Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

OMNIFIT HIP STEM#9 #6097-0940

Facility

$3,096.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,733.76
Max. Negotiated Rate	$3,003.12
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,167.20
Rate for Payer: Health Management Network Commercial	$2,631.60
Rate for Payer: MDX Hawaii PPO	$3,003.12
Rate for Payer: University Health Alliance Commercial	$1,733.76

OMNIFIT HIP STEM#9 #6097-0940

Facility

$3,096.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,578.96
Max. Negotiated Rate	$3,003.12
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,167.20
Rate for Payer: Health Management Network Commercial	$2,631.60
Rate for Payer: Kaiser Permanente Commercial	$1,950.48
Rate for Payer: Kaiser Permanente Medicaid	$1,578.96
Rate for Payer: MDX Hawaii PPO	$3,003.12
Rate for Payer: University Health Alliance Commercial	$1,733.76

ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [100610]

Facility

$1,172.00

Service Code	HCPCS J0585
Hospital Revenue Code	250
Min. Negotiated Rate	$996.20
Max. Negotiated Rate	$1,136.84
Rate for Payer: Cash Price	$703.20
Rate for Payer: Health Management Network Commercial	$996.20
Rate for Payer: MDX Hawaii PPO	$1,136.84

ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [100610]

Facility

$1,172.00

Service Code	HCPCS J0585
Hospital Revenue Code	636
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$1,136.84
Rate for Payer: AlohaCare Medicaid	$6.51
Rate for Payer: AlohaCare Medicare	$6.51
Rate for Payer: Cash Price	$703.20
Rate for Payer: Cash Price	$703.20
Rate for Payer: Devoted Health Medicare	$7.16
Rate for Payer: Hawaii Medical Service Association ABD	$6.50
Rate for Payer: Hawaii Medical Service Association Commercial	$8.14
Rate for Payer: Hawaii Medical Service Association Medicare	$6.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,113.40
Rate for Payer: Health Management Network Commercial	$996.20
Rate for Payer: Humana Medicare	$6.51
Rate for Payer: Kaiser Permanente Commercial	$738.36
Rate for Payer: Kaiser Permanente Medicaid	$597.72
Rate for Payer: Kaiser Permanente Medicare	$6.51
Rate for Payer: MDX Hawaii PPO	$1,136.84
Rate for Payer: Ohana Health Plan Medicaid	$7.16
Rate for Payer: Ohana Health Plan Medicare	$6.51
Rate for Payer: UnitedHealthcare Medicaid	$703.20
Rate for Payer: UnitedHealthcare Medicare	$6.51
Rate for Payer: University Health Alliance Commercial	$854.27

ONCONTROL BONE LESION TRAY

Facility

$600.00

Hospital Revenue Code	272
Min. Negotiated Rate	$306.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Hawaii Western Management Group Commercial	$570.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Kaiser Permanente Commercial	$378.00
Rate for Payer: Kaiser Permanente Medicaid	$306.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: University Health Alliance Commercial	$437.34

ONCONTROL BONE LESION TRAY

Facility

$600.00

Hospital Revenue Code	272
Min. Negotiated Rate	$510.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: MDX Hawaii PPO	$582.00

ONCONTROL BONE MARROW TRAY

Facility

$600.00

Hospital Revenue Code	272
Min. Negotiated Rate	$510.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: MDX Hawaii PPO	$582.00

ONCONTROL BONE MARROW TRAY

Facility

$600.00

Hospital Revenue Code	272
Min. Negotiated Rate	$306.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Hawaii Western Management Group Commercial	$570.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Kaiser Permanente Commercial	$378.00
Rate for Payer: Kaiser Permanente Medicaid	$306.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: University Health Alliance Commercial	$437.34

ONDANSETRON 16 MG IN 50 ML NS IVPB-CNR FROM MDV (SIMPLE) [4080023]

Facility

$16.00

Service Code	HCPCS J2405
Hospital Revenue Code	250
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: MDX Hawaii PPO	$15.52

ONDANSETRON 16 MG IN 50 ML NS IVPB-CNR FROM MDV (SIMPLE) [4080023]

Facility

$16.00

Service Code	HCPCS J2405
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$9.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Western Management Group Commercial	$15.20
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Kaiser Permanente Commercial	$10.08
Rate for Payer: Kaiser Permanente Medicaid	$8.16
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: UnitedHealthcare Medicaid	$9.60
Rate for Payer: University Health Alliance Commercial	$11.66

ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]

Facility

$56.00

Service Code	HCPCS Q0162
Hospital Revenue Code	250
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cash Price	$34.80
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: MDX Hawaii PPO	$56.26

ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]

Facility

$58.00

Service Code	HCPCS Q0162
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$56.26
Rate for Payer: Cash Price	$34.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cash Price	$34.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$53.20
Rate for Payer: Hawaii Western Management Group Commercial	$55.10
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$36.54
Rate for Payer: Kaiser Permanente Commercial	$35.28
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: Kaiser Permanente Medicaid	$29.58
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: MDX Hawaii PPO	$56.26
Rate for Payer: UnitedHealthcare Medicaid	$34.80
Rate for Payer: UnitedHealthcare Medicaid	$33.60
Rate for Payer: University Health Alliance Commercial	$42.28
Rate for Payer: University Health Alliance Commercial	$40.82

ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION [106349]

Facility

$37.00

Service Code	HCPCS J2405
Hospital Revenue Code	250
Min. Negotiated Rate	$31.45
Max. Negotiated Rate	$35.89
Rate for Payer: Cash Price	$22.20
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: MDX Hawaii PPO	$35.89

ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION [106349]

