Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLUG 16MM/25MM 32-8105-038-00

Facility

$727.00

Hospital Revenue Code	272
Min. Negotiated Rate	$370.77
Max. Negotiated Rate	$705.19
Rate for Payer: Cash Price	$436.20
Rate for Payer: Hawaii Western Management Group Commercial	$690.65
Rate for Payer: Health Management Network Commercial	$617.95
Rate for Payer: Kaiser Permanente Commercial	$458.01
Rate for Payer: Kaiser Permanente Medicaid	$370.77
Rate for Payer: MDX Hawaii PPO	$705.19
Rate for Payer: University Health Alliance Commercial	$529.91

PLUG CABLE 5MM 661002S

Facility

$891.00

Hospital Revenue Code	272
Min. Negotiated Rate	$757.35
Max. Negotiated Rate	$864.27
Rate for Payer: Cash Price	$534.60
Rate for Payer: Health Management Network Commercial	$757.35
Rate for Payer: MDX Hawaii PPO	$864.27

PLUG CABLE 5MM 661002S

Facility

$891.00

Hospital Revenue Code	272
Min. Negotiated Rate	$454.41
Max. Negotiated Rate	$864.27
Rate for Payer: Cash Price	$534.60
Rate for Payer: Hawaii Western Management Group Commercial	$846.45
Rate for Payer: Health Management Network Commercial	$757.35
Rate for Payer: Kaiser Permanente Commercial	$561.33
Rate for Payer: Kaiser Permanente Medicaid	$454.41
Rate for Payer: MDX Hawaii PPO	$864.27
Rate for Payer: University Health Alliance Commercial	$649.45

PLUG LEAD BLIND 119602

Facility

$180.00

Hospital Revenue Code	272
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$174.60
Rate for Payer: Cash Price	$108.00
Rate for Payer: Hawaii Western Management Group Commercial	$171.00
Rate for Payer: Health Management Network Commercial	$153.00
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$91.80
Rate for Payer: MDX Hawaii PPO	$174.60
Rate for Payer: University Health Alliance Commercial	$131.20

PLUG LEAD BLIND 119602

Facility

$180.00

Hospital Revenue Code	272
Min. Negotiated Rate	$153.00
Max. Negotiated Rate	$174.60
Rate for Payer: Cash Price	$108.00
Rate for Payer: Health Management Network Commercial	$153.00
Rate for Payer: MDX Hawaii PPO	$174.60

PLUS STENT GRAFT BLN CATH

Facility

$1,698.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$865.98
Max. Negotiated Rate	$1,647.06
Rate for Payer: Cash Price	$1,018.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,613.10
Rate for Payer: Health Management Network Commercial	$1,443.30
Rate for Payer: Kaiser Permanente Commercial	$1,069.74
Rate for Payer: Kaiser Permanente Medicaid	$865.98
Rate for Payer: MDX Hawaii PPO	$1,647.06
Rate for Payer: University Health Alliance Commercial	$1,237.67

PLUS STENT GRAFT BLN CATH

Facility

$1,698.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$1,443.30
Max. Negotiated Rate	$1,647.06
Rate for Payer: Cash Price	$1,018.80
Rate for Payer: Health Management Network Commercial	$1,443.30
Rate for Payer: MDX Hawaii PPO	$1,647.06

PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [180721]

Facility

$510.00

Service Code	NDC 00005200001
Hospital Revenue Code	250
Min. Negotiated Rate	$433.50
Max. Negotiated Rate	$494.70
Rate for Payer: Cash Price	$306.00
Rate for Payer: Health Management Network Commercial	$433.50
Rate for Payer: MDX Hawaii PPO	$494.70

PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [180721]

Facility

$495.00

Service Code	NDC 00005200010
Hospital Revenue Code	250
Min. Negotiated Rate	$420.75
Max. Negotiated Rate	$480.15
Rate for Payer: Cash Price	$297.00
Rate for Payer: Health Management Network Commercial	$420.75
Rate for Payer: MDX Hawaii PPO	$480.15

PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [180721]

Facility

$510.00

Service Code	NDC 00005200002
Hospital Revenue Code	250
Min. Negotiated Rate	$433.50
Max. Negotiated Rate	$494.70
Rate for Payer: Cash Price	$306.00
Rate for Payer: Health Management Network Commercial	$433.50
Rate for Payer: MDX Hawaii PPO	$494.70

