Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE [1306]

Facility

$45.00

Service Code	NDC 76329330401
Hospital Revenue Code	250
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: MDX Hawaii PPO	$18.43

CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION [1312]

Facility

$55.00

Service Code	HCPCS J0612
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$33.00
Rate for Payer: Cash Price	$25.80
Rate for Payer: Cash Price	$33.00
Rate for Payer: Cash Price	$25.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.04
Rate for Payer: Hawaii Medical Service Association ABD	$0.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.04
Rate for Payer: Hawaii Western Management Group Commercial	$40.85
Rate for Payer: Hawaii Western Management Group Commercial	$52.25
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Kaiser Permanente Commercial	$34.65
Rate for Payer: Kaiser Permanente Commercial	$27.09
Rate for Payer: Kaiser Permanente Medicaid	$21.93
Rate for Payer: Kaiser Permanente Medicaid	$28.05
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: MDX Hawaii PPO	$41.71
Rate for Payer: UnitedHealthcare Medicaid	$25.80
Rate for Payer: UnitedHealthcare Medicaid	$33.00
Rate for Payer: University Health Alliance Commercial	$40.09
Rate for Payer: University Health Alliance Commercial	$31.34

CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION [1312]

Facility

$55.00

Service Code	HCPCS J0612
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	$25.80
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: MDX Hawaii PPO	$41.71
Rate for Payer: MDX Hawaii PPO	$53.35

CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION [166340]

Facility

$83.00

Service Code	HCPCS J0613
Hospital Revenue Code	250
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$49.80
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: MDX Hawaii PPO	$80.51

CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION [166340]

Facility

$83.00

Service Code	HCPCS J0613
Hospital Revenue Code	636
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$49.80
Rate for Payer: Cash Price	$49.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.08
Rate for Payer: Hawaii Western Management Group Commercial	$78.85
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Kaiser Permanente Commercial	$52.29
Rate for Payer: Kaiser Permanente Medicaid	$42.33
Rate for Payer: MDX Hawaii PPO	$80.51
Rate for Payer: UnitedHealthcare Medicaid	$49.80
Rate for Payer: University Health Alliance Commercial	$60.50

CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION [166340]

Facility

$83.00

Service Code	HCPCS J0612
Hospital Revenue Code	250
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$49.80
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: MDX Hawaii PPO	$80.51

CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION [166340]

Facility

$83.00

Service Code	HCPCS J0612
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$49.80
Rate for Payer: Cash Price	$49.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.04
Rate for Payer: Hawaii Western Management Group Commercial	$78.85
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Kaiser Permanente Commercial	$52.29
Rate for Payer: Kaiser Permanente Medicaid	$42.33
Rate for Payer: MDX Hawaii PPO	$80.51
Rate for Payer: UnitedHealthcare Medicaid	$49.80
Rate for Payer: University Health Alliance Commercial	$60.50

CALFACTANT 35 MG/ML IN 0.9% SODIUM CHLORIDE INTRATRACHEAL SUSPENSION [137618]

Facility

$951.00

Service Code	NDC 61938045603
Hospital Revenue Code	250
Min. Negotiated Rate	$808.35
Max. Negotiated Rate	$922.47
Rate for Payer: Cash Price	$570.60
Rate for Payer: Health Management Network Commercial	$808.35
Rate for Payer: MDX Hawaii PPO	$922.47

CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION [23063]

Facility

$42.00

Service Code	NDC 46122057310
Hospital Revenue Code	250
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: MDX Hawaii PPO	$40.74

CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION [23063]

Facility

$42.00

Service Code	NDC 46122057310
Hospital Revenue Code	637
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$26.46
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: University Health Alliance Commercial	$30.61

CANGRELOR 50 MG INTRAVENOUS SOLUTION [129848]

Facility

$1,702.00

Service Code	HCPCS C9460
Hospital Revenue Code	250
Min. Negotiated Rate	$1,446.70
Max. Negotiated Rate	$1,650.94
Rate for Payer: Cash Price	$1,021.20
Rate for Payer: Health Management Network Commercial	$1,446.70
Rate for Payer: MDX Hawaii PPO	$1,650.94

CANISTER SUCTION 1100CC

Facility

$101.00

Hospital Revenue Code	270
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$60.60
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: MDX Hawaii PPO	$97.97

CANISTER SUCTION 1100CC

Facility

$101.00

Hospital Revenue Code	270
Min. Negotiated Rate	$51.51
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$60.60
Rate for Payer: Hawaii Western Management Group Commercial	$95.95
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$63.63
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: University Health Alliance Commercial	$73.62

CANN TI 11MM 04.033.170S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

CANN TI 11MM 04.033.170S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

CANNULA

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

CANNULA

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

CANNULA 12MMX3CM AR-6592-12-40

Facility

$344.00

Hospital Revenue Code	272
Min. Negotiated Rate	$175.44
Max. Negotiated Rate	$333.68
Rate for Payer: Cash Price	$206.40
Rate for Payer: Hawaii Western Management Group Commercial	$326.80
Rate for Payer: Health Management Network Commercial	$292.40
Rate for Payer: Kaiser Permanente Commercial	$216.72
Rate for Payer: Kaiser Permanente Medicaid	$175.44
Rate for Payer: MDX Hawaii PPO	$333.68
Rate for Payer: University Health Alliance Commercial	$250.74

CANNULA 12MMX3CM AR-6592-12-40

Facility

$344.00

Hospital Revenue Code	272
Min. Negotiated Rate	$292.40
Max. Negotiated Rate	$333.68
Rate for Payer: Cash Price	$206.40
Rate for Payer: Health Management Network Commercial	$292.40
Rate for Payer: MDX Hawaii PPO	$333.68

CANNULA 3MMX22CM PAL-30MLS

Facility

$300.00

Hospital Revenue Code	272
Min. Negotiated Rate	$153.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: University Health Alliance Commercial	$218.67

CANNULA 3MMX22CM PAL-30MLS

Facility

$300.00

Hospital Revenue Code	272
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: MDX Hawaii PPO	$291.00

CANNULA 4X30 6.4MM PAL-4012LL

Facility

$302.00

Hospital Revenue Code	272
Min. Negotiated Rate	$256.70
Max. Negotiated Rate	$292.94
Rate for Payer: Cash Price	$181.20
Rate for Payer: Health Management Network Commercial	$256.70
Rate for Payer: MDX Hawaii PPO	$292.94

CANNULA 4X30 6.4MM PAL-4012LL

Facility

$302.00

Hospital Revenue Code	272
Min. Negotiated Rate	$154.02
Max. Negotiated Rate	$292.94
Rate for Payer: Cash Price	$181.20
Rate for Payer: Hawaii Western Management Group Commercial	$286.90
Rate for Payer: Health Management Network Commercial	$256.70
Rate for Payer: Kaiser Permanente Commercial	$190.26
Rate for Payer: Kaiser Permanente Medicaid	$154.02
Rate for Payer: MDX Hawaii PPO	$292.94
Rate for Payer: University Health Alliance Commercial	$220.13

CANNULA 5.75x7CM #AR-6560

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

CANNULA 5.75x7CM #AR-6560

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

Know your out-of-pocket cost for care.

All Charges