Facility

$37.00

Service Code	HCPCS J2405
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$35.89
Rate for Payer: Cash Price	$22.20
Rate for Payer: Cash Price	$22.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Western Management Group Commercial	$35.15
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Kaiser Permanente Commercial	$23.31
Rate for Payer: Kaiser Permanente Medicaid	$18.87
Rate for Payer: MDX Hawaii PPO	$35.89
Rate for Payer: UnitedHealthcare Medicaid	$22.20
Rate for Payer: University Health Alliance Commercial	$26.97

ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]

Facility

$4.00

Service Code	HCPCS J2405
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$4.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Commercial	$4.41
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: UnitedHealthcare Medicaid	$2.40
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: University Health Alliance Commercial	$5.10
Rate for Payer: University Health Alliance Commercial	$2.19
Rate for Payer: University Health Alliance Commercial	$2.92
Rate for Payer: University Health Alliance Commercial	$4.37

ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION [106348]

Facility

$4.00

Service Code	HCPCS J2405
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: MDX Hawaii PPO	$2.91

ONDANSETRON ODT (ZOFRAN) 4 MG (TAKE HOME) [4080383]

Facility

$15.00

Service Code	HCPCS Q0162
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

ONDANSETRON ODT (ZOFRAN) 4 MG (TAKE HOME) [4080383]

Facility

$15.00

Service Code	HCPCS Q0162
Hospital Revenue Code	253
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
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: UnitedHealthcare Medicaid	$0.01
Rate for Payer: University Health Alliance Commercial	$10.93

OPEN CRANIOTOMY EXCEPT TRAUMA

Facility

$29,551.41

Service Code	APR-DRG 0214
Min. Negotiated Rate	$29,551.41
Max. Negotiated Rate	$29,551.41
Rate for Payer: AlohaCare Medicaid	$29,551.41
Rate for Payer: Hawaii Medical Service Association ABD	$29,551.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29,551.41
Rate for Payer: Kaiser Permanente Medicaid	$29,551.41
Rate for Payer: Ohana Health Plan Medicaid	$29,551.41
Rate for Payer: UnitedHealthcare Medicaid	$29,551.41

OPEN CRANIOTOMY EXCEPT TRAUMA

Facility

$13,889.59

Service Code	APR-DRG 0212
Min. Negotiated Rate	$13,889.59
Max. Negotiated Rate	$13,889.59
Rate for Payer: AlohaCare Medicaid	$13,889.59
Rate for Payer: Hawaii Medical Service Association ABD	$13,889.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,889.59
Rate for Payer: Kaiser Permanente Medicaid	$13,889.59
Rate for Payer: Ohana Health Plan Medicaid	$13,889.59
Rate for Payer: UnitedHealthcare Medicaid	$13,889.59

OPEN CRANIOTOMY EXCEPT TRAUMA

Facility

$10,315.11

Service Code	APR-DRG 0211
Min. Negotiated Rate	$10,315.11
Max. Negotiated Rate	$10,315.11
Rate for Payer: AlohaCare Medicaid	$10,315.11
Rate for Payer: Hawaii Medical Service Association ABD	$10,315.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,315.11
Rate for Payer: Kaiser Permanente Medicaid	$10,315.11
Rate for Payer: Ohana Health Plan Medicaid	$10,315.11
Rate for Payer: UnitedHealthcare Medicaid	$10,315.11

OPEN CRANIOTOMY EXCEPT TRAUMA

Facility

$19,578.75

Service Code	APR-DRG 0213
Min. Negotiated Rate	$19,578.75
Max. Negotiated Rate	$19,578.75
Rate for Payer: AlohaCare Medicaid	$19,578.75
Rate for Payer: Hawaii Medical Service Association ABD	$19,578.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19,578.75
Rate for Payer: Kaiser Permanente Medicaid	$19,578.75
Rate for Payer: Ohana Health Plan Medicaid	$19,578.75
Rate for Payer: UnitedHealthcare Medicaid	$19,578.75

OPEN CRANIOTOMY FOR TRAUMA

Facility

$18,952.50

Service Code	APR-DRG 0203
Min. Negotiated Rate	$18,952.50
Max. Negotiated Rate	$18,952.50
Rate for Payer: AlohaCare Medicaid	$18,952.50
Rate for Payer: Hawaii Medical Service Association ABD	$18,952.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18,952.50
Rate for Payer: Kaiser Permanente Medicaid	$18,952.50
Rate for Payer: Ohana Health Plan Medicaid	$18,952.50
Rate for Payer: UnitedHealthcare Medicaid	$18,952.50

OPEN CRANIOTOMY FOR TRAUMA

Facility

$31,345.95

Service Code	APR-DRG 0204
Min. Negotiated Rate	$31,345.95
Max. Negotiated Rate	$31,345.95
Rate for Payer: AlohaCare Medicaid	$31,345.95
Rate for Payer: Hawaii Medical Service Association ABD	$31,345.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$31,345.95
Rate for Payer: Kaiser Permanente Medicaid	$31,345.95
Rate for Payer: Ohana Health Plan Medicaid	$31,345.95
Rate for Payer: UnitedHealthcare Medicaid	$31,345.95

OPEN CRANIOTOMY FOR TRAUMA

Facility

$12,299.69

Service Code	APR-DRG 0201
Min. Negotiated Rate	$12,299.69
Max. Negotiated Rate	$12,299.69
Rate for Payer: AlohaCare Medicaid	$12,299.69
Rate for Payer: Hawaii Medical Service Association ABD	$12,299.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12,299.69
Rate for Payer: Kaiser Permanente Medicaid	$12,299.69
Rate for Payer: Ohana Health Plan Medicaid	$12,299.69
Rate for Payer: UnitedHealthcare Medicaid	$12,299.69

Know your out-of-pocket cost for care.

All Charges