Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

INSULIN LISPRO 100 UNIT/ML IJ SOLN (ADMELOG) [440184255]

Facility

$118.00

Service Code	HCPCS J1817
Hospital Revenue Code	636
Min. Negotiated Rate	$3.24
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$70.80
Rate for Payer: Cash Price	$70.80
Rate for Payer: Hawaii Medical Service Association ABD	$3.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.24
Rate for Payer: Hawaii Western Management Group Commercial	$112.10
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Kaiser Permanente Commercial	$74.34
Rate for Payer: Kaiser Permanente Medicaid	$60.18
Rate for Payer: MDX Hawaii PPO	$114.46
Rate for Payer: UnitedHealthcare Medicaid	$70.80
Rate for Payer: University Health Alliance Commercial	$86.01

INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP [70693]

Facility

$154.00

Service Code	HCPCS J1815
Hospital Revenue Code	250
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$149.38
Rate for Payer: Cash Price	$92.40
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: MDX Hawaii PPO	$149.38

INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP [70693]

Facility

$154.00

Service Code	HCPCS J1815
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$149.38
Rate for Payer: Cash Price	$92.40
Rate for Payer: Cash Price	$92.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Western Management Group Commercial	$146.30
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: Kaiser Permanente Commercial	$97.02
Rate for Payer: Kaiser Permanente Medicaid	$78.54
Rate for Payer: MDX Hawaii PPO	$149.38
Rate for Payer: UnitedHealthcare Medicaid	$92.40
Rate for Payer: University Health Alliance Commercial	$112.25

INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN [124854]

Facility

$85.00

Service Code	HCPCS J1815
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$82.45
Rate for Payer: Cash Price	$51.00
Rate for Payer: Cash Price	$51.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Western Management Group Commercial	$80.75
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Kaiser Permanente Commercial	$53.55
Rate for Payer: Kaiser Permanente Medicaid	$43.35
Rate for Payer: MDX Hawaii PPO	$82.45
Rate for Payer: UnitedHealthcare Medicaid	$51.00
Rate for Payer: University Health Alliance Commercial	$61.96

INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN [124854]

Facility

$85.00

Service Code	HCPCS J1815
Hospital Revenue Code	250
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$82.45
Rate for Payer: Cash Price	$51.00
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: MDX Hawaii PPO	$82.45

INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION [10284]

Facility

$116.00

Service Code	HCPCS J1815
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Cash Price	$69.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Western Management Group Commercial	$110.20
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: Kaiser Permanente Commercial	$73.08
Rate for Payer: Kaiser Permanente Medicaid	$59.16
Rate for Payer: MDX Hawaii PPO	$112.52
Rate for Payer: UnitedHealthcare Medicaid	$69.60
Rate for Payer: University Health Alliance Commercial	$84.55

INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION [10284]

Facility

$116.00

Service Code	HCPCS J1815
Hospital Revenue Code	250
Min. Negotiated Rate	$98.60
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: MDX Hawaii PPO	$112.52

INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION [168938]

Facility

$105.00

Service Code	NDC 00338012612
Hospital Revenue Code	250
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$101.85
Rate for Payer: Cash Price	$63.00
Rate for Payer: Health Management Network Commercial	$89.25
Rate for Payer: MDX Hawaii PPO	$101.85

INSULIN REGULAR 100 UNIT/ML SQ GLUCOSE CORRECTION SCALE [400932]

Facility

$116.00

Service Code	HCPCS J1817
Hospital Revenue Code	636
Min. Negotiated Rate	$3.24
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Cash Price	$69.60
Rate for Payer: Hawaii Medical Service Association ABD	$3.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.24
Rate for Payer: Hawaii Western Management Group Commercial	$110.20
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: Kaiser Permanente Commercial	$73.08
Rate for Payer: Kaiser Permanente Medicaid	$59.16
Rate for Payer: MDX Hawaii PPO	$112.52
Rate for Payer: UnitedHealthcare Medicaid	$69.60
Rate for Payer: University Health Alliance Commercial	$84.55

