Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CAP LCK HRS COCR ARS655200

Facility

$1,833.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,026.48
Max. Negotiated Rate	$1,778.01
Rate for Payer: Cash Price	$1,099.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,283.10
Rate for Payer: Health Management Network Commercial	$1,558.05
Rate for Payer: MDX Hawaii PPO	$1,778.01
Rate for Payer: University Health Alliance Commercial	$1,026.48

CAP LCK HRS COCR ARS655200

Facility

$1,833.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$934.83
Max. Negotiated Rate	$1,778.01
Rate for Payer: Cash Price	$1,099.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,283.10
Rate for Payer: Health Management Network Commercial	$1,558.05
Rate for Payer: Kaiser Permanente Commercial	$1,154.79
Rate for Payer: Kaiser Permanente Medicaid	$934.83
Rate for Payer: MDX Hawaii PPO	$1,778.01
Rate for Payer: University Health Alliance Commercial	$1,026.48

CAP LOCKING NCB 02.03150.300

Facility

$1,260.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$642.60
Max. Negotiated Rate	$1,222.20
Rate for Payer: Cash Price	$756.00
Rate for Payer: Hawaii Western Management Group Commercial	$882.00
Rate for Payer: Health Management Network Commercial	$1,071.00
Rate for Payer: Kaiser Permanente Commercial	$793.80
Rate for Payer: Kaiser Permanente Medicaid	$642.60
Rate for Payer: MDX Hawaii PPO	$1,222.20
Rate for Payer: University Health Alliance Commercial	$705.60

CAP LOCKING NCB 02.03150.300

Facility

$1,260.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$705.60
Max. Negotiated Rate	$1,222.20
Rate for Payer: Cash Price	$756.00
Rate for Payer: Hawaii Western Management Group Commercial	$882.00
Rate for Payer: Health Management Network Commercial	$1,071.00
Rate for Payer: MDX Hawaii PPO	$1,222.20
Rate for Payer: University Health Alliance Commercial	$705.60

CAPSAICIN 0.025 % TOPICAL CREAM [1350]

Facility

$35.00

Service Code	NDC 00536252525
Hospital Revenue Code	637
Min. Negotiated Rate	$17.85
Max. Negotiated Rate	$33.95
Rate for Payer: Cash Price	$21.00
Rate for Payer: Hawaii Western Management Group Commercial	$33.25
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: Kaiser Permanente Commercial	$22.05
Rate for Payer: Kaiser Permanente Medicaid	$17.85
Rate for Payer: MDX Hawaii PPO	$33.95
Rate for Payer: University Health Alliance Commercial	$25.51

CAPSAICIN 0.025 % TOPICAL CREAM [1350]

Facility

$35.00

Service Code	NDC 00536252525
Hospital Revenue Code	250
Min. Negotiated Rate	$29.75
Max. Negotiated Rate	$33.95
Rate for Payer: Cash Price	$21.00
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: MDX Hawaii PPO	$33.95

CAPS PROTECTIVE 11MM 394.97

Facility

$123.00

Hospital Revenue Code	272
Min. Negotiated Rate	$62.73
Max. Negotiated Rate	$119.31
Rate for Payer: Cash Price	$73.80
Rate for Payer: Hawaii Western Management Group Commercial	$116.85
Rate for Payer: Health Management Network Commercial	$104.55
Rate for Payer: Kaiser Permanente Commercial	$77.49
Rate for Payer: Kaiser Permanente Medicaid	$62.73
Rate for Payer: MDX Hawaii PPO	$119.31
Rate for Payer: University Health Alliance Commercial	$89.65

CAPS PROTECTIVE 11MM 394.97

Facility

$123.00

Hospital Revenue Code	272
Min. Negotiated Rate	$104.55
Max. Negotiated Rate	$119.31
Rate for Payer: Cash Price	$73.80
Rate for Payer: Health Management Network Commercial	$104.55
Rate for Payer: MDX Hawaii PPO	$119.31

CAPS PROTECTIVE 6MM 394.994

Facility

$398.00

Hospital Revenue Code	272
Min. Negotiated Rate	$338.30
Max. Negotiated Rate	$386.06
Rate for Payer: Cash Price	$238.80
Rate for Payer: Health Management Network Commercial	$338.30
Rate for Payer: MDX Hawaii PPO	$386.06

CAPS PROTECTIVE 6MM 394.994

Facility

$398.00

Hospital Revenue Code	272
Min. Negotiated Rate	$202.98
Max. Negotiated Rate	$386.06
Rate for Payer: Cash Price	$238.80
Rate for Payer: Hawaii Western Management Group Commercial	$378.10
Rate for Payer: Health Management Network Commercial	$338.30
Rate for Payer: Kaiser Permanente Commercial	$250.74
Rate for Payer: Kaiser Permanente Medicaid	$202.98
Rate for Payer: MDX Hawaii PPO	$386.06
Rate for Payer: University Health Alliance Commercial	$290.10

CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH CORACOID PROCESS TRANSFER

