Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PIN TRANSFIX 5050-4-300

Facility

$795.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$445.20
Max. Negotiated Rate	$771.15
Rate for Payer: Cash Price	$477.00
Rate for Payer: Hawaii Western Management Group Commercial	$556.50
Rate for Payer: Health Management Network Commercial	$675.75
Rate for Payer: MDX Hawaii PPO	$771.15
Rate for Payer: University Health Alliance Commercial	$445.20

PIN TRANSFIX 5050-4-300

Facility

$795.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$405.45
Max. Negotiated Rate	$771.15
Rate for Payer: Kaiser Permanente Medicaid	$405.45
Rate for Payer: Cash Price	$477.00
Rate for Payer: Hawaii Western Management Group Commercial	$556.50
Rate for Payer: Health Management Network Commercial	$675.75
Rate for Payer: Kaiser Permanente Commercial	$500.85
Rate for Payer: MDX Hawaii PPO	$771.15
Rate for Payer: University Health Alliance Commercial	$445.20

PIN VOLAR BUTTRESS 32MM VBP32

Facility

$1,680.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$940.80
Max. Negotiated Rate	$1,629.60
Rate for Payer: Cash Price	$1,008.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,176.00
Rate for Payer: Health Management Network Commercial	$1,428.00
Rate for Payer: MDX Hawaii PPO	$1,629.60
Rate for Payer: University Health Alliance Commercial	$940.80

PIN VOLAR BUTTRESS 32MM VBP32

Facility

$1,680.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$856.80
Max. Negotiated Rate	$1,629.60
Rate for Payer: Cash Price	$1,008.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,176.00
Rate for Payer: Health Management Network Commercial	$1,428.00
Rate for Payer: Kaiser Permanente Commercial	$1,058.40
Rate for Payer: Kaiser Permanente Medicaid	$856.80
Rate for Payer: MDX Hawaii PPO	$1,629.60
Rate for Payer: University Health Alliance Commercial	$940.80

PIN VOLAR BUTTRESS 42MM VBP42

Facility

$1,680.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$856.80
Max. Negotiated Rate	$1,629.60
Rate for Payer: Cash Price	$1,008.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,176.00
Rate for Payer: Health Management Network Commercial	$1,428.00
Rate for Payer: Kaiser Permanente Commercial	$1,058.40
Rate for Payer: Kaiser Permanente Medicaid	$856.80
Rate for Payer: MDX Hawaii PPO	$1,629.60
Rate for Payer: University Health Alliance Commercial	$940.80

PIN VOLAR BUTTRESS 42MM VBP42

Facility

$1,680.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$940.80
Max. Negotiated Rate	$1,629.60
Rate for Payer: Cash Price	$1,008.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,176.00
Rate for Payer: Health Management Network Commercial	$1,428.00
Rate for Payer: MDX Hawaii PPO	$1,629.60
Rate for Payer: University Health Alliance Commercial	$940.80

PIOGLITAZONE 30 MG TABLET [25529]

Facility

$33.00

Service Code	NDC 33342005510
Hospital Revenue Code	637
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$20.79
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: University Health Alliance Commercial	$24.05

PIOGLITAZONE 30 MG TABLET [25529]

Facility

$33.00

Service Code	NDC 33342005510
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: MDX Hawaii PPO	$32.01

PIONEER PLUS CATH PPLUS120

Facility

$5,790.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,952.90
Max. Negotiated Rate	$5,616.30
Rate for Payer: Cash Price	$3,474.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,500.50
Rate for Payer: Health Management Network Commercial	$4,921.50
Rate for Payer: Kaiser Permanente Commercial	$3,647.70
Rate for Payer: Kaiser Permanente Medicaid	$2,952.90
Rate for Payer: MDX Hawaii PPO	$5,616.30
Rate for Payer: University Health Alliance Commercial	$4,220.33

PIONEER PLUS CATH PPLUS120

Facility

$5,790.00

Hospital Revenue Code	272
Min. Negotiated Rate	$4,921.50
Max. Negotiated Rate	$5,616.30
Rate for Payer: Cash Price	$3,474.00
Rate for Payer: Health Management Network Commercial	$4,921.50
Rate for Payer: MDX Hawaii PPO	$5,616.30

PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION [18304]

