Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION [10323]

Facility

$2,226.00

Service Code	HCPCS Q9967
Hospital Revenue Code	255
Min. Negotiated Rate	$1,892.10
Max. Negotiated Rate	$2,159.22
Rate for Payer: Cash Price	$1,335.60
Rate for Payer: Cash Price	$254.40
Rate for Payer: Health Management Network Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: MDX Hawaii PPO	$2,159.22
Rate for Payer: MDX Hawaii PPO	$411.28

IOLENS 6.0 PRELOADED

Facility

$563.00

Service Code	HCPCS V2632
Hospital Revenue Code	276
Min. Negotiated Rate	$315.28
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$337.80
Rate for Payer: Hawaii Western Management Group Commercial	$394.10
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: University Health Alliance Commercial	$315.28

IOLENS 6.0 PRELOADED

Facility

$563.00

Service Code	HCPCS V2632
Hospital Revenue Code	276
Min. Negotiated Rate	$287.13
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$337.80
Rate for Payer: Cash Price	$337.80
Rate for Payer: Hawaii Western Management Group Commercial	$394.10
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$354.69
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: University Health Alliance Commercial	$315.28

IOLENS DIOP 10.0 SN60WF10.0

Facility

$750.00

Service Code	HCPCS V2632
Hospital Revenue Code	276
Min. Negotiated Rate	$311.40
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: UnitedHealthcare Medicaid	$311.40
Rate for Payer: University Health Alliance Commercial	$420.00

IOLENS DIOP 10.0 SN60WF10.0

Facility

$750.00

Service Code	HCPCS V2632
Hospital Revenue Code	276
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$420.00

IOLENS DIOP 11.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 11.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$883.83
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,091.79
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 12.0 SN6AT3 12.0

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$883.83
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,091.79
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 12.0 SN6AT3 12.0

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 12.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 12.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$883.83
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,091.79
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 14.0 SN6AT8 14.0

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$883.83
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,091.79
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 14.0 SN6AT8 14.0

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 15.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$883.83
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,091.79
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 15.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 17.5 SN6AT7 17.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$883.83
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,091.79
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 17.5 SN6AT7 17.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 20.0 13.0 5.5MM

Facility

$375.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$363.75
Rate for Payer: Cash Price	$225.00
Rate for Payer: Hawaii Western Management Group Commercial	$262.50
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Kaiser Permanente Commercial	$236.25
Rate for Payer: Kaiser Permanente Medicaid	$191.25
Rate for Payer: MDX Hawaii PPO	$363.75
Rate for Payer: University Health Alliance Commercial	$210.00

IOLENS DIOP 20.0 13.0 5.5MM

Facility

$375.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$363.75
Rate for Payer: Cash Price	$225.00
Rate for Payer: Hawaii Western Management Group Commercial	$262.50
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: MDX Hawaii PPO	$363.75
Rate for Payer: University Health Alliance Commercial	$210.00

IOLENS DIOP 20.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$883.83
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,091.79
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 20.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 23.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 23.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$883.83
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,091.79
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 8.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$883.83
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,091.79
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 8.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

Know your out-of-pocket cost for care.

All Charges