Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

KIT DISPOSABLE DX AR-8990DS

Facility

$1,376.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,169.60
Max. Negotiated Rate	$1,334.72
Rate for Payer: Cash Price	$825.60
Rate for Payer: Health Management Network Commercial	$1,169.60
Rate for Payer: MDX Hawaii PPO	$1,334.72

KIT DISPOSABLE DX AR-8990DS

Facility

$1,376.00

Hospital Revenue Code	272
Min. Negotiated Rate	$701.76
Max. Negotiated Rate	$1,334.72
Rate for Payer: Cash Price	$825.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,307.20
Rate for Payer: Health Management Network Commercial	$1,169.60
Rate for Payer: Kaiser Permanente Commercial	$866.88
Rate for Payer: Kaiser Permanente Medicaid	$701.76
Rate for Payer: MDX Hawaii PPO	$1,334.72
Rate for Payer: University Health Alliance Commercial	$1,002.97

KIT DRAINAGE PLEURX 1000ML

Facility

$236.00

Hospital Revenue Code	272
Min. Negotiated Rate	$120.36
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$148.68
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: University Health Alliance Commercial	$172.02

KIT DRAINAGE PLEURX 1000ML

Facility

$236.00

Hospital Revenue Code	272
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: MDX Hawaii PPO	$228.92

KIT DRAPE DRUG

Facility

$1,938.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,647.30
Max. Negotiated Rate	$1,879.86
Rate for Payer: Cash Price	$1,162.80
Rate for Payer: Health Management Network Commercial	$1,647.30
Rate for Payer: MDX Hawaii PPO	$1,879.86

KIT DRAPE DRUG

Facility

$1,938.00

Hospital Revenue Code	272
Min. Negotiated Rate	$988.38
Max. Negotiated Rate	$1,879.86
Rate for Payer: Cash Price	$1,162.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,841.10
Rate for Payer: Health Management Network Commercial	$1,647.30
Rate for Payer: Kaiser Permanente Commercial	$1,220.94
Rate for Payer: Kaiser Permanente Medicaid	$988.38
Rate for Payer: MDX Hawaii PPO	$1,879.86
Rate for Payer: University Health Alliance Commercial	$1,412.61

KIT ENDO COMPLIANCE

Facility

$1,222.00

Hospital Revenue Code	272
Min. Negotiated Rate	$623.22
Max. Negotiated Rate	$1,185.34
Rate for Payer: Cash Price	$733.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,160.90
Rate for Payer: Health Management Network Commercial	$1,038.70
Rate for Payer: Kaiser Permanente Commercial	$769.86
Rate for Payer: Kaiser Permanente Medicaid	$623.22
Rate for Payer: MDX Hawaii PPO	$1,185.34
Rate for Payer: University Health Alliance Commercial	$890.72

KIT ENDO COMPLIANCE

Facility

$1,222.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,038.70
Max. Negotiated Rate	$1,185.34
Rate for Payer: Cash Price	$733.20
Rate for Payer: Health Management Network Commercial	$1,038.70
Rate for Payer: MDX Hawaii PPO	$1,185.34

KIT FIBERTAK DISP AR-3650DS

Facility

$1,138.00

Hospital Revenue Code	272
Min. Negotiated Rate	$967.30
Max. Negotiated Rate	$1,103.86
Rate for Payer: Cash Price	$682.80
Rate for Payer: Health Management Network Commercial	$967.30
Rate for Payer: MDX Hawaii PPO	$1,103.86

KIT FIBERTAK DISP AR-3650DS

Facility

$1,138.00

Hospital Revenue Code	272
Min. Negotiated Rate	$580.38
Max. Negotiated Rate	$1,103.86
Rate for Payer: Cash Price	$682.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,081.10
Rate for Payer: Health Management Network Commercial	$967.30
Rate for Payer: Kaiser Permanente Commercial	$716.94
Rate for Payer: Kaiser Permanente Medicaid	$580.38
Rate for Payer: MDX Hawaii PPO	$1,103.86
Rate for Payer: University Health Alliance Commercial	$829.49

KIT FOR PREPARATION OF TC 99M-ALBUMIN 2 MG INTRAVENOUS SOLUTION [209535]

Facility

$113.00

Service Code	NDC 69945013910
Hospital Revenue Code	343
Min. Negotiated Rate	$57.63
Max. Negotiated Rate	$109.61
Rate for Payer: Cash Price	$67.80
Rate for Payer: Hawaii Western Management Group Commercial	$107.35
Rate for Payer: Health Management Network Commercial	$96.05
Rate for Payer: Kaiser Permanente Commercial	$71.19
Rate for Payer: Kaiser Permanente Medicaid	$57.63
Rate for Payer: MDX Hawaii PPO	$109.61
Rate for Payer: University Health Alliance Commercial	$82.37

KIT FOR PREPARATION OF TC 99M-ALBUMIN 2 MG INTRAVENOUS SOLUTION [209535]

Facility

$113.00

Service Code	NDC 69945013910
Hospital Revenue Code	343
Min. Negotiated Rate	$96.05
Max. Negotiated Rate	$109.61
Rate for Payer: Cash Price	$67.80
Rate for Payer: Health Management Network Commercial	$96.05
Rate for Payer: MDX Hawaii PPO	$109.61

KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM 20 MG IV SOLUTION [98466]

Facility

$69.00

Service Code	HCPCS A9503
Hospital Revenue Code	343
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$41.40
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: MDX Hawaii PPO	$66.93

KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM 20 MG IV SOLUTION [98466]

