Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

LEAD PLEXA PROMRI 413997

Facility

$8,000.00

Service Code	HCPCS C1777
Hospital Revenue Code	278
Min. Negotiated Rate	$4,480.00
Max. Negotiated Rate	$7,760.00
Rate for Payer: Cash Price	$4,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,600.00
Rate for Payer: Health Management Network Commercial	$6,800.00
Rate for Payer: MDX Hawaii PPO	$7,760.00
Rate for Payer: University Health Alliance Commercial	$4,480.00

LEAD RESPIRATORY SENSING

Facility

$6,750.00

Service Code	HCPCS C1778
Hospital Revenue Code	278
Min. Negotiated Rate	$3,442.50
Max. Negotiated Rate	$6,547.50
Rate for Payer: Cash Price	$4,050.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,725.00
Rate for Payer: Health Management Network Commercial	$5,737.50
Rate for Payer: Kaiser Permanente Commercial	$4,252.50
Rate for Payer: Kaiser Permanente Medicaid	$3,442.50
Rate for Payer: MDX Hawaii PPO	$6,547.50
Rate for Payer: University Health Alliance Commercial	$3,780.00

LEAD RESPIRATORY SENSING

Facility

$6,750.00

Service Code	HCPCS C1778
Hospital Revenue Code	278
Min. Negotiated Rate	$3,780.00
Max. Negotiated Rate	$6,547.50
Rate for Payer: Cash Price	$4,050.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,725.00
Rate for Payer: Health Management Network Commercial	$5,737.50
Rate for Payer: MDX Hawaii PPO	$6,547.50
Rate for Payer: University Health Alliance Commercial	$3,780.00

LEAD TEMP PACING 5FR

Facility

$394.00

Service Code	HCPCS C1883
Hospital Revenue Code	275
Min. Negotiated Rate	$200.94
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Hawaii Western Management Group Commercial	$275.80
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Kaiser Permanente Commercial	$248.22
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: University Health Alliance Commercial	$220.64

LEAD TEMP PACING 5FR

Facility

$394.00

Service Code	HCPCS C1883
Hospital Revenue Code	275
Min. Negotiated Rate	$220.64
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Hawaii Western Management Group Commercial	$275.80
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: University Health Alliance Commercial	$220.64

LEAD TEMP PACING 6FR

Facility

$394.00

Service Code	HCPCS C1883
Hospital Revenue Code	275
Min. Negotiated Rate	$200.94
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Hawaii Western Management Group Commercial	$275.80
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Kaiser Permanente Commercial	$248.22
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: University Health Alliance Commercial	$220.64

LEAD TEMP PACING 6FR

Facility

$394.00

Service Code	HCPCS C1883
Hospital Revenue Code	275
Min. Negotiated Rate	$220.64
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Hawaii Western Management Group Commercial	$275.80
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: University Health Alliance Commercial	$220.64

LEAD TEMP PACING 7FR

Facility

$394.00

Service Code	HCPCS C1883
Hospital Revenue Code	275
Min. Negotiated Rate	$200.94
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Hawaii Western Management Group Commercial	$275.80
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Kaiser Permanente Commercial	$248.22
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: University Health Alliance Commercial	$220.64

LEAD TEMP PACING 7FR

Facility

$394.00

Service Code	HCPCS C1883
Hospital Revenue Code	275
Min. Negotiated Rate	$220.64
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Hawaii Western Management Group Commercial	$275.80
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: University Health Alliance Commercial	$220.64

LEAD TENDRIL 2088TC/46

Facility

$1,575.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

LEAD TENDRIL 2088TC/46

Facility

$1,575.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$803.25
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$992.25
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

LEAD TENDRIL 2088TC/52

Facility

$1,575.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

LEAD TENDRIL 2088TC/52

Facility

$1,575.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$803.25
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$992.25
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

LEMAITRE VALVULOTOME 1009-00

Facility

$6,598.00

Hospital Revenue Code	272
Min. Negotiated Rate	$5,608.30
Max. Negotiated Rate	$6,400.06
Rate for Payer: Cash Price	$3,958.80
Rate for Payer: Health Management Network Commercial	$5,608.30
Rate for Payer: MDX Hawaii PPO	$6,400.06

LEMAITRE VALVULOTOME 1009-00

Facility

$6,598.00

Hospital Revenue Code	272
Min. Negotiated Rate	$3,364.98
Max. Negotiated Rate	$6,400.06
Rate for Payer: Cash Price	$3,958.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,268.10
Rate for Payer: Health Management Network Commercial	$5,608.30
Rate for Payer: Kaiser Permanente Commercial	$4,156.74
Rate for Payer: Kaiser Permanente Medicaid	$3,364.98
Rate for Payer: MDX Hawaii PPO	$6,400.06
Rate for Payer: University Health Alliance Commercial	$4,809.28

