Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

LOSARTAN 50 MG TABLET [14824]

Facility

$8.00

Service Code	NDC 68084034701
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$7.76

LOSARTAN TABLETS (COZAAR) 25 MG (TAKE HOME) [4080371]

Facility

$15.00

Service Code	NDC 00004080159
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: MDX Hawaii PPO	$14.55

LOSARTAN TABLETS (COZAAR) 25 MG (TAKE HOME) [4080371]

Facility

$15.00

Service Code	NDC 00004080159
Hospital Revenue Code	253
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$9.45
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: University Health Alliance Commercial	$10.93

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC

Facility

$56,054.46

Service Code	MSDRG 493
Min. Negotiated Rate	$28,846.25
Max. Negotiated Rate	$56,054.46
Rate for Payer: AlohaCare Medicare	$28,846.25
Rate for Payer: Devoted Health Medicare	$31,730.88
Rate for Payer: Hawaii Medical Service Association Commercial	$56,054.46
Rate for Payer: Hawaii Medical Service Association Medicare	$28,846.25
Rate for Payer: Humana Medicare	$28,846.25
Rate for Payer: Kaiser Permanente Commercial	$43,747.72
Rate for Payer: Kaiser Permanente Medicare	$28,846.25
Rate for Payer: Ohana Health Plan Medicare	$28,846.25
Rate for Payer: UnitedHealthcare Medicare	$28,846.25

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC

Facility

$63,335.10

Service Code	MSDRG 492
Min. Negotiated Rate	$41,761.72
Max. Negotiated Rate	$63,335.10
Rate for Payer: AlohaCare Medicare	$41,761.72
Rate for Payer: Devoted Health Medicare	$45,937.89
Rate for Payer: Hawaii Medical Service Association Commercial	$56,054.46
Rate for Payer: Hawaii Medical Service Association Medicare	$41,761.72
Rate for Payer: Humana Medicare	$41,761.72
Rate for Payer: Kaiser Permanente Commercial	$63,335.10
Rate for Payer: Kaiser Permanente Medicare	$41,761.72
Rate for Payer: Ohana Health Plan Medicare	$41,761.72
Rate for Payer: UnitedHealthcare Medicare	$41,761.72

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC

Facility

$34,612.12

Service Code	MSDRG 494
Min. Negotiated Rate	$22,822.45
Max. Negotiated Rate	$34,612.12
Rate for Payer: AlohaCare Medicare	$22,822.45
Rate for Payer: Devoted Health Medicare	$25,104.69
Rate for Payer: Hawaii Medical Service Association Commercial	$33,098.82
Rate for Payer: Hawaii Medical Service Association Medicare	$22,822.45
Rate for Payer: Humana Medicare	$22,822.45
Rate for Payer: Kaiser Permanente Commercial	$34,612.12
Rate for Payer: Kaiser Permanente Medicare	$22,822.45
Rate for Payer: Ohana Health Plan Medicare	$22,822.45
Rate for Payer: UnitedHealthcare Medicare	$22,822.45

LOWER EXTREMITY ARTERIAL PROCEDURES

Facility

$10,921.73

Service Code	APR-DRG 1812
Min. Negotiated Rate	$10,921.73
Max. Negotiated Rate	$10,921.73
Rate for Payer: AlohaCare Medicaid	$10,921.73
Rate for Payer: Hawaii Medical Service Association ABD	$10,921.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,921.73
Rate for Payer: Kaiser Permanente Medicaid	$10,921.73
Rate for Payer: Ohana Health Plan Medicaid	$10,921.73
Rate for Payer: UnitedHealthcare Medicaid	$10,921.73

LOWER EXTREMITY ARTERIAL PROCEDURES

Facility

$26,325.90

Service Code	APR-DRG 1814
Min. Negotiated Rate	$26,325.90
Max. Negotiated Rate	$26,325.90
Rate for Payer: AlohaCare Medicaid	$26,325.90
Rate for Payer: Hawaii Medical Service Association ABD	$26,325.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26,325.90
Rate for Payer: Kaiser Permanente Medicaid	$26,325.90
Rate for Payer: Ohana Health Plan Medicaid	$26,325.90
Rate for Payer: UnitedHealthcare Medicaid	$26,325.90

