Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PHYTONADIONE (VITAMIN K) 1 MG/ML ORAL SOLUTION [4080281]

Facility

$74.00

Service Code	HCPCS J3430
Hospital Revenue Code	636
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$71.78
Rate for Payer: Cash Price	$44.40
Rate for Payer: Cash Price	$44.40
Rate for Payer: Hawaii Medical Service Association ABD	$2.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.84
Rate for Payer: Hawaii Western Management Group Commercial	$70.30
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Kaiser Permanente Commercial	$46.62
Rate for Payer: Kaiser Permanente Medicaid	$37.74
Rate for Payer: MDX Hawaii PPO	$71.78
Rate for Payer: UnitedHealthcare Medicaid	$44.40
Rate for Payer: University Health Alliance Commercial	$53.94

PICC LINE REMOVAL (PRO OR TECH RN VISIT) MEDICARE ONLY

Facility

$513.00

Service Code	HCPCS G0463
Hospital Charge Code	761G046301
Hospital Revenue Code	761
Min. Negotiated Rate	$96.65
Max. Negotiated Rate	$497.61
Rate for Payer: AlohaCare Medicaid	$157.28
Rate for Payer: AlohaCare Medicare	$157.28
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cash Price	$307.80
Rate for Payer: Devoted Health Medicare	$173.01
Rate for Payer: Hawaii Medical Service Association Commercial	$196.60
Rate for Payer: Hawaii Medical Service Association Medicare	$157.28
Rate for Payer: Hawaii Western Management Group Commercial	$487.35
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Humana Medicare	$157.28
Rate for Payer: Kaiser Permanente Commercial	$323.19
Rate for Payer: Kaiser Permanente Medicaid	$261.63
Rate for Payer: Kaiser Permanente Medicare	$157.28
Rate for Payer: MDX Hawaii PPO	$497.61
Rate for Payer: Ohana Health Plan Medicaid	$173.01
Rate for Payer: Ohana Health Plan Medicare	$157.28
Rate for Payer: UnitedHealthcare Medicaid	$96.65
Rate for Payer: UnitedHealthcare Medicare	$157.28
Rate for Payer: University Health Alliance Commercial	$373.93

PICC LINE REMOVAL (PRO OR TECH RN VISIT) MEDICARE ONLY

Facility

$513.00

Service Code	HCPCS G0463
Hospital Charge Code	761G046301
Hospital Revenue Code	761
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$307.80
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: MDX Hawaii PPO	$497.61

PICO TWO DRSG 10X20 66022002

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$669.80
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: MDX Hawaii PPO	$764.36

PICO TWO DRSG 10X20 66022002

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$401.88
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Hawaii Western Management Group Commercial	$748.60
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Kaiser Permanente Commercial	$496.44
Rate for Payer: Kaiser Permanente Medicaid	$401.88
Rate for Payer: MDX Hawaii PPO	$764.36
Rate for Payer: University Health Alliance Commercial	$574.37

PICO TWO DRSG 10X30 66022003

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$669.80
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: MDX Hawaii PPO	$764.36

PICO TWO DRSG 10X30 66022003

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$401.88
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Hawaii Western Management Group Commercial	$748.60
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Kaiser Permanente Commercial	$496.44
Rate for Payer: Kaiser Permanente Medicaid	$401.88
Rate for Payer: MDX Hawaii PPO	$764.36
Rate for Payer: University Health Alliance Commercial	$574.37

PICO TWO DRSG 10X40 66022004

Facility

$1,470.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,249.50
Max. Negotiated Rate	$1,425.90
Rate for Payer: Cash Price	$882.00
Rate for Payer: Health Management Network Commercial	$1,249.50
Rate for Payer: MDX Hawaii PPO	$1,425.90

