Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CABLE BUTTON NCB 47-223-060-01

Facility

$956.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$535.36
Max. Negotiated Rate	$927.32
Rate for Payer: Cash Price	$573.60
Rate for Payer: Hawaii Western Management Group Commercial	$669.20
Rate for Payer: Health Management Network Commercial	$812.60
Rate for Payer: MDX Hawaii PPO	$927.32
Rate for Payer: University Health Alliance Commercial	$535.36

CABLE BUTTON NCB 47-223-060-01

Facility

$956.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$487.56
Max. Negotiated Rate	$927.32
Rate for Payer: Cash Price	$573.60
Rate for Payer: Hawaii Western Management Group Commercial	$669.20
Rate for Payer: Health Management Network Commercial	$812.60
Rate for Payer: Kaiser Permanente Commercial	$602.28
Rate for Payer: Kaiser Permanente Medicaid	$487.56
Rate for Payer: MDX Hawaii PPO	$927.32
Rate for Payer: University Health Alliance Commercial	$535.36

CABLE GRIP SYS 2232-05-18

Facility

$1,715.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$960.40
Max. Negotiated Rate	$1,663.55
Rate for Payer: Cash Price	$1,029.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,200.50
Rate for Payer: Health Management Network Commercial	$1,457.75
Rate for Payer: MDX Hawaii PPO	$1,663.55
Rate for Payer: University Health Alliance Commercial	$960.40

CABLE GRIP SYS 2232-05-18

Facility

$1,715.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$874.65
Max. Negotiated Rate	$1,663.55
Rate for Payer: Cash Price	$1,029.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,200.50
Rate for Payer: Health Management Network Commercial	$1,457.75
Rate for Payer: Kaiser Permanente Commercial	$1,080.45
Rate for Payer: Kaiser Permanente Medicaid	$874.65
Rate for Payer: MDX Hawaii PPO	$1,663.55
Rate for Payer: University Health Alliance Commercial	$960.40

CABLE PACING REMINGTON

Facility

$111.00

Hospital Revenue Code	272
Min. Negotiated Rate	$56.61
Max. Negotiated Rate	$107.67
Rate for Payer: Cash Price	$66.60
Rate for Payer: Hawaii Western Management Group Commercial	$105.45
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: Kaiser Permanente Commercial	$69.93
Rate for Payer: Kaiser Permanente Medicaid	$56.61
Rate for Payer: MDX Hawaii PPO	$107.67
Rate for Payer: University Health Alliance Commercial	$80.91

CABLE PACING REMINGTON

Facility

$111.00

Hospital Revenue Code	272
Min. Negotiated Rate	$94.35
Max. Negotiated Rate	$107.67
Rate for Payer: Cash Price	$66.60
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: MDX Hawaii PPO	$107.67

CABLE PIN 4MMX40 2232-50-19

Facility

$2,100.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,176.00
Max. Negotiated Rate	$2,037.00
Rate for Payer: Cash Price	$1,260.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,470.00
Rate for Payer: Health Management Network Commercial	$1,785.00
Rate for Payer: MDX Hawaii PPO	$2,037.00
Rate for Payer: University Health Alliance Commercial	$1,176.00

CABLE PIN 4MMX40 2232-50-19

Facility

$2,100.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,071.00
Max. Negotiated Rate	$2,037.00
Rate for Payer: Cash Price	$1,260.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,470.00
Rate for Payer: Health Management Network Commercial	$1,785.00
Rate for Payer: Kaiser Permanente Commercial	$1,323.00
Rate for Payer: Kaiser Permanente Medicaid	$1,071.00
Rate for Payer: MDX Hawaii PPO	$2,037.00
Rate for Payer: University Health Alliance Commercial	$1,176.00

CABLE PIN 4MMX65 2232-50-21

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,020.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,260.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

CABLE PIN 4MMX65 2232-50-21

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

CABLES 23x53MM 00-2232-002-04

Facility

$4,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

CABLES 23x53MM 00-2232-002-04

Facility

$4,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,040.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$2,520.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

CABLE SLEEVE SM 2MM 6704-0-520

Facility

$1,314.00

Hospital Revenue Code	278
Min. Negotiated Rate	$735.84
Max. Negotiated Rate	$1,274.58
Rate for Payer: Cash Price	$788.40
Rate for Payer: Hawaii Western Management Group Commercial	$919.80
Rate for Payer: Health Management Network Commercial	$1,116.90
Rate for Payer: MDX Hawaii PPO	$1,274.58
Rate for Payer: University Health Alliance Commercial	$735.84

CABLE SLEEVE SM 2MM 6704-0-520

Facility

$1,314.00

Hospital Revenue Code	278
Min. Negotiated Rate	$670.14
Max. Negotiated Rate	$1,274.58
Rate for Payer: Cash Price	$788.40
Rate for Payer: Hawaii Western Management Group Commercial	$919.80
Rate for Payer: Health Management Network Commercial	$1,116.90
Rate for Payer: Kaiser Permanente Commercial	$827.82
Rate for Payer: Kaiser Permanente Medicaid	$670.14
Rate for Payer: MDX Hawaii PPO	$1,274.58
Rate for Payer: University Health Alliance Commercial	$735.84

CABLE TEST PATIENT 357501

Facility

$200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: MDX Hawaii PPO	$194.00

CABLE TEST PATIENT 357501

Facility

$200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: University Health Alliance Commercial	$145.78

CABLE TWIST LOCK 357664

Facility

$320.00

Hospital Revenue Code	272
Min. Negotiated Rate	$272.00
Max. Negotiated Rate	$310.40
Rate for Payer: Cash Price	$192.00
Rate for Payer: Health Management Network Commercial	$272.00
Rate for Payer: MDX Hawaii PPO	$310.40

CABLE TWIST LOCK 357664

Facility

$320.00

Hospital Revenue Code	272
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$310.40
Rate for Payer: Cash Price	$192.00
Rate for Payer: Hawaii Western Management Group Commercial	$304.00
Rate for Payer: Health Management Network Commercial	$272.00
Rate for Payer: Kaiser Permanente Commercial	$201.60
Rate for Payer: Kaiser Permanente Medicaid	$163.20
Rate for Payer: MDX Hawaii PPO	$310.40
Rate for Payer: University Health Alliance Commercial	$233.25

CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [109034]

Facility

$51.00

Service Code	NDC 51754050001
Hospital Revenue Code	250
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: MDX Hawaii PPO	$49.47

CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [109034]

Facility

$258.00

Service Code	NDC 25021060103
Hospital Revenue Code	250
Min. Negotiated Rate	$219.30
Max. Negotiated Rate	$250.26
Rate for Payer: Cash Price	$154.80
Rate for Payer: Cash Price	$43.20
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Health Management Network Commercial	$219.30
Rate for Payer: MDX Hawaii PPO	$250.26
Rate for Payer: MDX Hawaii PPO	$69.84

CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]

Facility

$118.00

Service Code	NDC 00517250210
Hospital Revenue Code	250
Min. Negotiated Rate	$100.30
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$70.80
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: MDX Hawaii PPO	$114.46

CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]

Facility

$118.00

Service Code	NDC 00517250201
Hospital Revenue Code	250
Min. Negotiated Rate	$100.30
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$70.80
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: MDX Hawaii PPO	$114.46

CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]

Facility

$9.00

Service Code	NDC 00904253321
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

CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]

Facility

$16.00

Service Code	NDC 00395041396
Hospital Revenue Code	250
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: MDX Hawaii PPO	$15.52

CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]

Facility

$9.00

Service Code	NDC 00904253321
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

Know your out-of-pocket cost for care.

All Charges