LOWER EXTREMITY ARTERIAL PROCEDURES

Facility

$8,062.80

Service Code	APR-DRG 1811
Min. Negotiated Rate	$8,062.80
Max. Negotiated Rate	$8,062.80
Rate for Payer: AlohaCare Medicaid	$8,062.80
Rate for Payer: Hawaii Medical Service Association ABD	$8,062.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,062.80
Rate for Payer: Kaiser Permanente Medicaid	$8,062.80
Rate for Payer: Ohana Health Plan Medicaid	$8,062.80
Rate for Payer: UnitedHealthcare Medicaid	$8,062.80

LOWER EXTREMITY ARTERIAL PROCEDURES

Facility

$16,719.16

Service Code	APR-DRG 1813
Min. Negotiated Rate	$16,719.16
Max. Negotiated Rate	$16,719.16
Rate for Payer: AlohaCare Medicaid	$16,719.16
Rate for Payer: Hawaii Medical Service Association ABD	$16,719.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16,719.16
Rate for Payer: Kaiser Permanente Medicaid	$16,719.16
Rate for Payer: Ohana Health Plan Medicaid	$16,719.16
Rate for Payer: UnitedHealthcare Medicaid	$16,719.16

LOW INTENSITY HEPARIN CALCULATOR BOLUS [4080207]

Facility

$17.00

Service Code	HCPCS J1644
Hospital Revenue Code	636
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$10.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$9.45
Rate for Payer: Kaiser Permanente Commercial	$10.71
Rate for Payer: Kaiser Permanente Commercial	$19.53
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: UnitedHealthcare Medicaid	$9.00
Rate for Payer: UnitedHealthcare Medicaid	$10.20
Rate for Payer: UnitedHealthcare Medicaid	$18.60
Rate for Payer: University Health Alliance Commercial	$12.39
Rate for Payer: University Health Alliance Commercial	$10.93
Rate for Payer: University Health Alliance Commercial	$22.60

LOW INTENSITY HEPARIN CALCULATOR BOLUS [4080207]

Facility

$31.00

Service Code	HCPCS J1644
Hospital Revenue Code	250
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: MDX Hawaii PPO	$16.49

LUNG TRANSPLANT

Facility

$223,390.95

Service Code	MSDRG 007
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$223,390.95
Rate for Payer: AlohaCare Medicare	$147,298.89
Rate for Payer: Devoted Health Medicare	$162,028.78
Rate for Payer: Hawaii Medical Service Association Medicare	$147,298.89
Rate for Payer: Kaiser Permanente Commercial	$223,390.95
Rate for Payer: Kaiser Permanente Medicare	$147,298.89
Rate for Payer: Ohana Health Plan Medicare	$147,298.89
Rate for Payer: UnitedHealthcare Medicare	$147,298.89
Rate for Payer: University Health Alliance Commercial	$10,400.00

LURASIDONE 20 MG TABLET [113587]

Facility

$95.00

Service Code	NDC 62332049430
Hospital Revenue Code	250
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$57.00
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: MDX Hawaii PPO	$92.15

LURASIDONE 20 MG TABLET [113587]

Facility

$95.00

Service Code	NDC 62332049430
Hospital Revenue Code	637
Min. Negotiated Rate	$48.45
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$57.00
Rate for Payer: Hawaii Western Management Group Commercial	$90.25
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Kaiser Permanente Commercial	$59.85
Rate for Payer: Kaiser Permanente Medicaid	$48.45
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: University Health Alliance Commercial	$69.25

LURASIDONE 40 MG TABLET [107668]

Facility

$103.00

Service Code	NDC 47335068483
Hospital Revenue Code	250
Min. Negotiated Rate	$87.55
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$61.80
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: MDX Hawaii PPO	$99.91

LURASIDONE 40 MG TABLET [107668]

Facility

$95.00

Service Code	NDC 62332049530
Hospital Revenue Code	637
Min. Negotiated Rate	$48.45
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$57.00
Rate for Payer: Hawaii Western Management Group Commercial	$90.25
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Kaiser Permanente Commercial	$59.85
Rate for Payer: Kaiser Permanente Medicaid	$48.45
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: University Health Alliance Commercial	$69.25