PICO TWO DRSG 10X40 66022004

Facility

$1,470.00

Hospital Revenue Code	272
Min. Negotiated Rate	$749.70
Max. Negotiated Rate	$1,425.90
Rate for Payer: Cash Price	$882.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,396.50
Rate for Payer: Health Management Network Commercial	$1,249.50
Rate for Payer: Kaiser Permanente Commercial	$926.10
Rate for Payer: Kaiser Permanente Medicaid	$749.70
Rate for Payer: MDX Hawaii PPO	$1,425.90
Rate for Payer: University Health Alliance Commercial	$1,071.48

PILLOW HIP ABDUCT LRG

Facility

$143.00

Hospital Revenue Code	271
Min. Negotiated Rate	$121.55
Max. Negotiated Rate	$138.71
Rate for Payer: Cash Price	$85.80
Rate for Payer: Health Management Network Commercial	$121.55
Rate for Payer: MDX Hawaii PPO	$138.71

PILLOW HIP ABDUCT LRG

Facility

$143.00

Hospital Revenue Code	271
Min. Negotiated Rate	$72.93
Max. Negotiated Rate	$138.71
Rate for Payer: Cash Price	$85.80
Rate for Payer: Hawaii Western Management Group Commercial	$135.85
Rate for Payer: Health Management Network Commercial	$121.55
Rate for Payer: Kaiser Permanente Commercial	$90.09
Rate for Payer: Kaiser Permanente Medicaid	$72.93
Rate for Payer: MDX Hawaii PPO	$138.71
Rate for Payer: University Health Alliance Commercial	$104.23

PILLOW HIP ABDUCT MED

Facility

$137.00

Hospital Revenue Code	271
Min. Negotiated Rate	$69.87
Max. Negotiated Rate	$132.89
Rate for Payer: Cash Price	$82.20
Rate for Payer: Hawaii Western Management Group Commercial	$130.15
Rate for Payer: Health Management Network Commercial	$116.45
Rate for Payer: Kaiser Permanente Commercial	$86.31
Rate for Payer: Kaiser Permanente Medicaid	$69.87
Rate for Payer: MDX Hawaii PPO	$132.89
Rate for Payer: University Health Alliance Commercial	$99.86

PILLOW HIP ABDUCT MED

Facility

$137.00

Hospital Revenue Code	271
Min. Negotiated Rate	$116.45
Max. Negotiated Rate	$132.89
Rate for Payer: Cash Price	$82.20
Rate for Payer: Health Management Network Commercial	$116.45
Rate for Payer: MDX Hawaii PPO	$132.89

PILLOW HIP ABDUCT SML

Facility

$106.00

Hospital Revenue Code	271
Min. Negotiated Rate	$54.06
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Hawaii Western Management Group Commercial	$100.70
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$66.78
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: University Health Alliance Commercial	$77.26

PILLOW HIP ABDUCT SML

Facility

$106.00

Hospital Revenue Code	271
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: MDX Hawaii PPO	$102.82

PILOCARPINE 1 % EYE DROPS [6279]

Facility

$279.00

Service Code	NDC 70069018101
Hospital Revenue Code	637
Min. Negotiated Rate	$142.29
Max. Negotiated Rate	$270.63
Rate for Payer: Cash Price	$167.40
Rate for Payer: Hawaii Western Management Group Commercial	$265.05
Rate for Payer: Health Management Network Commercial	$237.15
Rate for Payer: Kaiser Permanente Commercial	$175.77
Rate for Payer: Kaiser Permanente Medicaid	$142.29
Rate for Payer: MDX Hawaii PPO	$270.63
Rate for Payer: University Health Alliance Commercial	$203.36

PILOCARPINE 1 % EYE DROPS [6279]

Facility

$296.00

Service Code	NDC 61314020315
Hospital Revenue Code	250
Min. Negotiated Rate	$251.60
Max. Negotiated Rate	$287.12
Rate for Payer: Cash Price	$177.60
Rate for Payer: Health Management Network Commercial	$251.60
Rate for Payer: MDX Hawaii PPO	$287.12

PILOCARPINE 1 % EYE DROPS [6279]

Facility

$279.00

Service Code	NDC 70069018101
Hospital Revenue Code	250
Min. Negotiated Rate	$237.15
Max. Negotiated Rate	$270.63
Rate for Payer: Cash Price	$167.40
Rate for Payer: Health Management Network Commercial	$237.15
Rate for Payer: MDX Hawaii PPO	$270.63

