Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PATELLA S39X11MM X3 5550-G-391

Facility

$3,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,031.68
Max. Negotiated Rate	$3,519.16
Rate for Payer: Cash Price	$2,176.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,539.60
Rate for Payer: Health Management Network Commercial	$3,083.80
Rate for Payer: MDX Hawaii PPO	$3,519.16
Rate for Payer: University Health Alliance Commercial	$2,031.68

PATELLA SUTPLT II AR-13070M-S

Facility

$9,318.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$4,752.18
Max. Negotiated Rate	$9,038.46
Rate for Payer: Cash Price	$5,590.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,522.60
Rate for Payer: Health Management Network Commercial	$7,920.30
Rate for Payer: Kaiser Permanente Commercial	$5,870.34
Rate for Payer: Kaiser Permanente Medicaid	$4,752.18
Rate for Payer: MDX Hawaii PPO	$9,038.46
Rate for Payer: University Health Alliance Commercial	$5,218.08

PATELLA SUTPLT II AR-13070M-S

Facility

$9,318.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$5,218.08
Max. Negotiated Rate	$9,038.46
Rate for Payer: Cash Price	$5,590.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,522.60
Rate for Payer: Health Management Network Commercial	$7,920.30
Rate for Payer: MDX Hawaii PPO	$9,038.46
Rate for Payer: University Health Alliance Commercial	$5,218.08

PATELLA SUTRE AR-13070M-P-S

Facility

$7,787.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,971.37
Max. Negotiated Rate	$7,553.39
Rate for Payer: Cash Price	$4,672.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,450.90
Rate for Payer: Health Management Network Commercial	$6,618.95
Rate for Payer: Kaiser Permanente Commercial	$4,905.81
Rate for Payer: Kaiser Permanente Medicaid	$3,971.37
Rate for Payer: MDX Hawaii PPO	$7,553.39
Rate for Payer: University Health Alliance Commercial	$4,360.72

PATELLA SUTRE AR-13070M-P-S

Facility

$7,787.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$4,360.72
Max. Negotiated Rate	$7,553.39
Rate for Payer: Cash Price	$4,672.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,450.90
Rate for Payer: Health Management Network Commercial	$6,618.95
Rate for Payer: MDX Hawaii PPO	$7,553.39
Rate for Payer: University Health Alliance Commercial	$4,360.72

PATELLA X3 S31X9MM 5550-G-319

Facility

$3,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,850.28
Max. Negotiated Rate	$3,519.16
Rate for Payer: Cash Price	$2,176.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,539.60
Rate for Payer: Health Management Network Commercial	$3,083.80
Rate for Payer: Kaiser Permanente Commercial	$2,285.64
Rate for Payer: Kaiser Permanente Medicaid	$1,850.28
Rate for Payer: MDX Hawaii PPO	$3,519.16
Rate for Payer: University Health Alliance Commercial	$2,031.68

PATELLA X3 S31X9MM 5550-G-319

Facility

$3,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,031.68
Max. Negotiated Rate	$3,519.16
Rate for Payer: Cash Price	$2,176.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,539.60
Rate for Payer: Health Management Network Commercial	$3,083.80
Rate for Payer: MDX Hawaii PPO	$3,519.16
Rate for Payer: University Health Alliance Commercial	$2,031.68

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC

Facility

$33,656.94

Service Code	MSDRG 543
Min. Negotiated Rate	$11,692.72
Max. Negotiated Rate	$33,656.94
Rate for Payer: AlohaCare Medicare	$11,692.72
Rate for Payer: Devoted Health Medicare	$12,861.99
Rate for Payer: Hawaii Medical Service Association Commercial	$33,656.94
Rate for Payer: Hawaii Medical Service Association Medicare	$11,692.72
Rate for Payer: Humana Medicare	$11,692.72
Rate for Payer: Kaiser Permanente Commercial	$17,733.00
Rate for Payer: Kaiser Permanente Medicare	$11,692.72
Rate for Payer: Ohana Health Plan Medicare	$11,692.72
Rate for Payer: UnitedHealthcare Medicare	$11,692.72

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC

Facility

$33,656.94

Service Code	MSDRG 542
Min. Negotiated Rate	$20,092.63
Max. Negotiated Rate	$33,656.94
Rate for Payer: AlohaCare Medicare	$20,092.63
Rate for Payer: Devoted Health Medicare	$22,101.89
Rate for Payer: Hawaii Medical Service Association Commercial	$33,656.94
Rate for Payer: Hawaii Medical Service Association Medicare	$20,092.63
Rate for Payer: Humana Medicare	$20,092.63
Rate for Payer: Kaiser Permanente Commercial	$30,472.12
Rate for Payer: Kaiser Permanente Medicare	$20,092.63
Rate for Payer: Ohana Health Plan Medicare	$20,092.63
Rate for Payer: UnitedHealthcare Medicare	$20,092.63

