Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

BRUSH CYSTOLOGY ENDO

Facility

$93.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$47.43
Max. Negotiated Rate	$90.21
Rate for Payer: Cash Price	$55.80
Rate for Payer: Hawaii Western Management Group Commercial	$88.35
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Kaiser Permanente Commercial	$58.59
Rate for Payer: Kaiser Permanente Medicaid	$47.43
Rate for Payer: MDX Hawaii PPO	$90.21
Rate for Payer: University Health Alliance Commercial	$67.79

BRUSH CYTOLOGY BILIARY

Facility

$429.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$218.79
Max. Negotiated Rate	$416.13
Rate for Payer: Cash Price	$257.40
Rate for Payer: Hawaii Western Management Group Commercial	$407.55
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Kaiser Permanente Commercial	$270.27
Rate for Payer: Kaiser Permanente Medicaid	$218.79
Rate for Payer: MDX Hawaii PPO	$416.13
Rate for Payer: University Health Alliance Commercial	$312.70

BRUSH CYTOLOGY BILIARY

Facility

$429.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$364.65
Max. Negotiated Rate	$416.13
Rate for Payer: Cash Price	$257.40
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: MDX Hawaii PPO	$416.13

BRUSH FEMERAL SIMPULSE

Facility

$78.00

Hospital Revenue Code	272
Min. Negotiated Rate	$39.78
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$46.80
Rate for Payer: Hawaii Western Management Group Commercial	$74.10
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Kaiser Permanente Commercial	$49.14
Rate for Payer: Kaiser Permanente Medicaid	$39.78
Rate for Payer: MDX Hawaii PPO	$75.66
Rate for Payer: University Health Alliance Commercial	$56.85

BRUSH FEMERAL SIMPULSE

Facility

$78.00

Hospital Revenue Code	272
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$46.80
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: MDX Hawaii PPO	$75.66

BRUSH SINGLE USE SOFT

Facility

$71.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$36.21
Max. Negotiated Rate	$68.87
Rate for Payer: Cash Price	$42.60
Rate for Payer: Hawaii Western Management Group Commercial	$67.45
Rate for Payer: Health Management Network Commercial	$60.35
Rate for Payer: Kaiser Permanente Commercial	$44.73
Rate for Payer: Kaiser Permanente Medicaid	$36.21
Rate for Payer: MDX Hawaii PPO	$68.87
Rate for Payer: University Health Alliance Commercial	$51.75

BRUSH SINGLE USE SOFT

Facility

$71.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$60.35
Max. Negotiated Rate	$68.87
Rate for Payer: Cash Price	$42.60
Rate for Payer: Health Management Network Commercial	$60.35
Rate for Payer: MDX Hawaii PPO	$68.87

BTB TIGHTROPE II AR-1588BTB2J

Facility

$1,717.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$961.52
Max. Negotiated Rate	$1,665.49
Rate for Payer: Cash Price	$1,030.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,201.90
Rate for Payer: Health Management Network Commercial	$1,459.45
Rate for Payer: MDX Hawaii PPO	$1,665.49
Rate for Payer: University Health Alliance Commercial	$961.52

BTB TIGHTROPE II AR-1588BTB2J

Facility

$1,717.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$875.67
Max. Negotiated Rate	$1,665.49
Rate for Payer: Cash Price	$1,030.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,201.90
Rate for Payer: Health Management Network Commercial	$1,459.45
Rate for Payer: Kaiser Permanente Commercial	$1,081.71
Rate for Payer: Kaiser Permanente Medicaid	$875.67
Rate for Payer: MDX Hawaii PPO	$1,665.49
Rate for Payer: University Health Alliance Commercial	$961.52

BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]

Facility

$29.00

Service Code	HCPCS J7626
Hospital Revenue Code	636
Min. Negotiated Rate	$1.28
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	$1.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.28
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

BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]

Facility

$29.00

Service Code	HCPCS J7626
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

BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]

Facility

$28.00

Service Code	HCPCS J7626
Hospital Revenue Code	636
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Hawaii Medical Service Association ABD	$1.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.28
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$17.64
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: UnitedHealthcare Medicaid	$16.80
Rate for Payer: University Health Alliance Commercial	$20.41

BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]

Facility

$28.00

Service Code	HCPCS J7626
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: MDX Hawaii PPO	$27.16

BUDESONIDE/FORMOTEROL 160-4.5 MCG (SYMBICORT) (60 PUFF(S)) (TAKE HOME) [4080395]

Facility

$15.00

Service Code	NDC 00004080183
Hospital Revenue Code	253
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
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: University Health Alliance Commercial	$10.93

