Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

INTROD PERCUTANEOUS TRACH

Facility

$1,712.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$873.12
Max. Negotiated Rate	$1,660.64
Rate for Payer: Cash Price	$1,027.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,626.40
Rate for Payer: Health Management Network Commercial	$1,455.20
Rate for Payer: Kaiser Permanente Commercial	$1,078.56
Rate for Payer: Kaiser Permanente Medicaid	$873.12
Rate for Payer: MDX Hawaii PPO	$1,660.64
Rate for Payer: University Health Alliance Commercial	$1,247.88

INTROD STENT INTRO SYSTEM

Facility

$332.00

Hospital Revenue Code	272
Min. Negotiated Rate	$169.32
Max. Negotiated Rate	$322.04
Rate for Payer: Cash Price	$199.20
Rate for Payer: Hawaii Western Management Group Commercial	$315.40
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Kaiser Permanente Commercial	$209.16
Rate for Payer: Kaiser Permanente Medicaid	$169.32
Rate for Payer: MDX Hawaii PPO	$322.04
Rate for Payer: University Health Alliance Commercial	$241.99

INTROD STENT INTRO SYSTEM

Facility

$332.00

Hospital Revenue Code	272
Min. Negotiated Rate	$282.20
Max. Negotiated Rate	$322.04
Rate for Payer: Cash Price	$199.20
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: MDX Hawaii PPO	$322.04

INTRODUCER 12FRX30 PERFORMER

Facility

$240.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Hawaii Western Management Group Commercial	$228.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: University Health Alliance Commercial	$174.94

INTRODUCER 12FRX30 PERFORMER

Facility

$240.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: MDX Hawaii PPO	$232.80

INTRODUCER 6X10 PINNACLE

Facility

$140.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$119.00
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: MDX Hawaii PPO	$135.80

INTRODUCER 6X10 PINNACLE

Facility

$140.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Hawaii Western Management Group Commercial	$133.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: Kaiser Permanente Medicaid	$71.40
Rate for Payer: MDX Hawaii PPO	$135.80
Rate for Payer: University Health Alliance Commercial	$102.05

INTRODUCER KIT 5FR MICRO

Facility

$125.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$121.25
Rate for Payer: Cash Price	$75.00
Rate for Payer: Hawaii Western Management Group Commercial	$118.75
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Kaiser Permanente Commercial	$78.75
Rate for Payer: Kaiser Permanente Medicaid	$63.75
Rate for Payer: MDX Hawaii PPO	$121.25
Rate for Payer: University Health Alliance Commercial	$91.11

INTRODUCER KIT 5FR MICRO

Facility

$125.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$106.25
Max. Negotiated Rate	$121.25
Rate for Payer: Cash Price	$75.00
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: MDX Hawaii PPO	$121.25

INTRODUCER KIT SR-4F21G7D-MP

Facility

$713.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$606.05
Max. Negotiated Rate	$691.61
Rate for Payer: Cash Price	$427.80
Rate for Payer: Health Management Network Commercial	$606.05
Rate for Payer: MDX Hawaii PPO	$691.61

INTRODUCER KIT SR-4F21G7D-MP

Facility

$713.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$363.63
Max. Negotiated Rate	$691.61
Rate for Payer: Cash Price	$427.80
Rate for Payer: Hawaii Western Management Group Commercial	$677.35
Rate for Payer: Health Management Network Commercial	$606.05
Rate for Payer: Kaiser Permanente Commercial	$449.19
Rate for Payer: Kaiser Permanente Medicaid	$363.63
Rate for Payer: MDX Hawaii PPO	$691.61
Rate for Payer: University Health Alliance Commercial	$519.71

INTRODUCER SHEATH DSF1033

Facility

$2,322.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,184.22
Max. Negotiated Rate	$2,252.34
Rate for Payer: Cash Price	$1,393.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,205.90
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: Kaiser Permanente Commercial	$1,462.86
Rate for Payer: Kaiser Permanente Medicaid	$1,184.22
Rate for Payer: MDX Hawaii PPO	$2,252.34
Rate for Payer: University Health Alliance Commercial	$1,692.51

INTRODUCER SHEATH DSF1033

Facility

$2,322.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,973.70
Max. Negotiated Rate	$2,252.34
Rate for Payer: Cash Price	$1,393.20
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: MDX Hawaii PPO	$2,252.34

INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;

Facility

$2,837.00

Service Code	CPT 36901
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$1,859.62
Rate for Payer: AlohaCare Medicare	$1,859.62
Rate for Payer: Devoted Health Medicare	$2,045.58
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,859.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$1,859.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,859.62
Rate for Payer: Ohana Health Plan Medicaid	$2,045.58
Rate for Payer: Ohana Health Plan Medicare	$1,859.62
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,859.62

Facility

$8,270.00

Service Code	CPT 36902
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$6,723.70
Rate for Payer: AlohaCare Medicare	$6,723.70
Rate for Payer: Devoted Health Medicare	$7,396.07
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,723.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$6,723.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,723.70
Rate for Payer: Ohana Health Plan Medicaid	$7,396.07
Rate for Payer: Ohana Health Plan Medicare	$6,723.70
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,723.70
Rate for Payer: University Health Alliance Commercial	$6,743.44

INTRO PERCUTANEOUS CATH KIT 8F

Facility

$340.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$289.00
Max. Negotiated Rate	$329.80
Rate for Payer: Cash Price	$204.00
Rate for Payer: Health Management Network Commercial	$289.00
Rate for Payer: MDX Hawaii PPO	$329.80

INTRO PERCUTANEOUS CATH KIT 8F

Facility

$340.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$173.40
Max. Negotiated Rate	$329.80
Rate for Payer: Cash Price	$204.00
Rate for Payer: Hawaii Western Management Group Commercial	$323.00
Rate for Payer: Health Management Network Commercial	$289.00
Rate for Payer: Kaiser Permanente Commercial	$214.20
Rate for Payer: Kaiser Permanente Medicaid	$173.40
Rate for Payer: MDX Hawaii PPO	$329.80
Rate for Payer: University Health Alliance Commercial	$247.83

INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE

Facility

$4,035.20

Service Code	CPT 31500
Hospital Revenue Code	361
Min. Negotiated Rate	$93.64
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$279.80
Rate for Payer: AlohaCare Medicare	$279.80
Rate for Payer: Devoted Health Medicare	$307.78
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$279.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$279.80
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$279.80
Rate for Payer: Ohana Health Plan Medicaid	$307.78
Rate for Payer: Ohana Health Plan Medicare	$279.80
Rate for Payer: UnitedHealthcare Medicaid	$93.64
Rate for Payer: UnitedHealthcare Medicare	$279.80
Rate for Payer: University Health Alliance Commercial	$4,035.20

IODINE-POTASSIUM IODIDE 5 %-10 % TOPICAL SOLUTION [111216]

Facility

$136.00

Service Code	NDC 38779059805
Hospital Revenue Code	637
Min. Negotiated Rate	$69.36
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$81.60
Rate for Payer: Hawaii Western Management Group Commercial	$129.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Kaiser Permanente Commercial	$85.68
Rate for Payer: Kaiser Permanente Medicaid	$69.36
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: University Health Alliance Commercial	$99.13

IODINE-POTASSIUM IODIDE 5 %-10 % TOPICAL SOLUTION [111216]

Facility

$136.00

Service Code	NDC 38779059805
Hospital Revenue Code	250
Min. Negotiated Rate	$115.60
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$81.60
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: MDX Hawaii PPO	$131.92

IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]

Facility

$223.00

Service Code	HCPCS Q9967
Hospital Revenue Code	255
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$216.31
Rate for Payer: Cash Price	$133.80
Rate for Payer: Cash Price	$133.80
Rate for Payer: Cash Price	$267.00
Rate for Payer: Cash Price	$267.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.15
Rate for Payer: Hawaii Medical Service Association ABD	$0.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.15
Rate for Payer: Hawaii Western Management Group Commercial	$422.75
Rate for Payer: Hawaii Western Management Group Commercial	$211.85
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Health Management Network Commercial	$378.25
Rate for Payer: Kaiser Permanente Commercial	$280.35
Rate for Payer: Kaiser Permanente Commercial	$140.49
Rate for Payer: Kaiser Permanente Medicaid	$113.73
Rate for Payer: Kaiser Permanente Medicaid	$226.95
Rate for Payer: MDX Hawaii PPO	$431.65
Rate for Payer: MDX Hawaii PPO	$216.31
Rate for Payer: UnitedHealthcare Medicaid	$0.30
Rate for Payer: UnitedHealthcare Medicaid	$0.30
Rate for Payer: University Health Alliance Commercial	$162.54
Rate for Payer: University Health Alliance Commercial	$324.36

IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]

Facility

$223.00

Service Code	HCPCS Q9967
Hospital Revenue Code	255
Min. Negotiated Rate	$189.55
Max. Negotiated Rate	$216.31
Rate for Payer: Cash Price	$133.80
Rate for Payer: Cash Price	$267.00
Rate for Payer: Health Management Network Commercial	$378.25
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: MDX Hawaii PPO	$431.65
Rate for Payer: MDX Hawaii PPO	$216.31

IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [119842]

Facility

$195.00

Service Code	HCPCS Q9967
Hospital Revenue Code	255
Min. Negotiated Rate	$165.75
Max. Negotiated Rate	$189.15
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cash Price	$1,315.80
Rate for Payer: Cash Price	$333.60
Rate for Payer: Health Management Network Commercial	$472.60
Rate for Payer: Health Management Network Commercial	$1,864.05
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: MDX Hawaii PPO	$2,127.21
Rate for Payer: MDX Hawaii PPO	$539.32
Rate for Payer: MDX Hawaii PPO	$189.15

IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [119842]

Facility

$195.00

Service Code	HCPCS Q9967
Hospital Revenue Code	255
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$189.15
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cash Price	$1,315.80
Rate for Payer: Cash Price	$333.60
Rate for Payer: Cash Price	$333.60
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cash Price	$1,315.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.15
Rate for Payer: Hawaii Medical Service Association ABD	$0.15
Rate for Payer: Hawaii Medical Service Association ABD	$0.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.15
Rate for Payer: Hawaii Western Management Group Commercial	$2,083.35
Rate for Payer: Hawaii Western Management Group Commercial	$185.25
Rate for Payer: Hawaii Western Management Group Commercial	$528.20
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Health Management Network Commercial	$472.60
Rate for Payer: Health Management Network Commercial	$1,864.05
Rate for Payer: Kaiser Permanente Commercial	$350.28
Rate for Payer: Kaiser Permanente Commercial	$122.85
Rate for Payer: Kaiser Permanente Commercial	$1,381.59
Rate for Payer: Kaiser Permanente Medicaid	$283.56
Rate for Payer: Kaiser Permanente Medicaid	$1,118.43
Rate for Payer: Kaiser Permanente Medicaid	$99.45
Rate for Payer: MDX Hawaii PPO	$539.32
Rate for Payer: MDX Hawaii PPO	$189.15
Rate for Payer: MDX Hawaii PPO	$2,127.21
Rate for Payer: UnitedHealthcare Medicaid	$0.30
Rate for Payer: UnitedHealthcare Medicaid	$0.30
Rate for Payer: UnitedHealthcare Medicaid	$0.30
Rate for Payer: University Health Alliance Commercial	$405.27
Rate for Payer: University Health Alliance Commercial	$1,598.48
Rate for Payer: University Health Alliance Commercial	$142.14

IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION [10323]

Facility

$424.00

Service Code	HCPCS Q9967
Hospital Revenue Code	255
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$411.28
Rate for Payer: Cash Price	$254.40
Rate for Payer: Cash Price	$1,335.60
Rate for Payer: Cash Price	$254.40
Rate for Payer: Cash Price	$1,335.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.15
Rate for Payer: Hawaii Medical Service Association ABD	$0.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.15
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.70
Rate for Payer: Hawaii Western Management Group Commercial	$402.80
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: Health Management Network Commercial	$1,892.10
Rate for Payer: Kaiser Permanente Commercial	$1,402.38
Rate for Payer: Kaiser Permanente Commercial	$267.12
Rate for Payer: Kaiser Permanente Medicaid	$216.24
Rate for Payer: Kaiser Permanente Medicaid	$1,135.26
Rate for Payer: MDX Hawaii PPO	$2,159.22
Rate for Payer: MDX Hawaii PPO	$411.28
Rate for Payer: UnitedHealthcare Medicaid	$0.30
Rate for Payer: UnitedHealthcare Medicaid	$0.30
Rate for Payer: University Health Alliance Commercial	$1,622.53
Rate for Payer: University Health Alliance Commercial	$309.05

Know your out-of-pocket cost for care.

All Charges