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC

Facility

$33,656.94

Service Code	MSDRG 544
Min. Negotiated Rate	$8,583.01
Max. Negotiated Rate	$33,656.94
Rate for Payer: AlohaCare Medicare	$8,583.01
Rate for Payer: Devoted Health Medicare	$9,441.31
Rate for Payer: Hawaii Medical Service Association Commercial	$33,656.94
Rate for Payer: Hawaii Medical Service Association Medicare	$8,583.01
Rate for Payer: Humana Medicare	$8,583.01
Rate for Payer: Kaiser Permanente Commercial	$13,016.85
Rate for Payer: Kaiser Permanente Medicare	$8,583.01
Rate for Payer: Ohana Health Plan Medicare	$8,583.01
Rate for Payer: UnitedHealthcare Medicare	$8,583.01

PEC REPAIR LG EYELETS AR-2269

Facility

$3,465.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,767.15
Max. Negotiated Rate	$3,361.05
Rate for Payer: Cash Price	$2,079.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,425.50
Rate for Payer: Health Management Network Commercial	$2,945.25
Rate for Payer: Kaiser Permanente Commercial	$2,182.95
Rate for Payer: Kaiser Permanente Medicaid	$1,767.15
Rate for Payer: MDX Hawaii PPO	$3,361.05
Rate for Payer: University Health Alliance Commercial	$1,940.40

PEC REPAIR LG EYELETS AR-2269

Facility

$3,465.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,940.40
Max. Negotiated Rate	$3,361.05
Rate for Payer: Cash Price	$2,079.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,425.50
Rate for Payer: Health Management Network Commercial	$2,945.25
Rate for Payer: MDX Hawaii PPO	$3,361.05
Rate for Payer: University Health Alliance Commercial	$1,940.40

PEG3350 100 GRAM-SOD SULF 7.5 GRAM-NACL-KCL-ASCORBATE-C ORAL PWDR PACK [77400]

Facility

$182.00

Service Code	NDC 68682020175
Hospital Revenue Code	250
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$176.54
Rate for Payer: Cash Price	$109.20
Rate for Payer: Health Management Network Commercial	$154.70
Rate for Payer: MDX Hawaii PPO	$176.54

PEG3350 100 GRAM-SOD SULF 7.5 GRAM-NACL-KCL-ASCORBATE-C ORAL PWDR PACK [77400]

Facility

$182.00

Service Code	NDC 68682020175
Hospital Revenue Code	637
Min. Negotiated Rate	$92.82
Max. Negotiated Rate	$176.54
Rate for Payer: Cash Price	$109.20
Rate for Payer: Hawaii Western Management Group Commercial	$172.90
Rate for Payer: Health Management Network Commercial	$154.70
Rate for Payer: Kaiser Permanente Commercial	$114.66
Rate for Payer: Kaiser Permanente Medicaid	$92.82
Rate for Payer: MDX Hawaii PPO	$176.54
Rate for Payer: University Health Alliance Commercial	$132.66

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]

Facility

$70.00

Service Code	NDC 10572010001
Hospital Revenue Code	250
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$67.90
Rate for Payer: Cash Price	$42.00
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: MDX Hawaii PPO	$67.90

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]

Facility

$80.00

Service Code	NDC 52268010001
Hospital Revenue Code	637
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$77.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Hawaii Western Management Group Commercial	$76.00
Rate for Payer: Health Management Network Commercial	$68.00
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$40.80
Rate for Payer: MDX Hawaii PPO	$77.60
Rate for Payer: University Health Alliance Commercial	$58.31

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]

Facility

$70.00

Service Code	NDC 10572010001
Hospital Revenue Code	637
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$67.90
Rate for Payer: Cash Price	$42.00
Rate for Payer: Hawaii Western Management Group Commercial	$66.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: Kaiser Permanente Medicaid	$35.70
Rate for Payer: MDX Hawaii PPO	$67.90
Rate for Payer: University Health Alliance Commercial	$51.02

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]

