Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

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	$119.85
Max. Negotiated Rate	$227.95
Rate for Payer: Cash Price	$141.00
Rate for Payer: Hawaii Western Management Group Commercial	$223.25
Rate for Payer: Health Management Network Commercial	$199.75
Rate for Payer: Kaiser Permanente Commercial	$148.05
Rate for Payer: Kaiser Permanente Medicaid	$119.85
Rate for Payer: MDX Hawaii PPO	$227.95
Rate for Payer: University Health Alliance Commercial	$171.29

KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [103948]

Facility

$153.00

Service Code	HCPCS A9537
Hospital Revenue Code	343
Min. Negotiated Rate	$78.03
Max. Negotiated Rate	$148.41
Rate for Payer: Cash Price	$91.80
Rate for Payer: Hawaii Western Management Group Commercial	$145.35
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Kaiser Permanente Commercial	$96.39
Rate for Payer: Kaiser Permanente Medicaid	$78.03
Rate for Payer: MDX Hawaii PPO	$148.41
Rate for Payer: University Health Alliance Commercial	$111.52

KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [103948]

Facility

$153.00

Service Code	HCPCS A9537
Hospital Revenue Code	343
Min. Negotiated Rate	$130.05
Max. Negotiated Rate	$148.41
Rate for Payer: Cash Price	$91.80
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: MDX Hawaii PPO	$148.41

KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [190429]

Facility

$2,385.00

Service Code	HCPCS A9520
Hospital Revenue Code	343
Min. Negotiated Rate	$2,027.25
Max. Negotiated Rate	$2,313.45
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Health Management Network Commercial	$2,027.25
Rate for Payer: MDX Hawaii PPO	$2,313.45

KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [190429]

Facility

$2,385.00

Service Code	HCPCS A9520
Hospital Revenue Code	343
Min. Negotiated Rate	$1,216.35
Max. Negotiated Rate	$2,313.45
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,265.75
Rate for Payer: Health Management Network Commercial	$2,027.25
Rate for Payer: Kaiser Permanente Commercial	$1,502.55
Rate for Payer: Kaiser Permanente Medicaid	$1,216.35
Rate for Payer: MDX Hawaii PPO	$2,313.45
Rate for Payer: University Health Alliance Commercial	$1,738.43

KIT INFERIOR GLENOID G000-0100

Facility

$2,637.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,241.45
Max. Negotiated Rate	$2,557.89
Rate for Payer: Cash Price	$1,582.20
Rate for Payer: Health Management Network Commercial	$2,241.45
Rate for Payer: MDX Hawaii PPO	$2,557.89

KIT INFERIOR GLENOID G000-0100

Facility

$2,637.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,344.87
Max. Negotiated Rate	$2,557.89
Rate for Payer: Cash Price	$1,582.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,505.15
Rate for Payer: Health Management Network Commercial	$2,241.45
Rate for Payer: Kaiser Permanente Commercial	$1,661.31
Rate for Payer: Kaiser Permanente Medicaid	$1,344.87
Rate for Payer: MDX Hawaii PPO	$2,557.89
Rate for Payer: University Health Alliance Commercial	$1,922.11

KIT IN-LINE INJECTION HOUSING

Facility

$130.00

Hospital Revenue Code	272
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$126.10
Rate for Payer: Cash Price	$78.00
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: Kaiser Permanente Medicaid	$66.30
Rate for Payer: MDX Hawaii PPO	$126.10
Rate for Payer: University Health Alliance Commercial	$94.76

KIT IN-LINE INJECTION HOUSING

Facility

$130.00

Hospital Revenue Code	272
Min. Negotiated Rate	$110.50
Max. Negotiated Rate	$126.10
Rate for Payer: Cash Price	$78.00
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: MDX Hawaii PPO	$126.10

KIT INTERSTIM REVISION 3560031

Facility

$1,452.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,234.20
Max. Negotiated Rate	$1,408.44
Rate for Payer: Cash Price	$871.20
Rate for Payer: Health Management Network Commercial	$1,234.20
Rate for Payer: MDX Hawaii PPO	$1,408.44

KIT INTERSTIM REVISION 3560031

Facility

$1,452.00

Hospital Revenue Code	272
Min. Negotiated Rate	$740.52
Max. Negotiated Rate	$1,408.44
Rate for Payer: Cash Price	$871.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,379.40
Rate for Payer: Health Management Network Commercial	$1,234.20
Rate for Payer: Kaiser Permanente Commercial	$914.76
Rate for Payer: Kaiser Permanente Medicaid	$740.52
Rate for Payer: MDX Hawaii PPO	$1,408.44
Rate for Payer: University Health Alliance Commercial	$1,058.36

KIT IV CATH 2 LUMEN

Facility

$170.00

Service Code	HCPCS C1751
Hospital Revenue Code	272
Min. Negotiated Rate	$86.70
Max. Negotiated Rate	$164.90
Rate for Payer: Cash Price	$102.00
Rate for Payer: Hawaii Western Management Group Commercial	$161.50
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: Kaiser Permanente Medicaid	$86.70
Rate for Payer: MDX Hawaii PPO	$164.90
Rate for Payer: University Health Alliance Commercial	$123.91