PILOCARPINE 1 % EYE DROPS [6279]

Facility

$296.00

Service Code	NDC 61314020315
Hospital Revenue Code	637
Min. Negotiated Rate	$150.96
Max. Negotiated Rate	$287.12
Rate for Payer: Cash Price	$177.60
Rate for Payer: Hawaii Western Management Group Commercial	$281.20
Rate for Payer: Health Management Network Commercial	$251.60
Rate for Payer: Kaiser Permanente Commercial	$186.48
Rate for Payer: Kaiser Permanente Medicaid	$150.96
Rate for Payer: MDX Hawaii PPO	$287.12
Rate for Payer: University Health Alliance Commercial	$215.75

PILOCARPINE 2 % EYE DROPS [6280]

Facility

$285.00

Service Code	NDC 70069019101
Hospital Revenue Code	637
Min. Negotiated Rate	$145.35
Max. Negotiated Rate	$276.45
Rate for Payer: Cash Price	$171.00
Rate for Payer: Hawaii Western Management Group Commercial	$270.75
Rate for Payer: Health Management Network Commercial	$242.25
Rate for Payer: Kaiser Permanente Commercial	$179.55
Rate for Payer: Kaiser Permanente Medicaid	$145.35
Rate for Payer: MDX Hawaii PPO	$276.45
Rate for Payer: University Health Alliance Commercial	$207.74

PILOCARPINE 2 % EYE DROPS [6280]

Facility

$285.00

Service Code	NDC 70069019101
Hospital Revenue Code	250
Min. Negotiated Rate	$242.25
Max. Negotiated Rate	$276.45
Rate for Payer: Cash Price	$171.00
Rate for Payer: Health Management Network Commercial	$242.25
Rate for Payer: MDX Hawaii PPO	$276.45

PILOCARPINE 4 % EYE DROPS [6282]

Facility

$318.00

Service Code	NDC 61314020615
Hospital Revenue Code	250
Min. Negotiated Rate	$270.30
Max. Negotiated Rate	$308.46
Rate for Payer: Cash Price	$190.80
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: MDX Hawaii PPO	$308.46

PILOCARPINE 4 % EYE DROPS [6282]

Facility

$299.00

Service Code	NDC 70069020101
Hospital Revenue Code	250
Min. Negotiated Rate	$254.15
Max. Negotiated Rate	$290.03
Rate for Payer: Cash Price	$179.40
Rate for Payer: Health Management Network Commercial	$254.15
Rate for Payer: MDX Hawaii PPO	$290.03

PILOCARPINE 4 % EYE DROPS [6282]

Facility

$318.00

Service Code	NDC 61314020615
Hospital Revenue Code	637
Min. Negotiated Rate	$162.18
Max. Negotiated Rate	$308.46
Rate for Payer: Cash Price	$190.80
Rate for Payer: Hawaii Western Management Group Commercial	$302.10
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Kaiser Permanente Commercial	$200.34
Rate for Payer: Kaiser Permanente Medicaid	$162.18
Rate for Payer: MDX Hawaii PPO	$308.46
Rate for Payer: University Health Alliance Commercial	$231.79

PILOCARPINE 4 % EYE DROPS [6282]

Facility

$299.00

Service Code	NDC 70069020101
Hospital Revenue Code	637
Min. Negotiated Rate	$152.49
Max. Negotiated Rate	$290.03
Rate for Payer: Cash Price	$179.40
Rate for Payer: Hawaii Western Management Group Commercial	$284.05
Rate for Payer: Health Management Network Commercial	$254.15
Rate for Payer: Kaiser Permanente Commercial	$188.37
Rate for Payer: Kaiser Permanente Medicaid	$152.49
Rate for Payer: MDX Hawaii PPO	$290.03
Rate for Payer: University Health Alliance Commercial	$217.94

Know your out-of-pocket cost for care.

All Charges