Facility

$80.00

Service Code	NDC 52268010001
Hospital Revenue Code	250
Min. Negotiated Rate	$68.00
Max. Negotiated Rate	$77.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Health Management Network Commercial	$68.00
Rate for Payer: MDX Hawaii PPO	$77.60

PEG CEMENTED 40MM 5542-P-0040

Facility

$9,208.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,696.08
Max. Negotiated Rate	$8,931.76
Rate for Payer: Cash Price	$5,524.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,445.60
Rate for Payer: Health Management Network Commercial	$7,826.80
Rate for Payer: Kaiser Permanente Commercial	$5,801.04
Rate for Payer: Kaiser Permanente Medicaid	$4,696.08
Rate for Payer: MDX Hawaii PPO	$8,931.76
Rate for Payer: University Health Alliance Commercial	$5,156.48

PEG CEMENTED 40MM 5542-P-0040

Facility

$9,208.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,156.48
Max. Negotiated Rate	$8,931.76
Rate for Payer: Cash Price	$5,524.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,445.60
Rate for Payer: Health Management Network Commercial	$7,826.80
Rate for Payer: MDX Hawaii PPO	$8,931.76
Rate for Payer: University Health Alliance Commercial	$5,156.48

PEG DRILL 1/4" #6541-4-525

Facility

$1,729.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,469.65
Max. Negotiated Rate	$1,677.13
Rate for Payer: Cash Price	$1,037.40
Rate for Payer: Health Management Network Commercial	$1,469.65
Rate for Payer: MDX Hawaii PPO	$1,677.13

PEG DRILL 1/4" #6541-4-525

Facility

$1,729.00

Hospital Revenue Code	272
Min. Negotiated Rate	$881.79
Max. Negotiated Rate	$1,677.13
Rate for Payer: Cash Price	$1,037.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,642.55
Rate for Payer: Health Management Network Commercial	$1,469.65
Rate for Payer: Kaiser Permanente Commercial	$1,089.27
Rate for Payer: Kaiser Permanente Medicaid	$881.79
Rate for Payer: MDX Hawaii PPO	$1,677.13
Rate for Payer: University Health Alliance Commercial	$1,260.27

PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR [129658]

Facility

$8,202.00

Service Code	HCPCS J2506
Hospital Revenue Code	636
Min. Negotiated Rate	$58.40
Max. Negotiated Rate	$7,955.94
Rate for Payer: AlohaCare Medicaid	$127.38
Rate for Payer: AlohaCare Medicare	$127.38
Rate for Payer: Cash Price	$4,921.20
Rate for Payer: Cash Price	$4,921.20
Rate for Payer: Devoted Health Medicare	$140.12
Rate for Payer: Hawaii Medical Service Association ABD	$58.40
Rate for Payer: Hawaii Medical Service Association Commercial	$159.22
Rate for Payer: Hawaii Medical Service Association Medicare	$127.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$58.40
Rate for Payer: Hawaii Western Management Group Commercial	$7,791.90
Rate for Payer: Health Management Network Commercial	$6,971.70
Rate for Payer: Humana Medicare	$127.38
Rate for Payer: Kaiser Permanente Commercial	$5,167.26
Rate for Payer: Kaiser Permanente Medicaid	$4,183.02
Rate for Payer: Kaiser Permanente Medicare	$127.38
Rate for Payer: MDX Hawaii PPO	$7,955.94
Rate for Payer: Ohana Health Plan Medicaid	$140.12
Rate for Payer: Ohana Health Plan Medicare	$127.38
Rate for Payer: UnitedHealthcare Medicaid	$4,921.20
Rate for Payer: UnitedHealthcare Medicare	$127.38
Rate for Payer: University Health Alliance Commercial	$5,978.44

PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR [129658]

Facility

$8,202.00

Service Code	HCPCS J2506
Hospital Revenue Code	250
Min. Negotiated Rate	$6,971.70
Max. Negotiated Rate	$7,955.94
Rate for Payer: Cash Price	$4,921.20
Rate for Payer: Health Management Network Commercial	$6,971.70
Rate for Payer: MDX Hawaii PPO	$7,955.94

PEGFILGRASTIM-APGF 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [176068]

Facility

$5,210.00

Service Code	HCPCS Q5122
Hospital Revenue Code	250
Min. Negotiated Rate	$4,428.50
Max. Negotiated Rate	$5,053.70
Rate for Payer: Cash Price	$3,126.00
Rate for Payer: Health Management Network Commercial	$4,428.50
Rate for Payer: MDX Hawaii PPO	$5,053.70

Know your out-of-pocket cost for care.

All Charges