Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CANNULA PASSPORT AR-6592-10-40

Facility

$160.00

Hospital Revenue Code	272
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: MDX Hawaii PPO	$155.20

CANNULA PASSPORT AR-6592-10-50

Facility

$160.00

Hospital Revenue Code	272
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Hawaii Western Management Group Commercial	$152.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Medicaid	$81.60
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: University Health Alliance Commercial	$116.62

CANNULA PASSPORT AR-6592-10-50

Facility

$160.00

Hospital Revenue Code	272
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: MDX Hawaii PPO	$155.20

CANNULA PASSPORT AR-6592-12-30

Facility

$252.00

Hospital Revenue Code	272
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$244.44
Rate for Payer: Cash Price	$151.20
Rate for Payer: Health Management Network Commercial	$214.20
Rate for Payer: MDX Hawaii PPO	$244.44

CANNULA PASSPORT AR-6592-12-30

Facility

$252.00

Hospital Revenue Code	272
Min. Negotiated Rate	$128.52
Max. Negotiated Rate	$244.44
Rate for Payer: Cash Price	$151.20
Rate for Payer: Hawaii Western Management Group Commercial	$239.40
Rate for Payer: Health Management Network Commercial	$214.20
Rate for Payer: Kaiser Permanente Commercial	$158.76
Rate for Payer: Kaiser Permanente Medicaid	$128.52
Rate for Payer: MDX Hawaii PPO	$244.44
Rate for Payer: University Health Alliance Commercial	$183.68

CANNULA REDUCER 12-8MM 470381

Facility

$125.00

Hospital Revenue Code	272
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$121.25
Rate for Payer: Cash Price	$75.00
Rate for Payer: Hawaii Western Management Group Commercial	$118.75
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Kaiser Permanente Commercial	$78.75
Rate for Payer: Kaiser Permanente Medicaid	$63.75
Rate for Payer: MDX Hawaii PPO	$121.25
Rate for Payer: University Health Alliance Commercial	$91.11

CANNULA REDUCER 12-8MM 470381

Facility

$125.00

Hospital Revenue Code	272
Min. Negotiated Rate	$106.25
Max. Negotiated Rate	$121.25
Rate for Payer: Cash Price	$75.00
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: MDX Hawaii PPO	$121.25

CANNULA REP STP 5-12

Facility

$213.00

Hospital Revenue Code	272
Min. Negotiated Rate	$181.05
Max. Negotiated Rate	$206.61
Rate for Payer: Cash Price	$127.80
Rate for Payer: Health Management Network Commercial	$181.05
Rate for Payer: MDX Hawaii PPO	$206.61

CANNULA REP STP 5-12

Facility

$213.00

Hospital Revenue Code	272
Min. Negotiated Rate	$108.63
Max. Negotiated Rate	$206.61
Rate for Payer: Cash Price	$127.80
Rate for Payer: Hawaii Western Management Group Commercial	$202.35
Rate for Payer: Health Management Network Commercial	$181.05
Rate for Payer: Kaiser Permanente Commercial	$134.19
Rate for Payer: Kaiser Permanente Medicaid	$108.63
Rate for Payer: MDX Hawaii PPO	$206.61
Rate for Payer: University Health Alliance Commercial	$155.26

CANNULA SEAL 5MM-8MM 470361

Facility

$113.00

Hospital Revenue Code	272
Min. Negotiated Rate	$96.05
Max. Negotiated Rate	$109.61
Rate for Payer: Cash Price	$67.80
Rate for Payer: Health Management Network Commercial	$96.05
Rate for Payer: MDX Hawaii PPO	$109.61

CANNULA SEAL 5MM-8MM 470361

Facility

$113.00

Hospital Revenue Code	272
Min. Negotiated Rate	$57.63
Max. Negotiated Rate	$109.61
Rate for Payer: Cash Price	$67.80
Rate for Payer: Hawaii Western Management Group Commercial	$107.35
Rate for Payer: Health Management Network Commercial	$96.05
Rate for Payer: Kaiser Permanente Commercial	$71.19
Rate for Payer: Kaiser Permanente Medicaid	$57.63
Rate for Payer: MDX Hawaii PPO	$109.61
Rate for Payer: University Health Alliance Commercial	$82.37

CANNULA SILI 8.0X40 3910080040

Facility

$214.00

Hospital Revenue Code	272
Min. Negotiated Rate	$109.14
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$128.40
Rate for Payer: Hawaii Western Management Group Commercial	$203.30
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$134.82
Rate for Payer: Kaiser Permanente Medicaid	$109.14
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: University Health Alliance Commercial	$155.98

CANNULA SILI 8.0X40 3910080040

Facility

$214.00

Hospital Revenue Code	272
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$128.40
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: MDX Hawaii PPO	$207.58