PNEUMOPERITONEUNM NDL PN120

Facility

$232.00

Hospital Revenue Code	272
Min. Negotiated Rate	$197.20
Max. Negotiated Rate	$225.04
Rate for Payer: Cash Price	$139.20
Rate for Payer: Health Management Network Commercial	$197.20
Rate for Payer: MDX Hawaii PPO	$225.04

PNEUMOPERITONEUNM NDL PN120

Facility

$232.00

Hospital Revenue Code	272
Min. Negotiated Rate	$118.32
Max. Negotiated Rate	$225.04
Rate for Payer: Cash Price	$139.20
Rate for Payer: Hawaii Western Management Group Commercial	$220.40
Rate for Payer: Health Management Network Commercial	$197.20
Rate for Payer: Kaiser Permanente Commercial	$146.16
Rate for Payer: Kaiser Permanente Medicaid	$118.32
Rate for Payer: MDX Hawaii PPO	$225.04
Rate for Payer: University Health Alliance Commercial	$169.10

PNEUMOTHORAX WITH CC

Facility

$18,962.92

Service Code	MSDRG 200
Min. Negotiated Rate	$12,503.73
Max. Negotiated Rate	$18,962.92
Rate for Payer: AlohaCare Medicare	$12,503.73
Rate for Payer: Devoted Health Medicare	$13,754.10
Rate for Payer: Hawaii Medical Service Association Commercial	$17,786.98
Rate for Payer: Hawaii Medical Service Association Medicare	$12,503.73
Rate for Payer: Humana Medicare	$12,503.73
Rate for Payer: Kaiser Permanente Commercial	$18,962.92
Rate for Payer: Kaiser Permanente Medicare	$12,503.73
Rate for Payer: Ohana Health Plan Medicare	$12,503.73
Rate for Payer: UnitedHealthcare Medicare	$12,503.73

PNEUMOTHORAX WITH MCC

Facility

$30,430.72

Service Code	MSDRG 199
Min. Negotiated Rate	$18,757.62
Max. Negotiated Rate	$30,430.72
Rate for Payer: AlohaCare Medicare	$20,065.33
Rate for Payer: Devoted Health Medicare	$22,071.86
Rate for Payer: Hawaii Medical Service Association Commercial	$18,757.62
Rate for Payer: Hawaii Medical Service Association Medicare	$20,065.33
Rate for Payer: Humana Medicare	$20,065.33
Rate for Payer: Kaiser Permanente Commercial	$30,430.72
Rate for Payer: Kaiser Permanente Medicare	$20,065.33
Rate for Payer: Ohana Health Plan Medicare	$20,065.33
Rate for Payer: UnitedHealthcare Medicare	$20,065.33

PNEUMOTHORAX WITHOUT CC/MCC

Facility

$14,098.55

Service Code	MSDRG 201
Min. Negotiated Rate	$8,133.73
Max. Negotiated Rate	$14,098.55
Rate for Payer: AlohaCare Medicare	$8,133.73
Rate for Payer: Devoted Health Medicare	$8,947.10
Rate for Payer: Hawaii Medical Service Association Commercial	$14,098.55
Rate for Payer: Hawaii Medical Service Association Medicare	$8,133.73
Rate for Payer: Humana Medicare	$8,133.73
Rate for Payer: Kaiser Permanente Commercial	$12,335.48
Rate for Payer: Kaiser Permanente Medicare	$8,133.73
Rate for Payer: Ohana Health Plan Medicare	$8,133.73
Rate for Payer: UnitedHealthcare Medicare	$8,133.73

POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC

Facility

$27,054.90

Service Code	MSDRG 917
Min. Negotiated Rate	$17,839.39
Max. Negotiated Rate	$27,054.90
Rate for Payer: AlohaCare Medicare	$17,839.39
Rate for Payer: Devoted Health Medicare	$19,623.33
Rate for Payer: Hawaii Medical Service Association Commercial	$21,087.15
Rate for Payer: Hawaii Medical Service Association Medicare	$17,839.39
Rate for Payer: Humana Medicare	$17,839.39
Rate for Payer: Kaiser Permanente Commercial	$27,054.90
Rate for Payer: Kaiser Permanente Medicare	$17,839.39
Rate for Payer: Ohana Health Plan Medicare	$17,839.39
Rate for Payer: UnitedHealthcare Medicare	$17,839.39

POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC

Facility

$16,088.36

Service Code	MSDRG 918
Min. Negotiated Rate	$9,748.87
Max. Negotiated Rate	$16,088.36
Rate for Payer: AlohaCare Medicare	$9,748.87
Rate for Payer: Devoted Health Medicare	$10,723.76
Rate for Payer: Hawaii Medical Service Association Commercial	$16,088.36
Rate for Payer: Hawaii Medical Service Association Medicare	$9,748.87
Rate for Payer: Humana Medicare	$9,748.87
Rate for Payer: Kaiser Permanente Commercial	$14,784.98
Rate for Payer: Kaiser Permanente Medicare	$9,748.87
Rate for Payer: Ohana Health Plan Medicare	$9,748.87
Rate for Payer: UnitedHealthcare Medicare	$9,748.87

POISONING OF MEDICINAL AGENTS

Facility

$7,066.77

Service Code	APR-DRG 8124
Min. Negotiated Rate	$7,066.77
Max. Negotiated Rate	$7,066.77
Rate for Payer: AlohaCare Medicaid	$7,066.77
Rate for Payer: Hawaii Medical Service Association ABD	$7,066.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,066.77
Rate for Payer: Kaiser Permanente Medicaid	$7,066.77
Rate for Payer: Ohana Health Plan Medicaid	$7,066.77
Rate for Payer: UnitedHealthcare Medicaid	$7,066.77

POISONING OF MEDICINAL AGENTS

Facility

$2,802.83

Service Code	APR-DRG 8122
Min. Negotiated Rate	$2,802.83
Max. Negotiated Rate	$2,802.83
Rate for Payer: AlohaCare Medicaid	$2,802.83
Rate for Payer: Hawaii Medical Service Association ABD	$2,802.83
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,802.83
Rate for Payer: Kaiser Permanente Medicaid	$2,802.83
Rate for Payer: Ohana Health Plan Medicaid	$2,802.83
Rate for Payer: UnitedHealthcare Medicaid	$2,802.83

POISONING OF MEDICINAL AGENTS

Facility

$1,956.18

Service Code	APR-DRG 8121
Min. Negotiated Rate	$1,956.18
Max. Negotiated Rate	$1,956.18
Rate for Payer: AlohaCare Medicaid	$1,956.18
Rate for Payer: Hawaii Medical Service Association ABD	$1,956.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,956.18
Rate for Payer: Kaiser Permanente Medicaid	$1,956.18
Rate for Payer: Ohana Health Plan Medicaid	$1,956.18
Rate for Payer: UnitedHealthcare Medicaid	$1,956.18

POISONING OF MEDICINAL AGENTS

Facility

$4,038.90

Service Code	APR-DRG 8123
Min. Negotiated Rate	$4,038.90
Max. Negotiated Rate	$4,038.90
Rate for Payer: AlohaCare Medicaid	$4,038.90
Rate for Payer: Hawaii Medical Service Association ABD	$4,038.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,038.90
Rate for Payer: Kaiser Permanente Medicaid	$4,038.90
Rate for Payer: Ohana Health Plan Medicaid	$4,038.90
Rate for Payer: UnitedHealthcare Medicaid	$4,038.90

POLATUZUMAB VEDOTIN-PIIQ 140 MG/7ML IV (WET SOLR VIAL) [430168184]

Facility

$22,834.00

Service Code	HCPCS J9309
Hospital Revenue Code	636
Min. Negotiated Rate	$136.23
Max. Negotiated Rate	$22,148.98
Rate for Payer: AlohaCare Medicaid	$137.23
Rate for Payer: AlohaCare Medicare	$137.23
Rate for Payer: Cash Price	$13,700.40
Rate for Payer: Cash Price	$13,700.40
Rate for Payer: Devoted Health Medicare	$150.95
Rate for Payer: Hawaii Medical Service Association ABD	$136.23
Rate for Payer: Hawaii Medical Service Association Commercial	$171.54
Rate for Payer: Hawaii Medical Service Association Medicare	$137.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.23
Rate for Payer: Hawaii Western Management Group Commercial	$21,692.30
Rate for Payer: Health Management Network Commercial	$19,408.90
Rate for Payer: Humana Medicare	$137.23
Rate for Payer: Kaiser Permanente Commercial	$14,385.42
Rate for Payer: Kaiser Permanente Medicaid	$11,645.34
Rate for Payer: Kaiser Permanente Medicare	$137.23
Rate for Payer: MDX Hawaii PPO	$22,148.98
Rate for Payer: Ohana Health Plan Medicaid	$150.95
Rate for Payer: Ohana Health Plan Medicare	$137.23
Rate for Payer: UnitedHealthcare Medicaid	$13,700.40
Rate for Payer: UnitedHealthcare Medicare	$137.23
Rate for Payer: University Health Alliance Commercial	$16,643.70

