Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$5,210.00

Service Code	HCPCS Q5122
Hospital Revenue Code	636
Min. Negotiated Rate	$132.04
Max. Negotiated Rate	$5,053.70
Rate for Payer: AlohaCare Medicaid	$133.31
Rate for Payer: AlohaCare Medicare	$133.31
Rate for Payer: Cash Price	$3,126.00
Rate for Payer: Cash Price	$3,126.00
Rate for Payer: Devoted Health Medicare	$146.64
Rate for Payer: Hawaii Medical Service Association ABD	$132.04
Rate for Payer: Hawaii Medical Service Association Commercial	$166.64
Rate for Payer: Hawaii Medical Service Association Medicare	$133.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$132.04
Rate for Payer: Hawaii Western Management Group Commercial	$4,949.50
Rate for Payer: Health Management Network Commercial	$4,428.50
Rate for Payer: Humana Medicare	$133.31
Rate for Payer: Kaiser Permanente Commercial	$3,282.30
Rate for Payer: Kaiser Permanente Medicaid	$2,657.10
Rate for Payer: Kaiser Permanente Medicare	$133.31
Rate for Payer: MDX Hawaii PPO	$5,053.70
Rate for Payer: Ohana Health Plan Medicaid	$146.64
Rate for Payer: Ohana Health Plan Medicare	$133.31
Rate for Payer: UnitedHealthcare Medicaid	$3,126.00
Rate for Payer: UnitedHealthcare Medicare	$133.31
Rate for Payer: University Health Alliance Commercial	$3,797.57

PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR [196326]

Facility

$5,510.00

Service Code	HCPCS Q5111
Hospital Revenue Code	250
Min. Negotiated Rate	$4,683.50
Max. Negotiated Rate	$5,344.70
Rate for Payer: Cash Price	$3,306.00
Rate for Payer: Health Management Network Commercial	$4,683.50
Rate for Payer: MDX Hawaii PPO	$5,344.70

PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR [196326]

Facility

$5,510.00

Service Code	HCPCS Q5111
Hospital Revenue Code	636
Min. Negotiated Rate	$135.89
Max. Negotiated Rate	$5,344.70
Rate for Payer: AlohaCare Medicaid	$135.89
Rate for Payer: AlohaCare Medicare	$135.89
Rate for Payer: Cash Price	$3,306.00
Rate for Payer: Cash Price	$3,306.00
Rate for Payer: Devoted Health Medicare	$149.48
Rate for Payer: Hawaii Medical Service Association ABD	$136.04
Rate for Payer: Hawaii Medical Service Association Commercial	$169.86
Rate for Payer: Hawaii Medical Service Association Medicare	$135.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.04
Rate for Payer: Hawaii Western Management Group Commercial	$5,234.50
Rate for Payer: Health Management Network Commercial	$4,683.50
Rate for Payer: Humana Medicare	$135.89
Rate for Payer: Kaiser Permanente Commercial	$3,471.30
Rate for Payer: Kaiser Permanente Medicaid	$2,810.10
Rate for Payer: Kaiser Permanente Medicare	$135.89
Rate for Payer: MDX Hawaii PPO	$5,344.70
Rate for Payer: Ohana Health Plan Medicaid	$149.48
Rate for Payer: Ohana Health Plan Medicare	$135.89
Rate for Payer: UnitedHealthcare Medicaid	$3,306.00
Rate for Payer: UnitedHealthcare Medicare	$135.89
Rate for Payer: University Health Alliance Commercial	$4,016.24

PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [164810]

Facility

$5,510.00

Service Code	HCPCS Q5111
Hospital Revenue Code	636
Min. Negotiated Rate	$135.89
Max. Negotiated Rate	$5,344.70
Rate for Payer: AlohaCare Medicaid	$135.89
Rate for Payer: AlohaCare Medicare	$135.89
Rate for Payer: Cash Price	$3,306.00
Rate for Payer: Cash Price	$3,306.00
Rate for Payer: Devoted Health Medicare	$149.48
Rate for Payer: Hawaii Medical Service Association ABD	$136.04
Rate for Payer: Hawaii Medical Service Association Commercial	$169.86
Rate for Payer: Hawaii Medical Service Association Medicare	$135.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.04
Rate for Payer: Hawaii Western Management Group Commercial	$5,234.50
Rate for Payer: Health Management Network Commercial	$4,683.50
Rate for Payer: Humana Medicare	$135.89
Rate for Payer: Kaiser Permanente Commercial	$3,471.30
Rate for Payer: Kaiser Permanente Medicaid	$2,810.10
Rate for Payer: Kaiser Permanente Medicare	$135.89
Rate for Payer: MDX Hawaii PPO	$5,344.70
Rate for Payer: Ohana Health Plan Medicaid	$149.48
Rate for Payer: Ohana Health Plan Medicare	$135.89
Rate for Payer: UnitedHealthcare Medicaid	$3,306.00
Rate for Payer: UnitedHealthcare Medicare	$135.89
Rate for Payer: University Health Alliance Commercial	$4,016.24

PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [164810]

Facility

$5,510.00

Service Code	HCPCS Q5111
Hospital Revenue Code	250
Min. Negotiated Rate	$4,683.50
Max. Negotiated Rate	$5,344.70
Rate for Payer: Cash Price	$3,306.00
Rate for Payer: Health Management Network Commercial	$4,683.50
Rate for Payer: MDX Hawaii PPO	$5,344.70

PEGINTERFERON ALFA-2A 180 MCG/ML SUBCUTANEOUS SOLUTION [34034]

Facility

$1,837.00

Service Code	HCPCS S0145
Hospital Revenue Code	636
Min. Negotiated Rate	$936.87
Max. Negotiated Rate	$1,781.89
Rate for Payer: Cash Price	$1,102.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,745.15
Rate for Payer: Health Management Network Commercial	$1,561.45
Rate for Payer: Kaiser Permanente Commercial	$1,157.31
Rate for Payer: Kaiser Permanente Medicaid	$936.87
Rate for Payer: MDX Hawaii PPO	$1,781.89
Rate for Payer: UnitedHealthcare Medicaid	$1,102.20
Rate for Payer: University Health Alliance Commercial	$1,338.99

PEGINTERFERON ALFA-2A 180 MCG/ML SUBCUTANEOUS SOLUTION [34034]

Facility

$1,837.00

Service Code	HCPCS S0145
Hospital Revenue Code	250
Min. Negotiated Rate	$1,561.45
Max. Negotiated Rate	$1,781.89
Rate for Payer: Cash Price	$1,102.20
Rate for Payer: Health Management Network Commercial	$1,561.45
Rate for Payer: MDX Hawaii PPO	$1,781.89

PEG KIT 20FR M00568201

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Hawaii Western Management Group Commercial	$228.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: University Health Alliance Commercial	$174.94

PEG KIT 20FR M00568201

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: MDX Hawaii PPO	$232.80

PEG OXFORD FEMORAL TWIN MED

Facility

$3,840.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,958.40
Max. Negotiated Rate	$3,724.80
Rate for Payer: Cash Price	$2,304.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,688.00
Rate for Payer: Health Management Network Commercial	$3,264.00
Rate for Payer: Kaiser Permanente Commercial	$2,419.20
Rate for Payer: Kaiser Permanente Medicaid	$1,958.40
Rate for Payer: MDX Hawaii PPO	$3,724.80
Rate for Payer: University Health Alliance Commercial	$2,150.40

PEG OXFORD FEMORAL TWIN MED

Facility

$3,840.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,150.40
Max. Negotiated Rate	$3,724.80
Rate for Payer: Cash Price	$2,304.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,688.00
Rate for Payer: Health Management Network Commercial	$3,264.00
Rate for Payer: MDX Hawaii PPO	$3,724.80
Rate for Payer: University Health Alliance Commercial	$2,150.40

PEG THREADED 2.5X20MM TP20

Facility

$600.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
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	$420.00
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	$336.00

PEG THREADED 2.5X20MM TP20

Facility

$600.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$336.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Hawaii Western Management Group Commercial	$420.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: University Health Alliance Commercial	$336.00

PEG THREADED 2.5X24MM TP24

Facility

$600.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
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	$420.00
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	$336.00

PEG THREADED 2.5X24MM TP24

Facility

$600.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$336.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Hawaii Western Management Group Commercial	$420.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: University Health Alliance Commercial	$336.00

PEG THREADED 2.5X30MM TP30000

Facility

$417.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$212.67
Max. Negotiated Rate	$404.49
Rate for Payer: Cash Price	$250.20
Rate for Payer: Hawaii Western Management Group Commercial	$291.90
Rate for Payer: Health Management Network Commercial	$354.45
Rate for Payer: Kaiser Permanente Commercial	$262.71
Rate for Payer: Kaiser Permanente Medicaid	$212.67
Rate for Payer: MDX Hawaii PPO	$404.49
Rate for Payer: University Health Alliance Commercial	$233.52

PEG THREADED 2.5X30MM TP30000

Facility

$417.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$233.52
Max. Negotiated Rate	$404.49
Rate for Payer: Cash Price	$250.20
Rate for Payer: Hawaii Western Management Group Commercial	$291.90
Rate for Payer: Health Management Network Commercial	$354.45
Rate for Payer: MDX Hawaii PPO	$404.49
Rate for Payer: University Health Alliance Commercial	$233.52