CANNULA SILICONE 8.0MMX40MM

Facility

$214.00

Hospital Revenue Code	272
Min. Negotiated Rate	$109.14
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$128.40
Rate for Payer: Hawaii Western Management Group Commercial	$203.30
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$134.82
Rate for Payer: Kaiser Permanente Medicaid	$109.14
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: University Health Alliance Commercial	$155.98

CANNULA SILICONE 8.0MMX40MM

Facility

$214.00

Hospital Revenue Code	272
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$128.40
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: MDX Hawaii PPO	$207.58

CANNULA TWIST-IN 7X7CM AR-6570

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: MDX Hawaii PPO	$727.50

CANNULA TWIST-IN 7X7CM AR-6570

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$546.67

CANNULA TWIST IN AR-6570TD

Facility

$168.00

Hospital Revenue Code	272
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$100.80
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: MDX Hawaii PPO	$162.96

CANNULA TWIST IN AR-6570TD

Facility

$168.00

Hospital Revenue Code	272
Min. Negotiated Rate	$85.68
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$100.80
Rate for Payer: Hawaii Western Management Group Commercial	$159.60
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Kaiser Permanente Commercial	$105.84
Rate for Payer: Kaiser Permanente Medicaid	$85.68
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: University Health Alliance Commercial	$122.46

CAP AND OBTURATOR IAS8-DV

Facility

$420.00

Hospital Revenue Code	272
Min. Negotiated Rate	$357.00
Max. Negotiated Rate	$407.40
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Management Network Commercial	$357.00
Rate for Payer: MDX Hawaii PPO	$407.40

CAP AND OBTURATOR IAS8-DV

Facility

$420.00

Hospital Revenue Code	272
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$407.40
Rate for Payer: Cash Price	$252.00
Rate for Payer: Hawaii Western Management Group Commercial	$399.00
Rate for Payer: Health Management Network Commercial	$357.00
Rate for Payer: Kaiser Permanente Commercial	$264.60
Rate for Payer: Kaiser Permanente Medicaid	$214.20
Rate for Payer: MDX Hawaii PPO	$407.40
Rate for Payer: University Health Alliance Commercial	$306.14

CAPECITABINE 500 MG TABLET [22994]

Facility

$98.00

Service Code	HCPCS J8522
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$95.06
Rate for Payer: AlohaCare Medicaid	$0.03
Rate for Payer: AlohaCare Medicare	$0.03
Rate for Payer: Cash Price	$58.80
Rate for Payer: Cash Price	$58.80
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Hawaii Medical Service Association ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Commercial	$0.04
Rate for Payer: Hawaii Medical Service Association Medicare	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.05
Rate for Payer: Hawaii Western Management Group Commercial	$93.10
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Humana Medicare	$0.03
Rate for Payer: Kaiser Permanente Commercial	$61.74
Rate for Payer: Kaiser Permanente Medicaid	$49.98
Rate for Payer: Kaiser Permanente Medicare	$0.03
Rate for Payer: MDX Hawaii PPO	$95.06
Rate for Payer: Ohana Health Plan Medicaid	$0.03
Rate for Payer: Ohana Health Plan Medicare	$0.03
Rate for Payer: UnitedHealthcare Medicaid	$58.80
Rate for Payer: UnitedHealthcare Medicare	$0.03
Rate for Payer: University Health Alliance Commercial	$71.43

CAPECITABINE 500 MG TABLET [22994]

Facility

$98.00

Service Code	HCPCS J8522
Hospital Revenue Code	250
Min. Negotiated Rate	$83.30
Max. Negotiated Rate	$95.06
Rate for Payer: Cash Price	$58.80
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: MDX Hawaii PPO	$95.06

CAP END 5MM 2341-0005S

Facility

$1,071.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$599.76
Max. Negotiated Rate	$1,038.87
Rate for Payer: Cash Price	$642.60
Rate for Payer: Hawaii Western Management Group Commercial	$749.70
Rate for Payer: Health Management Network Commercial	$910.35
Rate for Payer: MDX Hawaii PPO	$1,038.87
Rate for Payer: University Health Alliance Commercial	$599.76

CAP END 5MM 2341-0005S

Facility

$1,071.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$546.21
Max. Negotiated Rate	$1,038.87
Rate for Payer: Cash Price	$642.60
Rate for Payer: Hawaii Western Management Group Commercial	$749.70
Rate for Payer: Health Management Network Commercial	$910.35
Rate for Payer: Kaiser Permanente Commercial	$674.73
Rate for Payer: Kaiser Permanente Medicaid	$546.21
Rate for Payer: MDX Hawaii PPO	$1,038.87
Rate for Payer: University Health Alliance Commercial	$599.76

Know your out-of-pocket cost for care.

All Charges