POLATUZUMAB VEDOTIN-PIIQ 140 MG/7ML IV (WET SOLR VIAL) [430168184]

Facility

$22,834.00

Service Code	HCPCS J9309
Hospital Revenue Code	250
Min. Negotiated Rate	$19,408.90
Max. Negotiated Rate	$22,148.98
Rate for Payer: Cash Price	$13,700.40
Rate for Payer: Health Management Network Commercial	$19,408.90
Rate for Payer: MDX Hawaii PPO	$22,148.98

POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION [168184]

Facility

$12,848.00

Service Code	HCPCS J9309
Hospital Revenue Code	636
Min. Negotiated Rate	$136.23
Max. Negotiated Rate	$12,462.56
Rate for Payer: AlohaCare Medicaid	$137.23
Rate for Payer: AlohaCare Medicaid	$137.23
Rate for Payer: AlohaCare Medicare	$137.23
Rate for Payer: AlohaCare Medicare	$137.23
Rate for Payer: Cash Price	$13,700.40
Rate for Payer: Cash Price	$7,708.80
Rate for Payer: Cash Price	$7,708.80
Rate for Payer: Cash Price	$13,700.40
Rate for Payer: Devoted Health Medicare	$150.95
Rate for Payer: Devoted Health Medicare	$150.95
Rate for Payer: Hawaii Medical Service Association ABD	$136.23
Rate for Payer: Hawaii Medical Service Association ABD	$136.23
Rate for Payer: Hawaii Medical Service Association Commercial	$171.54
Rate for Payer: Hawaii Medical Service Association Commercial	$171.54
Rate for Payer: Hawaii Medical Service Association Medicare	$137.23
Rate for Payer: Hawaii Medical Service Association Medicare	$137.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.23
Rate for Payer: Hawaii Western Management Group Commercial	$12,205.60
Rate for Payer: Hawaii Western Management Group Commercial	$21,692.30
Rate for Payer: Health Management Network Commercial	$19,408.90
Rate for Payer: Health Management Network Commercial	$10,920.80
Rate for Payer: Humana Medicare	$137.23
Rate for Payer: Humana Medicare	$137.23
Rate for Payer: Kaiser Permanente Commercial	$14,385.42
Rate for Payer: Kaiser Permanente Commercial	$8,094.24
Rate for Payer: Kaiser Permanente Medicaid	$6,552.48
Rate for Payer: Kaiser Permanente Medicaid	$11,645.34
Rate for Payer: Kaiser Permanente Medicare	$137.23
Rate for Payer: Kaiser Permanente Medicare	$137.23
Rate for Payer: MDX Hawaii PPO	$22,148.98
Rate for Payer: MDX Hawaii PPO	$12,462.56
Rate for Payer: Ohana Health Plan Medicaid	$150.95
Rate for Payer: Ohana Health Plan Medicaid	$150.95
Rate for Payer: Ohana Health Plan Medicare	$137.23
Rate for Payer: Ohana Health Plan Medicare	$137.23
Rate for Payer: UnitedHealthcare Medicaid	$7,708.80
Rate for Payer: UnitedHealthcare Medicaid	$13,700.40
Rate for Payer: UnitedHealthcare Medicare	$137.23
Rate for Payer: UnitedHealthcare Medicare	$137.23
Rate for Payer: University Health Alliance Commercial	$16,643.70
Rate for Payer: University Health Alliance Commercial	$9,364.91

POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION [168184]

Facility

$12,848.00

Service Code	HCPCS J9309
Hospital Revenue Code	250
Min. Negotiated Rate	$10,920.80
Max. Negotiated Rate	$12,462.56
Rate for Payer: Cash Price	$7,708.80
Rate for Payer: Cash Price	$13,700.40
Rate for Payer: Health Management Network Commercial	$19,408.90
Rate for Payer: Health Management Network Commercial	$10,920.80
Rate for Payer: MDX Hawaii PPO	$12,462.56
Rate for Payer: MDX Hawaii PPO	$22,148.98

Know your out-of-pocket cost for care.

All Charges