INSULIN REGULAR 100 UNIT/ML SQ GLUCOSE CORRECTION SCALE [400932]

Facility

$116.00

Service Code	HCPCS J1817
Hospital Revenue Code	250
Min. Negotiated Rate	$98.60
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: MDX Hawaii PPO	$112.52

INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION [10289]

Facility

$116.00

Service Code	HCPCS J1817
Hospital Revenue Code	250
Min. Negotiated Rate	$98.60
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Cash Price	$7.20
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$112.52

INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION [10289]

Facility

$116.00

Service Code	HCPCS J1817
Hospital Revenue Code	636
Min. Negotiated Rate	$3.24
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Cash Price	$69.60
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$7.20
Rate for Payer: Hawaii Medical Service Association ABD	$3.24
Rate for Payer: Hawaii Medical Service Association ABD	$3.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.24
Rate for Payer: Hawaii Western Management Group Commercial	$110.20
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: Kaiser Permanente Commercial	$7.56
Rate for Payer: Kaiser Permanente Commercial	$73.08
Rate for Payer: Kaiser Permanente Medicaid	$59.16
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$112.52
Rate for Payer: UnitedHealthcare Medicaid	$69.60
Rate for Payer: UnitedHealthcare Medicaid	$7.20
Rate for Payer: University Health Alliance Commercial	$8.75
Rate for Payer: University Health Alliance Commercial	$84.55

INTEGRA BILAYER MATRX #BMW2021

Facility

$7,000.00

Service Code	HCPCS C9363
Hospital Revenue Code	636
Min. Negotiated Rate	$147.01
Max. Negotiated Rate	$6,790.00
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Western Management Group Commercial	$6,650.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$4,410.00
Rate for Payer: Kaiser Permanente Medicaid	$3,570.00
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$6,790.00
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicaid	$4,200.00
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$5,102.30

INTEGRA BILAYER MATRX #BMW2021

Facility

$7,000.00

Service Code	HCPCS C9363
Hospital Revenue Code	636
Min. Negotiated Rate	$5,950.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: MDX Hawaii PPO	$6,790.00

INTEGRA BILAYER MATRX #BMW4051

Facility

$10,898.00

Service Code	HCPCS C9363
Hospital Revenue Code	636
Min. Negotiated Rate	$9,263.30
Max. Negotiated Rate	$10,571.06
Rate for Payer: Cash Price	$6,538.80
Rate for Payer: Health Management Network Commercial	$9,263.30
Rate for Payer: MDX Hawaii PPO	$10,571.06

INTEGRA BILAYER MATRX #BMW4051

Facility

$10,898.00

Service Code	HCPCS C9363
Hospital Revenue Code	636
Min. Negotiated Rate	$147.01
Max. Negotiated Rate	$10,571.06
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$6,538.80
Rate for Payer: Cash Price	$6,538.80
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Western Management Group Commercial	$10,353.10
Rate for Payer: Health Management Network Commercial	$9,263.30
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$6,865.74
Rate for Payer: Kaiser Permanente Medicaid	$5,557.98
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$10,571.06
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicaid	$6,538.80
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$7,943.55

INTEGRATED PORT ALLOX2-FH12SE

Facility

$3,300.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,683.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Kaiser Permanente Commercial	$2,079.00
Rate for Payer: Kaiser Permanente Medicaid	$1,683.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

INTEGRATED PORT ALLOX2-FH12SE

Facility

$3,300.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,848.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