Facility

$29.00

Service Code	HCPCS J2543
Hospital Revenue Code	250
Min. Negotiated Rate	$24.65
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$17.40
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: MDX Hawaii PPO	$28.13

PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION [18304]

Facility

$29.00

Service Code	HCPCS J2543
Hospital Revenue Code	636
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$17.40
Rate for Payer: Cash Price	$17.40
Rate for Payer: Hawaii Medical Service Association ABD	$1.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.11
Rate for Payer: Hawaii Western Management Group Commercial	$27.55
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Kaiser Permanente Commercial	$18.27
Rate for Payer: Kaiser Permanente Medicaid	$14.79
Rate for Payer: MDX Hawaii PPO	$28.13
Rate for Payer: UnitedHealthcare Medicaid	$17.40
Rate for Payer: University Health Alliance Commercial	$21.14

PIPERACILLIN-TAZOBACTAM 3.375 G/15 ML IV (WET SOLR VIAL) [43018303]

Facility

$34.00

Service Code	HCPCS J2543
Hospital Revenue Code	636
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$20.40
Rate for Payer: Cash Price	$20.40
Rate for Payer: Cash Price	$28.20
Rate for Payer: Cash Price	$28.20
Rate for Payer: Hawaii Medical Service Association ABD	$1.11
Rate for Payer: Hawaii Medical Service Association ABD	$1.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.11
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Hawaii Western Management Group Commercial	$44.65
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$29.61
Rate for Payer: Kaiser Permanente Commercial	$21.42
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: Kaiser Permanente Medicaid	$23.97
Rate for Payer: MDX Hawaii PPO	$45.59
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: UnitedHealthcare Medicaid	$28.20
Rate for Payer: University Health Alliance Commercial	$34.26
Rate for Payer: University Health Alliance Commercial	$24.78

PIPERACILLIN-TAZOBACTAM 3.375 G/15 ML IV (WET SOLR VIAL) [43018303]

Facility

$47.00

Service Code	HCPCS J2543
Hospital Revenue Code	250
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$45.59
Rate for Payer: Cash Price	$28.20
Rate for Payer: Cash Price	$20.40
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: MDX Hawaii PPO	$45.59

PIPERACILLIN-TAZOBACTAM 3.375 G IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080103]

Facility

$613.00

Service Code	HCPCS J2543
Hospital Revenue Code	636
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$594.61
Rate for Payer: Cash Price	$367.80
Rate for Payer: Cash Price	$367.80
Rate for Payer: Hawaii Medical Service Association ABD	$1.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.11
Rate for Payer: Hawaii Western Management Group Commercial	$582.35
Rate for Payer: Health Management Network Commercial	$521.05
Rate for Payer: Kaiser Permanente Commercial	$386.19
Rate for Payer: Kaiser Permanente Medicaid	$312.63
Rate for Payer: MDX Hawaii PPO	$594.61
Rate for Payer: UnitedHealthcare Medicaid	$367.80
Rate for Payer: University Health Alliance Commercial	$446.82

PIPERACILLIN-TAZOBACTAM 3.375 G IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080103]

Facility

$613.00

Service Code	HCPCS J2543
Hospital Revenue Code	250
Min. Negotiated Rate	$521.05
Max. Negotiated Rate	$594.61
Rate for Payer: Cash Price	$367.80
Rate for Payer: Health Management Network Commercial	$521.05
Rate for Payer: MDX Hawaii PPO	$594.61

PIPERACILLIN-TAZOBACTAM 3.375 GRAM/50 ML DEXTROSE(ISO-OS) IV PIGGYBACK [34524]

Facility

$86.00

Service Code	HCPCS J2543
Hospital Revenue Code	250
Min. Negotiated Rate	$73.10
Max. Negotiated Rate	$83.42
Rate for Payer: Cash Price	$51.60
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: MDX Hawaii PPO	$83.42

PIPERACILLIN-TAZOBACTAM 3.375 GRAM/50 ML DEXTROSE(ISO-OS) IV PIGGYBACK [34524]

Facility

$86.00

Service Code	HCPCS J2543
Hospital Revenue Code	636
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$83.42
Rate for Payer: Cash Price	$51.60
Rate for Payer: Cash Price	$51.60
Rate for Payer: Hawaii Medical Service Association ABD	$1.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.11
Rate for Payer: Hawaii Western Management Group Commercial	$81.70
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Kaiser Permanente Commercial	$54.18
Rate for Payer: Kaiser Permanente Medicaid	$43.86
Rate for Payer: MDX Hawaii PPO	$83.42
Rate for Payer: UnitedHealthcare Medicaid	$51.60
Rate for Payer: University Health Alliance Commercial	$62.69

PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]

Facility

$47.00

Service Code	HCPCS J2543
Hospital Revenue Code	636
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$45.59
Rate for Payer: Cash Price	$28.20
Rate for Payer: Cash Price	$28.20
Rate for Payer: Hawaii Medical Service Association ABD	$1.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.11
Rate for Payer: Hawaii Western Management Group Commercial	$44.65
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Kaiser Permanente Commercial	$29.61
Rate for Payer: Kaiser Permanente Medicaid	$23.97
Rate for Payer: MDX Hawaii PPO	$45.59
Rate for Payer: UnitedHealthcare Medicaid	$28.20
Rate for Payer: University Health Alliance Commercial	$34.26

PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]

Facility

$47.00

Service Code	HCPCS J2543
Hospital Revenue Code	250
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$45.59
Rate for Payer: Cash Price	$28.20
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: MDX Hawaii PPO	$45.59

PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION [18302]

Facility

$55.00

Service Code	HCPCS J2543
Hospital Revenue Code	250
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$33.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cash Price	$35.40
Rate for Payer: Cash Price	$41.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: MDX Hawaii PPO	$57.23
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: MDX Hawaii PPO	$66.93

PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION [18302]

Facility

$55.00

Service Code	HCPCS J2543
Hospital Revenue Code	636
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$33.00
Rate for Payer: Cash Price	$33.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cash Price	$35.40
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cash Price	$35.40
Rate for Payer: Cash Price	$41.40
Rate for Payer: Cash Price	$41.40
Rate for Payer: Hawaii Medical Service Association ABD	$1.11
Rate for Payer: Hawaii Medical Service Association ABD	$1.11
Rate for Payer: Hawaii Medical Service Association ABD	$1.11
Rate for Payer: Hawaii Medical Service Association ABD	$1.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.11
Rate for Payer: Hawaii Western Management Group Commercial	$52.25
Rate for Payer: Hawaii Western Management Group Commercial	$56.05
Rate for Payer: Hawaii Western Management Group Commercial	$65.55
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$34.65
Rate for Payer: Kaiser Permanente Commercial	$43.47
Rate for Payer: Kaiser Permanente Commercial	$37.17
Rate for Payer: Kaiser Permanente Commercial	$15.12
Rate for Payer: Kaiser Permanente Medicaid	$35.19
Rate for Payer: Kaiser Permanente Medicaid	$30.09
Rate for Payer: Kaiser Permanente Medicaid	$28.05
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: MDX Hawaii PPO	$57.23
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: MDX Hawaii PPO	$66.93
Rate for Payer: UnitedHealthcare Medicaid	$33.00
Rate for Payer: UnitedHealthcare Medicaid	$41.40
Rate for Payer: UnitedHealthcare Medicaid	$35.40
Rate for Payer: UnitedHealthcare Medicaid	$14.40
Rate for Payer: University Health Alliance Commercial	$50.29
Rate for Payer: University Health Alliance Commercial	$17.49
Rate for Payer: University Health Alliance Commercial	$40.09
Rate for Payer: University Health Alliance Commercial	$43.01

PLACEMENT OF SETON

Facility

$6,743.44

Service Code	CPT 46020
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$3,279.01
Rate for Payer: AlohaCare Medicare	$3,279.01
Rate for Payer: Devoted Health Medicare	$3,606.91
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,279.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,279.01
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,279.01
Rate for Payer: Ohana Health Plan Medicaid	$3,606.91
Rate for Payer: Ohana Health Plan Medicare	$3,279.01
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,279.01
Rate for Payer: University Health Alliance Commercial	$6,743.44

PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITHOUT SEPARATE NEPHROSTOMY CATHETER

Facility

$8,270.00

Service Code	CPT 50694
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22
Rate for Payer: University Health Alliance Commercial	$5,160.40

Facility

$6,743.44

Service Code	CPT 50693
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22
Rate for Payer: University Health Alliance Commercial	$6,743.44

Know your out-of-pocket cost for care.

All Charges