LURASIDONE 40 MG TABLET [107668]

Facility

$103.00

Service Code	NDC 47335068483
Hospital Revenue Code	637
Min. Negotiated Rate	$52.53
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$61.80
Rate for Payer: Hawaii Western Management Group Commercial	$97.85
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Kaiser Permanente Commercial	$64.89
Rate for Payer: Kaiser Permanente Medicaid	$52.53
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: University Health Alliance Commercial	$75.08

LURASIDONE 40 MG TABLET [107668]

Facility

$95.00

Service Code	NDC 62332049530
Hospital Revenue Code	250
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$57.00
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: MDX Hawaii PPO	$92.15

LURBINECTEDIN 4 MG/8 ML IV (WET SOLR VIAL) [430173604]

Facility

$10,400.00

Service Code	HCPCS J9223
Hospital Revenue Code	250
Min. Negotiated Rate	$8,840.00
Max. Negotiated Rate	$10,088.00
Rate for Payer: Cash Price	$6,240.00
Rate for Payer: Health Management Network Commercial	$8,840.00
Rate for Payer: MDX Hawaii PPO	$10,088.00

LURBINECTEDIN 4 MG/8 ML IV (WET SOLR VIAL) [430173604]

Facility

$10,400.00

Service Code	HCPCS J9223
Hospital Revenue Code	636
Min. Negotiated Rate	$206.13
Max. Negotiated Rate	$10,088.00
Rate for Payer: AlohaCare Medicaid	$212.10
Rate for Payer: AlohaCare Medicare	$212.10
Rate for Payer: Cash Price	$6,240.00
Rate for Payer: Cash Price	$6,240.00
Rate for Payer: Devoted Health Medicare	$233.31
Rate for Payer: Hawaii Medical Service Association ABD	$206.13
Rate for Payer: Hawaii Medical Service Association Commercial	$265.12
Rate for Payer: Hawaii Medical Service Association Medicare	$212.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$206.13
Rate for Payer: Hawaii Western Management Group Commercial	$9,880.00
Rate for Payer: Health Management Network Commercial	$8,840.00
Rate for Payer: Humana Medicare	$212.10
Rate for Payer: Kaiser Permanente Commercial	$6,552.00
Rate for Payer: Kaiser Permanente Medicaid	$5,304.00
Rate for Payer: Kaiser Permanente Medicare	$212.10
Rate for Payer: MDX Hawaii PPO	$10,088.00
Rate for Payer: Ohana Health Plan Medicaid	$233.31
Rate for Payer: Ohana Health Plan Medicare	$212.10
Rate for Payer: UnitedHealthcare Medicaid	$6,240.00
Rate for Payer: UnitedHealthcare Medicare	$212.10
Rate for Payer: University Health Alliance Commercial	$7,580.56

LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [173604]

Facility

$10,400.00

Service Code	HCPCS J9223
Hospital Revenue Code	250
Min. Negotiated Rate	$8,840.00
Max. Negotiated Rate	$10,088.00
Rate for Payer: Cash Price	$6,240.00
Rate for Payer: Cash Price	$7,333.20
Rate for Payer: Health Management Network Commercial	$10,388.70
Rate for Payer: Health Management Network Commercial	$8,840.00
Rate for Payer: MDX Hawaii PPO	$10,088.00
Rate for Payer: MDX Hawaii PPO	$11,855.34

LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [173604]