INTELLIS ADAPTIVESTIM 97715

Facility

$45,900.00

Service Code	HCPCS C1820
Hospital Revenue Code	278
Min. Negotiated Rate	$25,704.00
Max. Negotiated Rate	$44,523.00
Rate for Payer: Cash Price	$27,540.00
Rate for Payer: Hawaii Western Management Group Commercial	$32,130.00
Rate for Payer: Health Management Network Commercial	$39,015.00
Rate for Payer: MDX Hawaii PPO	$44,523.00
Rate for Payer: University Health Alliance Commercial	$25,704.00

INTELLIS ADAPTIVESTIM 97715

Facility

$45,900.00

Service Code	HCPCS C1820
Hospital Revenue Code	278
Min. Negotiated Rate	$23,409.00
Max. Negotiated Rate	$44,523.00
Rate for Payer: Cash Price	$27,540.00
Rate for Payer: Hawaii Western Management Group Commercial	$32,130.00
Rate for Payer: Health Management Network Commercial	$39,015.00
Rate for Payer: Kaiser Permanente Commercial	$28,917.00
Rate for Payer: Kaiser Permanente Medicaid	$23,409.00
Rate for Payer: MDX Hawaii PPO	$44,523.00
Rate for Payer: University Health Alliance Commercial	$25,704.00

INTENTIONAL SELF-HARM & ATTEMPTED SUICIDE

Facility

$2,649.55

Service Code	APR-DRG 8172
Min. Negotiated Rate	$2,649.55
Max. Negotiated Rate	$2,649.55
Rate for Payer: AlohaCare Medicaid	$2,649.55
Rate for Payer: Hawaii Medical Service Association ABD	$2,649.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,649.55
Rate for Payer: Kaiser Permanente Medicaid	$2,649.55
Rate for Payer: Ohana Health Plan Medicaid	$2,649.55
Rate for Payer: UnitedHealthcare Medicaid	$2,649.55

INTENTIONAL SELF-HARM & ATTEMPTED SUICIDE

Facility

$2,097.07

Service Code	APR-DRG 8171
Min. Negotiated Rate	$2,097.07
Max. Negotiated Rate	$2,097.07
Rate for Payer: AlohaCare Medicaid	$2,097.07
Rate for Payer: Hawaii Medical Service Association ABD	$2,097.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,097.07
Rate for Payer: Kaiser Permanente Medicaid	$2,097.07
Rate for Payer: Ohana Health Plan Medicaid	$2,097.07
Rate for Payer: UnitedHealthcare Medicaid	$2,097.07

INTENTIONAL SELF-HARM & ATTEMPTED SUICIDE

Facility

$8,173.03

Service Code	APR-DRG 8174
Min. Negotiated Rate	$8,173.03
Max. Negotiated Rate	$8,173.03
Rate for Payer: AlohaCare Medicaid	$8,173.03
Rate for Payer: Hawaii Medical Service Association ABD	$8,173.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,173.03
Rate for Payer: Kaiser Permanente Medicaid	$8,173.03
Rate for Payer: Ohana Health Plan Medicaid	$8,173.03
Rate for Payer: UnitedHealthcare Medicaid	$8,173.03

INTENTIONAL SELF-HARM & ATTEMPTED SUICIDE

Facility

$4,256.76

Service Code	APR-DRG 8173
Min. Negotiated Rate	$4,256.76
Max. Negotiated Rate	$4,256.76
Rate for Payer: AlohaCare Medicaid	$4,256.76
Rate for Payer: Hawaii Medical Service Association ABD	$4,256.76
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,256.76
Rate for Payer: Kaiser Permanente Medicaid	$4,256.76
Rate for Payer: Ohana Health Plan Medicaid	$4,256.76
Rate for Payer: UnitedHealthcare Medicaid	$4,256.76

INTERCEED BARRIER 3X4IN

Facility

$1,741.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,479.85
Max. Negotiated Rate	$1,688.77
Rate for Payer: Cash Price	$1,044.60
Rate for Payer: Health Management Network Commercial	$1,479.85
Rate for Payer: MDX Hawaii PPO	$1,688.77

Know your out-of-pocket cost for care.

All Charges