Facility

$69.00

Service Code	HCPCS A9503
Hospital Revenue Code	343
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$41.40
Rate for Payer: Cash Price	$41.40
Rate for Payer: Hawaii Western Management Group Commercial	$65.55
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$43.47
Rate for Payer: Kaiser Permanente Medicaid	$35.19
Rate for Payer: MDX Hawaii PPO	$66.93
Rate for Payer: UnitedHealthcare Medicaid	$31.20
Rate for Payer: University Health Alliance Commercial	$50.29

KIT FOR PREPARATION OF TC 99M-PENTETIC ACID 20 MG IV SOLUTION [109481]

Facility

$325.00

Service Code	HCPCS A9505
Hospital Revenue Code	343
Min. Negotiated Rate	$59.80
Max. Negotiated Rate	$315.25
Rate for Payer: Cash Price	$195.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Hawaii Western Management Group Commercial	$308.75
Rate for Payer: Health Management Network Commercial	$276.25
Rate for Payer: Kaiser Permanente Commercial	$204.75
Rate for Payer: Kaiser Permanente Medicaid	$165.75
Rate for Payer: MDX Hawaii PPO	$315.25
Rate for Payer: UnitedHealthcare Medicaid	$59.80
Rate for Payer: University Health Alliance Commercial	$236.89

KIT FOR PREPARATION OF TC 99M-PENTETIC ACID 20 MG IV SOLUTION [109481]

Facility

$325.00

Service Code	HCPCS A9505
Hospital Revenue Code	343
Min. Negotiated Rate	$276.25
Max. Negotiated Rate	$315.25
Rate for Payer: Cash Price	$195.00
Rate for Payer: Health Management Network Commercial	$276.25
Rate for Payer: MDX Hawaii PPO	$315.25

KIT FOR PREPARATION OF TC-99M-SODIUM OXIDRONATE 3.15 MG IV SOLUTION [209306]

Facility

$63.00

Service Code	HCPCS A9561
Hospital Revenue Code	343
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cash Price	$37.80
Rate for Payer: Hawaii Western Management Group Commercial	$59.85
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$39.69
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: UnitedHealthcare Medicaid	$9.00
Rate for Payer: University Health Alliance Commercial	$45.92

KIT FOR PREPARATION OF TC-99M-SODIUM OXIDRONATE 3.15 MG IV SOLUTION [209306]

Facility

$63.00

Service Code	HCPCS A9561
Hospital Revenue Code	343
Min. Negotiated Rate	$53.55
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$37.80
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: MDX Hawaii PPO	$61.11

KIT FOR PREPARATION OF TC 99M-SODIUM THIOSULFATE 2 MG SOLUTION [171666]

Facility

$119.00

Service Code	HCPCS A9541
Hospital Revenue Code	343
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: MDX Hawaii PPO	$115.43

KIT FOR PREPARATION OF TC 99M-SODIUM THIOSULFATE 2 MG SOLUTION [171666]

Facility

$119.00

Service Code	HCPCS A9541
Hospital Revenue Code	343
Min. Negotiated Rate	$60.69
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Hawaii Western Management Group Commercial	$113.05
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Kaiser Permanente Commercial	$74.97
Rate for Payer: Kaiser Permanente Medicaid	$60.69
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: University Health Alliance Commercial	$86.74

KIT FOR PREPARATION TC-99M-SUCCIMER 1 MG INTRAVENOUS SOLUTION [98464]

Facility

$282.00

Service Code	NDC 17156052501
Hospital Revenue Code	343
Min. Negotiated Rate	$143.82
Max. Negotiated Rate	$273.54
Rate for Payer: Cash Price	$169.20
Rate for Payer: Hawaii Western Management Group Commercial	$267.90
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Kaiser Permanente Commercial	$177.66
Rate for Payer: Kaiser Permanente Medicaid	$143.82
Rate for Payer: MDX Hawaii PPO	$273.54
Rate for Payer: University Health Alliance Commercial	$205.55

KIT FOR PREPARATION TC-99M-SUCCIMER 1 MG INTRAVENOUS SOLUTION [98464]

Facility

$282.00

Service Code	NDC 17156052501
Hospital Revenue Code	343
Min. Negotiated Rate	$239.70
Max. Negotiated Rate	$273.54
Rate for Payer: Cash Price	$169.20
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: MDX Hawaii PPO	$273.54

KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) 1 MG INTRAVENOUS SOLUTION [208743]

Facility

$809.00

Service Code	HCPCS A9562
Hospital Revenue Code	343
Min. Negotiated Rate	$412.59
Max. Negotiated Rate	$784.73
Rate for Payer: Cash Price	$485.40
Rate for Payer: Hawaii Western Management Group Commercial	$768.55
Rate for Payer: Health Management Network Commercial	$687.65
Rate for Payer: Kaiser Permanente Commercial	$509.67
Rate for Payer: Kaiser Permanente Medicaid	$412.59
Rate for Payer: MDX Hawaii PPO	$784.73
Rate for Payer: University Health Alliance Commercial	$589.68

KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) 1 MG INTRAVENOUS SOLUTION [208743]

Facility

$809.00

Service Code	HCPCS A9562
Hospital Revenue Code	343
Min. Negotiated Rate	$687.65
Max. Negotiated Rate	$784.73
Rate for Payer: Cash Price	$485.40
Rate for Payer: Health Management Network Commercial	$687.65
Rate for Payer: MDX Hawaii PPO	$784.73

KIT FOR TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION [205836]

Facility

$235.00

Service Code	NDC 69945006820
Hospital Revenue Code	343
Min. Negotiated Rate	$199.75
Max. Negotiated Rate	$227.95
Rate for Payer: Cash Price	$141.00
Rate for Payer: Health Management Network Commercial	$199.75
Rate for Payer: MDX Hawaii PPO	$227.95

Know your out-of-pocket cost for care.

All Charges