BUDESONIDE/FORMOTEROL 160-4.5 MCG (SYMBICORT) (60 PUFF(S)) (TAKE HOME) [4080395]

Facility

$15.00

Service Code	NDC 00004080183
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

BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81454]

Facility

$478.00

Service Code	NDC 00186037028
Hospital Revenue Code	250
Min. Negotiated Rate	$406.30
Max. Negotiated Rate	$463.66
Rate for Payer: Cash Price	$286.80
Rate for Payer: Health Management Network Commercial	$406.30
Rate for Payer: MDX Hawaii PPO	$463.66

BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81454]

Facility

$478.00

Service Code	NDC 00186037028
Hospital Revenue Code	637
Min. Negotiated Rate	$243.78
Max. Negotiated Rate	$463.66
Rate for Payer: Cash Price	$286.80
Rate for Payer: Hawaii Western Management Group Commercial	$454.10
Rate for Payer: Health Management Network Commercial	$406.30
Rate for Payer: Kaiser Permanente Commercial	$301.14
Rate for Payer: Kaiser Permanente Medicaid	$243.78
Rate for Payer: MDX Hawaii PPO	$463.66
Rate for Payer: University Health Alliance Commercial	$348.41

BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81453]

Facility

$416.00

Service Code	NDC 00186037228
Hospital Revenue Code	637
Min. Negotiated Rate	$212.16
Max. Negotiated Rate	$403.52
Rate for Payer: Cash Price	$249.60
Rate for Payer: Hawaii Western Management Group Commercial	$395.20
Rate for Payer: Health Management Network Commercial	$353.60
Rate for Payer: Kaiser Permanente Commercial	$262.08
Rate for Payer: Kaiser Permanente Medicaid	$212.16
Rate for Payer: MDX Hawaii PPO	$403.52
Rate for Payer: University Health Alliance Commercial	$303.22

BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81453]

Facility

$416.00

Service Code	NDC 00186037228
Hospital Revenue Code	250
Min. Negotiated Rate	$353.60
Max. Negotiated Rate	$403.52
Rate for Payer: Cash Price	$249.60
Rate for Payer: Health Management Network Commercial	$353.60
Rate for Payer: MDX Hawaii PPO	$403.52

BULKAMID URETHRAL SYSTEM 50050

Facility

$2,300.00

Service Code	HCPCS L8606
Hospital Revenue Code	278
Min. Negotiated Rate	$1,173.00
Max. Negotiated Rate	$2,231.00
Rate for Payer: Cash Price	$1,380.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,610.00
Rate for Payer: Health Management Network Commercial	$1,955.00
Rate for Payer: Kaiser Permanente Commercial	$1,449.00
Rate for Payer: Kaiser Permanente Medicaid	$1,173.00
Rate for Payer: MDX Hawaii PPO	$2,231.00
Rate for Payer: University Health Alliance Commercial	$1,288.00

BULKAMID URETHRAL SYSTEM 50050

Facility

$2,300.00

Service Code	HCPCS L8606
Hospital Revenue Code	278
Min. Negotiated Rate	$1,288.00
Max. Negotiated Rate	$2,231.00
Rate for Payer: Cash Price	$1,380.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,610.00
Rate for Payer: Health Management Network Commercial	$1,955.00
Rate for Payer: MDX Hawaii PPO	$2,231.00
Rate for Payer: University Health Alliance Commercial	$1,288.00

BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]

Facility

$13.00

Service Code	HCPCS J1939
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: MDX Hawaii PPO	$2.91

BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]

Facility

$13.00

Service Code	HCPCS J1939
Hospital Revenue Code	636
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.61
Rate for Payer: Hawaii Medical Service Association ABD	$0.61
Rate for Payer: Hawaii Medical Service Association ABD	$0.61
Rate for Payer: Hawaii Medical Service Association ABD	$0.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.61
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.61
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$8.19
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Commercial	$8.82
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: UnitedHealthcare Medicaid	$7.80
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicaid	$8.40
Rate for Payer: UnitedHealthcare Medicaid	$6.00
Rate for Payer: University Health Alliance Commercial	$2.19
Rate for Payer: University Health Alliance Commercial	$7.29
Rate for Payer: University Health Alliance Commercial	$9.48
Rate for Payer: University Health Alliance Commercial	$10.20

BUMETANIDE 0.5 MG TABLET [9309]

Facility

$2.00

Service Code	NDC 51672422301
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

BUMETANIDE 0.5 MG TABLET [9309]

Facility

$9.00

Service Code	NDC 42799011901
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: University Health Alliance Commercial	$6.56

Know your out-of-pocket cost for care.

All Charges