Facility

$16,700.00

Service Code	CPT 23462
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$16,700.00
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$16,700.00

CAPSURE NOVUS LEAD 5076-45CM

Facility

$2,250.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$1,260.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: University Health Alliance Commercial	$1,260.00

CAPSURE NOVUS LEAD 5076-45CM

Facility

$2,250.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$1,147.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: University Health Alliance Commercial	$1,260.00

CAPSURE NOVUS LEAD 5076-52CM

Facility

$1,725.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$966.00
Max. Negotiated Rate	$1,673.25
Rate for Payer: Cash Price	$1,035.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,207.50
Rate for Payer: Health Management Network Commercial	$1,466.25
Rate for Payer: MDX Hawaii PPO	$1,673.25
Rate for Payer: University Health Alliance Commercial	$966.00

CAPSURE NOVUS LEAD 5076-52CM

Facility

$1,725.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$879.75
Max. Negotiated Rate	$1,673.25
Rate for Payer: Cash Price	$1,035.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,207.50
Rate for Payer: Health Management Network Commercial	$1,466.25
Rate for Payer: Kaiser Permanente Commercial	$1,086.75
Rate for Payer: Kaiser Permanente Medicaid	$879.75
Rate for Payer: MDX Hawaii PPO	$1,673.25
Rate for Payer: University Health Alliance Commercial	$966.00

CAPSURE NOVUS LEAD 5076-58CM

Facility

$1,725.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$966.00
Max. Negotiated Rate	$1,673.25
Rate for Payer: Cash Price	$1,035.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,207.50
Rate for Payer: Health Management Network Commercial	$1,466.25
Rate for Payer: MDX Hawaii PPO	$1,673.25
Rate for Payer: University Health Alliance Commercial	$966.00

CAPSURE NOVUS LEAD 5076-58CM

Facility

$1,725.00

Service Code	HCPCS C1898
Hospital Revenue Code	275
Min. Negotiated Rate	$879.75
Max. Negotiated Rate	$1,673.25
Rate for Payer: Cash Price	$1,035.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,207.50
Rate for Payer: Health Management Network Commercial	$1,466.25
Rate for Payer: Kaiser Permanente Commercial	$1,086.75
Rate for Payer: Kaiser Permanente Medicaid	$879.75
Rate for Payer: MDX Hawaii PPO	$1,673.25
Rate for Payer: University Health Alliance Commercial	$966.00

CAPTOPRIL 12.5 MG TABLET [9401]

Facility

$6.00

Service Code	NDC 60687030411
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

CAPTOPRIL 12.5 MG TABLET [9401]

Facility

$6.00

Service Code	NDC 60687030411
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

CAPTOPRIL 12.5 MG TABLET [9401]

Facility

$6.00

Service Code	NDC 60687030421
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

CAPTOPRIL 12.5 MG TABLET [9401]

Facility

$6.00

Service Code	NDC 60687030421
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION [201039]

Facility

$178.00

Service Code	NDC 51672404709
Hospital Revenue Code	250
Min. Negotiated Rate	$151.30
Max. Negotiated Rate	$172.66
Rate for Payer: Cash Price	$106.80
Rate for Payer: Health Management Network Commercial	$151.30
Rate for Payer: MDX Hawaii PPO	$172.66

CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION [201039]

Facility

$178.00

Service Code	NDC 70954024010
Hospital Revenue Code	250
Min. Negotiated Rate	$151.30
Max. Negotiated Rate	$172.66
Rate for Payer: Cash Price	$106.80
Rate for Payer: Health Management Network Commercial	$151.30
Rate for Payer: MDX Hawaii PPO	$172.66

CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION [201039]

Facility

$178.00

Service Code	NDC 51672404709
Hospital Revenue Code	637
Min. Negotiated Rate	$90.78
Max. Negotiated Rate	$172.66
Rate for Payer: Cash Price	$106.80
Rate for Payer: Hawaii Western Management Group Commercial	$169.10
Rate for Payer: Health Management Network Commercial	$151.30
Rate for Payer: Kaiser Permanente Commercial	$112.14
Rate for Payer: Kaiser Permanente Medicaid	$90.78
Rate for Payer: MDX Hawaii PPO	$172.66
Rate for Payer: University Health Alliance Commercial	$129.74

CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION [201039]

Facility

$178.00

Service Code	NDC 70954024010
Hospital Revenue Code	637
Min. Negotiated Rate	$90.78
Max. Negotiated Rate	$172.66
Rate for Payer: Cash Price	$106.80
Rate for Payer: Hawaii Western Management Group Commercial	$169.10
Rate for Payer: Health Management Network Commercial	$151.30
Rate for Payer: Kaiser Permanente Commercial	$112.14
Rate for Payer: Kaiser Permanente Medicaid	$90.78
Rate for Payer: MDX Hawaii PPO	$172.66
Rate for Payer: University Health Alliance Commercial	$129.74

Know your out-of-pocket cost for care.

All Charges