Facility

$12,222.00

Service Code	HCPCS J9223
Hospital Revenue Code	636
Min. Negotiated Rate	$206.13
Max. Negotiated Rate	$11,855.34
Rate for Payer: AlohaCare Medicaid	$212.10
Rate for Payer: AlohaCare Medicaid	$212.10
Rate for Payer: AlohaCare Medicare	$212.10
Rate for Payer: AlohaCare Medicare	$212.10
Rate for Payer: Cash Price	$6,240.00
Rate for Payer: Cash Price	$6,240.00
Rate for Payer: Cash Price	$7,333.20
Rate for Payer: Cash Price	$7,333.20
Rate for Payer: Devoted Health Medicare	$233.31
Rate for Payer: Devoted Health Medicare	$233.31
Rate for Payer: Hawaii Medical Service Association ABD	$206.13
Rate for Payer: Hawaii Medical Service Association ABD	$206.13
Rate for Payer: Hawaii Medical Service Association Commercial	$265.12
Rate for Payer: Hawaii Medical Service Association Commercial	$265.12
Rate for Payer: Hawaii Medical Service Association Medicare	$212.10
Rate for Payer: Hawaii Medical Service Association Medicare	$212.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$206.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$206.13
Rate for Payer: Hawaii Western Management Group Commercial	$9,880.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,610.90
Rate for Payer: Health Management Network Commercial	$8,840.00
Rate for Payer: Health Management Network Commercial	$10,388.70
Rate for Payer: Humana Medicare	$212.10
Rate for Payer: Humana Medicare	$212.10
Rate for Payer: Kaiser Permanente Commercial	$6,552.00
Rate for Payer: Kaiser Permanente Commercial	$7,699.86
Rate for Payer: Kaiser Permanente Medicaid	$6,233.22
Rate for Payer: Kaiser Permanente Medicaid	$5,304.00
Rate for Payer: Kaiser Permanente Medicare	$212.10
Rate for Payer: Kaiser Permanente Medicare	$212.10
Rate for Payer: MDX Hawaii PPO	$10,088.00
Rate for Payer: MDX Hawaii PPO	$11,855.34
Rate for Payer: Ohana Health Plan Medicaid	$233.31
Rate for Payer: Ohana Health Plan Medicaid	$233.31
Rate for Payer: Ohana Health Plan Medicare	$212.10
Rate for Payer: Ohana Health Plan Medicare	$212.10
Rate for Payer: UnitedHealthcare Medicaid	$7,333.20
Rate for Payer: UnitedHealthcare Medicaid	$6,240.00
Rate for Payer: UnitedHealthcare Medicare	$212.10
Rate for Payer: UnitedHealthcare Medicare	$212.10
Rate for Payer: University Health Alliance Commercial	$7,580.56
Rate for Payer: University Health Alliance Commercial	$8,908.62

LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION [170335]

Facility

$5,436.00

Service Code	HCPCS J0896
Hospital Revenue Code	636
Min. Negotiated Rate	$41.96
Max. Negotiated Rate	$5,272.92
Rate for Payer: AlohaCare Medicaid	$42.75
Rate for Payer: AlohaCare Medicare	$42.75
Rate for Payer: Cash Price	$3,261.60
Rate for Payer: Cash Price	$3,261.60
Rate for Payer: Devoted Health Medicare	$47.02
Rate for Payer: Hawaii Medical Service Association ABD	$41.96
Rate for Payer: Hawaii Medical Service Association Commercial	$53.44
Rate for Payer: Hawaii Medical Service Association Medicare	$42.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$41.96
Rate for Payer: Hawaii Western Management Group Commercial	$5,164.20
Rate for Payer: Health Management Network Commercial	$4,620.60
Rate for Payer: Humana Medicare	$42.75
Rate for Payer: Kaiser Permanente Commercial	$3,424.68
Rate for Payer: Kaiser Permanente Medicaid	$2,772.36
Rate for Payer: Kaiser Permanente Medicare	$42.75
Rate for Payer: MDX Hawaii PPO	$5,272.92
Rate for Payer: Ohana Health Plan Medicaid	$47.02
Rate for Payer: Ohana Health Plan Medicare	$42.75
Rate for Payer: UnitedHealthcare Medicaid	$3,261.60
Rate for Payer: UnitedHealthcare Medicare	$42.75
Rate for Payer: University Health Alliance Commercial	$3,962.30

LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION [170335]

Facility

$5,436.00

Service Code	HCPCS J0896
Hospital Revenue Code	250
Min. Negotiated Rate	$4,620.60
Max. Negotiated Rate	$5,272.92
Rate for Payer: Cash Price	$3,261.60
Rate for Payer: Health Management Network Commercial	$4,620.60
Rate for Payer: MDX Hawaii PPO	$5,272.92

Know your out-of-pocket cost for care.

All Charges