KIT IV CATH 2 LUMEN

Facility

$170.00

Service Code	HCPCS C1751
Hospital Revenue Code	272
Min. Negotiated Rate	$144.50
Max. Negotiated Rate	$164.90
Rate for Payer: Cash Price	$102.00
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: MDX Hawaii PPO	$164.90

KIT LEAD SURESCAN MRUI 978B128

Facility

$9,563.00

Service Code	HCPCS C1788
Hospital Revenue Code	278
Min. Negotiated Rate	$4,877.13
Max. Negotiated Rate	$9,276.11
Rate for Payer: Cash Price	$5,737.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,694.10
Rate for Payer: Health Management Network Commercial	$8,128.55
Rate for Payer: Kaiser Permanente Commercial	$6,024.69
Rate for Payer: Kaiser Permanente Medicaid	$4,877.13
Rate for Payer: MDX Hawaii PPO	$9,276.11
Rate for Payer: University Health Alliance Commercial	$5,355.28

KIT LEAD SURESCAN MRUI 978B128

Facility

$9,563.00

Service Code	HCPCS C1788
Hospital Revenue Code	278
Min. Negotiated Rate	$5,355.28
Max. Negotiated Rate	$9,276.11
Rate for Payer: Cash Price	$5,737.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,694.10
Rate for Payer: Health Management Network Commercial	$8,128.55
Rate for Payer: MDX Hawaii PPO	$9,276.11
Rate for Payer: University Health Alliance Commercial	$5,355.28

KIT LEEP REDIKIT

Facility

$202.00

Hospital Revenue Code	272
Min. Negotiated Rate	$171.70
Max. Negotiated Rate	$195.94
Rate for Payer: Cash Price	$121.20
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: MDX Hawaii PPO	$195.94

KIT LEEP REDIKIT

Facility

$202.00

Hospital Revenue Code	272
Min. Negotiated Rate	$103.02
Max. Negotiated Rate	$195.94
Rate for Payer: Cash Price	$121.20
Rate for Payer: Hawaii Western Management Group Commercial	$191.90
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Kaiser Permanente Commercial	$127.26
Rate for Payer: Kaiser Permanente Medicaid	$103.02
Rate for Payer: MDX Hawaii PPO	$195.94
Rate for Payer: University Health Alliance Commercial	$147.24

KIT MISCARRIAGE MANAGE #UEK

Facility

$392.00

Hospital Revenue Code	272
Min. Negotiated Rate	$199.92
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$235.20
Rate for Payer: Hawaii Western Management Group Commercial	$372.40
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$246.96
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: University Health Alliance Commercial	$285.73

KIT MISCARRIAGE MANAGE #UEK

Facility

$392.00

Hospital Revenue Code	272
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$235.20
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: MDX Hawaii PPO	$380.24

KIT NEPHROSTOMY BALLOON

Facility

$913.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$776.05
Max. Negotiated Rate	$885.61
Rate for Payer: Cash Price	$547.80
Rate for Payer: Health Management Network Commercial	$776.05
Rate for Payer: MDX Hawaii PPO	$885.61

KIT NEPHROSTOMY BALLOON

Facility

$913.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$465.63
Max. Negotiated Rate	$885.61
Rate for Payer: Kaiser Permanente Commercial	$575.19
Rate for Payer: Cash Price	$547.80
Rate for Payer: Hawaii Western Management Group Commercial	$867.35
Rate for Payer: Health Management Network Commercial	$776.05
Rate for Payer: Kaiser Permanente Medicaid	$465.63
Rate for Payer: MDX Hawaii PPO	$885.61
Rate for Payer: University Health Alliance Commercial	$665.49

KIT PERC ACCESS

Facility

$507.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$258.57
Max. Negotiated Rate	$491.79
Rate for Payer: Cash Price	$304.20
Rate for Payer: Hawaii Western Management Group Commercial	$481.65
Rate for Payer: Health Management Network Commercial	$430.95
Rate for Payer: Kaiser Permanente Commercial	$319.41
Rate for Payer: Kaiser Permanente Medicaid	$258.57
Rate for Payer: MDX Hawaii PPO	$491.79
Rate for Payer: University Health Alliance Commercial	$369.55

KIT PERC ACCESS

Facility

$507.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$430.95
Max. Negotiated Rate	$491.79
Rate for Payer: Cash Price	$304.20
Rate for Payer: Health Management Network Commercial	$430.95
Rate for Payer: MDX Hawaii PPO	$491.79

KIT PERCUTANEOUS INTRO SET

Facility

$249.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$126.99
Max. Negotiated Rate	$241.53
Rate for Payer: Cash Price	$149.40
Rate for Payer: Hawaii Western Management Group Commercial	$236.55
Rate for Payer: Health Management Network Commercial	$211.65
Rate for Payer: Kaiser Permanente Commercial	$156.87
Rate for Payer: Kaiser Permanente Medicaid	$126.99
Rate for Payer: MDX Hawaii PPO	$241.53
Rate for Payer: University Health Alliance Commercial	$181.50

KIT PERCUTANEOUS INTRO SET

Facility

$249.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$211.65
Max. Negotiated Rate	$241.53
Rate for Payer: Cash Price	$149.40
Rate for Payer: Health Management Network Commercial	$211.65
Rate for Payer: MDX Hawaii PPO	$241.53

Know your out-of-pocket cost for care.

All Charges