PEG TWIG FEMUR SMALL

Facility

$3,840.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,150.40
Max. Negotiated Rate	$3,724.80
Rate for Payer: Cash Price	$2,304.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,688.00
Rate for Payer: Health Management Network Commercial	$3,264.00
Rate for Payer: MDX Hawaii PPO	$3,724.80
Rate for Payer: University Health Alliance Commercial	$2,150.40

PEG TWIG FEMUR SMALL

Facility

$3,840.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,958.40
Max. Negotiated Rate	$3,724.80
Rate for Payer: Cash Price	$2,304.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,688.00
Rate for Payer: Health Management Network Commercial	$3,264.00
Rate for Payer: Kaiser Permanente Commercial	$2,419.20
Rate for Payer: Kaiser Permanente Medicaid	$1,958.40
Rate for Payer: MDX Hawaii PPO	$3,724.80
Rate for Payer: University Health Alliance Commercial	$2,150.40

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC

Facility

$40,427.16

Service Code	MSDRG 734
Min. Negotiated Rate	$24,227.16
Max. Negotiated Rate	$40,427.16
Rate for Payer: AlohaCare Medicare	$24,227.16
Rate for Payer: Devoted Health Medicare	$26,649.88
Rate for Payer: Hawaii Medical Service Association Commercial	$40,427.16
Rate for Payer: Hawaii Medical Service Association Medicare	$24,227.16
Rate for Payer: Humana Medicare	$24,227.16
Rate for Payer: Kaiser Permanente Commercial	$36,742.50
Rate for Payer: Kaiser Permanente Medicare	$24,227.16
Rate for Payer: Ohana Health Plan Medicare	$24,227.16
Rate for Payer: UnitedHealthcare Medicare	$24,227.16

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC

Facility

$40,427.16

Service Code	MSDRG 735
Min. Negotiated Rate	$15,304.06
Max. Negotiated Rate	$40,427.16
Rate for Payer: AlohaCare Medicare	$15,304.06
Rate for Payer: Devoted Health Medicare	$16,834.47
Rate for Payer: Hawaii Medical Service Association Commercial	$40,427.16
Rate for Payer: Hawaii Medical Service Association Medicare	$15,304.06
Rate for Payer: Humana Medicare	$15,304.06
Rate for Payer: Kaiser Permanente Commercial	$23,209.88
Rate for Payer: Kaiser Permanente Medicare	$15,304.06
Rate for Payer: Ohana Health Plan Medicare	$15,304.06
Rate for Payer: UnitedHealthcare Medicare	$15,304.06

PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS

Facility

$6,672.79

Service Code	APR-DRG 5101
Min. Negotiated Rate	$6,672.79
Max. Negotiated Rate	$6,672.79
Rate for Payer: AlohaCare Medicaid	$6,672.79
Rate for Payer: Hawaii Medical Service Association ABD	$6,672.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,672.79
Rate for Payer: Kaiser Permanente Medicaid	$6,672.79
Rate for Payer: Ohana Health Plan Medicaid	$6,672.79
Rate for Payer: UnitedHealthcare Medicaid	$6,672.79

PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS

Facility

$21,904.77

Service Code	APR-DRG 5104
Min. Negotiated Rate	$21,904.77
Max. Negotiated Rate	$21,904.77
Rate for Payer: AlohaCare Medicaid	$21,904.77
Rate for Payer: Hawaii Medical Service Association ABD	$21,904.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21,904.77
Rate for Payer: Kaiser Permanente Medicaid	$21,904.77
Rate for Payer: Ohana Health Plan Medicaid	$21,904.77
Rate for Payer: UnitedHealthcare Medicaid	$21,904.77

PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS

Facility

$8,463.95

Service Code	APR-DRG 5102
Min. Negotiated Rate	$8,463.95
Max. Negotiated Rate	$8,463.95
Rate for Payer: AlohaCare Medicaid	$8,463.95
Rate for Payer: Hawaii Medical Service Association ABD	$8,463.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,463.95
Rate for Payer: Kaiser Permanente Medicaid	$8,463.95
Rate for Payer: Ohana Health Plan Medicaid	$8,463.95
Rate for Payer: UnitedHealthcare Medicaid	$8,463.95

PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS

Facility

$13,266.01

Service Code	APR-DRG 5103
Min. Negotiated Rate	$13,266.01
Max. Negotiated Rate	$13,266.01
Rate for Payer: AlohaCare Medicaid	$13,266.01
Rate for Payer: Hawaii Medical Service Association ABD	$13,266.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,266.01
Rate for Payer: Kaiser Permanente Medicaid	$13,266.01
Rate for Payer: Ohana Health Plan Medicaid	$13,266.01
Rate for Payer: UnitedHealthcare Medicaid	$13,266.01

Know your out-of-pocket cost for care.

All Charges