LEUCOVORIN CALCIUM 100 MG/10ML IJ (WET SOLR VIAL) [4304392]

Facility

$48.00

Service Code	HCPCS J0640
Hospital Revenue Code	636
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Hawaii Western Management Group Commercial	$45.60
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Commercial	$30.24
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: UnitedHealthcare Medicaid	$36.00
Rate for Payer: UnitedHealthcare Medicaid	$28.80
Rate for Payer: University Health Alliance Commercial	$34.99
Rate for Payer: University Health Alliance Commercial	$43.73

LEUCOVORIN CALCIUM 100 MG/10ML IJ (WET SOLR VIAL) [4304392]

Facility

$48.00

Service Code	HCPCS J0640
Hospital Revenue Code	250
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: MDX Hawaii PPO	$58.20

LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]

Facility

$48.00

Service Code	HCPCS J0640
Hospital Revenue Code	636
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Western Management Group Commercial	$45.60
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$30.24
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: UnitedHealthcare Medicaid	$28.80
Rate for Payer: UnitedHealthcare Medicaid	$36.00
Rate for Payer: University Health Alliance Commercial	$34.99
Rate for Payer: University Health Alliance Commercial	$43.73

LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]

Facility

$48.00

Service Code	HCPCS J0640
Hospital Revenue Code	250
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: MDX Hawaii PPO	$46.56

LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]

Facility

$70.00

Service Code	HCPCS J0640
Hospital Revenue Code	636
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$67.90
Rate for Payer: Cash Price	$42.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cash Price	$42.00
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Western Management Group Commercial	$66.50
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Hawaii Western Management Group Commercial	$68.40
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: Kaiser Permanente Commercial	$45.36
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$35.70
Rate for Payer: Kaiser Permanente Medicaid	$36.72
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: MDX Hawaii PPO	$67.90
Rate for Payer: UnitedHealthcare Medicaid	$36.00
Rate for Payer: UnitedHealthcare Medicaid	$43.20
Rate for Payer: UnitedHealthcare Medicaid	$42.00
Rate for Payer: University Health Alliance Commercial	$52.48
Rate for Payer: University Health Alliance Commercial	$43.73
Rate for Payer: University Health Alliance Commercial	$51.02

LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]

Facility

$72.00

Service Code	HCPCS J0640
Hospital Revenue Code	250
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$42.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: MDX Hawaii PPO	$67.90

LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]

Facility

$168.00

Service Code	HCPCS J0640
Hospital Revenue Code	250
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$46.80
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: MDX Hawaii PPO	$75.66

LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]

Facility

$78.00

Service Code	HCPCS J0640
Hospital Revenue Code	636
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$46.80
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Western Management Group Commercial	$159.60
Rate for Payer: Hawaii Western Management Group Commercial	$74.10
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Kaiser Permanente Commercial	$49.14
Rate for Payer: Kaiser Permanente Commercial	$105.84
Rate for Payer: Kaiser Permanente Medicaid	$85.68
Rate for Payer: Kaiser Permanente Medicaid	$39.78
Rate for Payer: MDX Hawaii PPO	$75.66
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: UnitedHealthcare Medicaid	$100.80
Rate for Payer: UnitedHealthcare Medicaid	$46.80
Rate for Payer: University Health Alliance Commercial	$122.46
Rate for Payer: University Health Alliance Commercial	$56.85

LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]

Facility

$156.00

Service Code	HCPCS J0640
Hospital Revenue Code	250
Min. Negotiated Rate	$132.60
Max. Negotiated Rate	$151.32
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$95.40
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: Health Management Network Commercial	$135.15
Rate for Payer: MDX Hawaii PPO	$151.32
Rate for Payer: MDX Hawaii PPO	$154.23

LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]

Facility

$159.00

Service Code	HCPCS J0640
Hospital Revenue Code	636
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$154.23
Rate for Payer: Cash Price	$95.40
Rate for Payer: Cash Price	$95.40
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Western Management Group Commercial	$148.20
Rate for Payer: Hawaii Western Management Group Commercial	$151.05
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: Health Management Network Commercial	$135.15
Rate for Payer: Kaiser Permanente Commercial	$100.17
Rate for Payer: Kaiser Permanente Commercial	$98.28
Rate for Payer: Kaiser Permanente Medicaid	$81.09
Rate for Payer: Kaiser Permanente Medicaid	$79.56
Rate for Payer: MDX Hawaii PPO	$151.32
Rate for Payer: MDX Hawaii PPO	$154.23
Rate for Payer: UnitedHealthcare Medicaid	$95.40
Rate for Payer: UnitedHealthcare Medicaid	$93.60
Rate for Payer: University Health Alliance Commercial	$113.71
Rate for Payer: University Health Alliance Commercial	$115.90

Know your out-of-pocket cost for care.

All Charges