 22

Facility

$103.00

Service Code	HCPCS L1830
Hospital Revenue Code	274
Min. Negotiated Rate	$52.53
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$61.80
Rate for Payer: Cash Price	$61.80
Rate for Payer: Hawaii Western Management Group Commercial	$72.10
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Kaiser Permanente Commercial	$64.89
Rate for Payer: Kaiser Permanente Medicaid	$52.53
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: UnitedHealthcare Medicaid	$87.51
Rate for Payer: University Health Alliance Commercial	$57.68

IMMOBILIZER KNEE 22

Facility

$103.00

Service Code	HCPCS L1830
Hospital Revenue Code	274
Min. Negotiated Rate	$57.68
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$61.80
Rate for Payer: Hawaii Western Management Group Commercial	$72.10
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: University Health Alliance Commercial	$57.68

IMMOBILIZER KNEE 24

Facility

$94.00

Service Code	HCPCS L1830
Hospital Revenue Code	274
Min. Negotiated Rate	$52.64
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$56.40
Rate for Payer: Hawaii Western Management Group Commercial	$65.80
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: MDX Hawaii PPO	$91.18
Rate for Payer: University Health Alliance Commercial	$52.64

IMMOBILIZER KNEE 24

Facility

$94.00

Service Code	HCPCS L1830
Hospital Revenue Code	274
Min. Negotiated Rate	$47.94
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$56.40
Rate for Payer: Cash Price	$56.40
Rate for Payer: Hawaii Western Management Group Commercial	$65.80
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Kaiser Permanente Commercial	$59.22
Rate for Payer: Kaiser Permanente Medicaid	$47.94
Rate for Payer: MDX Hawaii PPO	$91.18
Rate for Payer: UnitedHealthcare Medicaid	$87.51
Rate for Payer: University Health Alliance Commercial	$52.64

IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)

Facility

$2,837.00

Service Code	CPT 90471
Hospital Revenue Code	360
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$85.06
Rate for Payer: AlohaCare Medicare	$85.06
Rate for Payer: Devoted Health Medicare	$93.57
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Commercial	$106.33
Rate for Payer: Hawaii Medical Service Association Medicare	$85.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.56
Rate for Payer: Humana Medicare	$85.06
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$85.06
Rate for Payer: Ohana Health Plan Medicaid	$93.57
Rate for Payer: Ohana Health Plan Medicare	$85.06
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$85.06

IMPELLA CP

Facility

$56,000.00

Hospital Revenue Code	278
Min. Negotiated Rate	$31,360.00
Max. Negotiated Rate	$54,320.00
Rate for Payer: Cash Price	$33,600.00
Rate for Payer: Hawaii Western Management Group Commercial	$39,200.00
Rate for Payer: Health Management Network Commercial	$47,600.00
Rate for Payer: MDX Hawaii PPO	$54,320.00
Rate for Payer: University Health Alliance Commercial	$31,360.00

IMPELLA CP

Facility

$56,000.00

Hospital Revenue Code	278
Min. Negotiated Rate	$28,560.00
Max. Negotiated Rate	$54,320.00
Rate for Payer: Cash Price	$33,600.00
Rate for Payer: Hawaii Western Management Group Commercial	$39,200.00
Rate for Payer: Health Management Network Commercial	$47,600.00
Rate for Payer: Kaiser Permanente Commercial	$35,280.00
Rate for Payer: Kaiser Permanente Medicaid	$28,560.00
Rate for Payer: MDX Hawaii PPO	$54,320.00
Rate for Payer: University Health Alliance Commercial	$31,360.00

IMPELLA LP COMPANION SHEATH 7F

Facility

$875.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$831.25
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$551.25
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$637.79

IMPELLA LP COMPANION SHEATH 7F

Facility

$875.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$743.75
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75

Know your out-of-pocket cost for care.

All Charges