Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CARBON FBR ROD 8.0X200 395.782

Facility

$727.00

Service Code	HCPCS L5785
Hospital Revenue Code	274
Min. Negotiated Rate	$407.12
Max. Negotiated Rate	$705.19
Rate for Payer: Cash Price	$436.20
Rate for Payer: Hawaii Western Management Group Commercial	$508.90
Rate for Payer: Health Management Network Commercial	$617.95
Rate for Payer: MDX Hawaii PPO	$705.19
Rate for Payer: University Health Alliance Commercial	$407.12

CARBON FBR ROD 8.0X200 395.782

Facility

$727.00

Service Code	HCPCS L5785
Hospital Revenue Code	274
Min. Negotiated Rate	$285.22
Max. Negotiated Rate	$705.19
Rate for Payer: Cash Price	$436.20
Rate for Payer: Cash Price	$436.20
Rate for Payer: Hawaii Western Management Group Commercial	$508.90
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: UnitedHealthcare Medicaid	$285.22
Rate for Payer: University Health Alliance Commercial	$407.12

CARBON FBR ROD 8.0X220 395.784

Facility

$907.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$462.57
Max. Negotiated Rate	$879.79
Rate for Payer: Cash Price	$544.20
Rate for Payer: Hawaii Western Management Group Commercial	$861.65
Rate for Payer: Health Management Network Commercial	$770.95
Rate for Payer: Kaiser Permanente Commercial	$571.41
Rate for Payer: Kaiser Permanente Medicaid	$462.57
Rate for Payer: MDX Hawaii PPO	$879.79
Rate for Payer: University Health Alliance Commercial	$661.11

CARBON FBR ROD 8.0X220 395.784

Facility

$907.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$770.95
Max. Negotiated Rate	$879.79
Rate for Payer: Cash Price	$544.20
Rate for Payer: Health Management Network Commercial	$770.95
Rate for Payer: MDX Hawaii PPO	$879.79

CARBON FBR ROD 8.0X240 395.786

Facility

$727.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$617.95
Max. Negotiated Rate	$705.19
Rate for Payer: Cash Price	$436.20
Rate for Payer: Health Management Network Commercial	$617.95
Rate for Payer: MDX Hawaii PPO	$705.19

CARBON FBR ROD 8.0X240 395.786

Facility

$727.00

Service Code	HCPCS C1713
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

CARBON FBR ROD 8.0X280 395.788

Facility

$917.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$779.45
Max. Negotiated Rate	$889.49
Rate for Payer: Cash Price	$550.20
Rate for Payer: Health Management Network Commercial	$779.45
Rate for Payer: MDX Hawaii PPO	$889.49

CARBON FBR ROD 8.0X280 395.788

Facility

$917.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$467.67
Max. Negotiated Rate	$889.49
Rate for Payer: Cash Price	$550.20
Rate for Payer: Hawaii Western Management Group Commercial	$871.15
Rate for Payer: Health Management Network Commercial	$779.45
Rate for Payer: Kaiser Permanente Commercial	$577.71
Rate for Payer: Kaiser Permanente Medicaid	$467.67
Rate for Payer: MDX Hawaii PPO	$889.49
Rate for Payer: University Health Alliance Commercial	$668.40

CARBON FBR ROD 8.0X360 395.796

Facility

$795.00

Hospital Revenue Code	272
Min. Negotiated Rate	$405.45
Max. Negotiated Rate	$771.15
Rate for Payer: Cash Price	$477.00
Rate for Payer: Hawaii Western Management Group Commercial	$755.25
Rate for Payer: Health Management Network Commercial	$675.75
Rate for Payer: Kaiser Permanente Commercial	$500.85
Rate for Payer: Kaiser Permanente Medicaid	$405.45
Rate for Payer: MDX Hawaii PPO	$771.15
Rate for Payer: University Health Alliance Commercial	$579.48

CARBON FBR ROD 8.0X360 395.796

Facility

$795.00

Hospital Revenue Code	272
Min. Negotiated Rate	$675.75
Max. Negotiated Rate	$771.15
Rate for Payer: Cash Price	$477.00
Rate for Payer: Health Management Network Commercial	$675.75
Rate for Payer: MDX Hawaii PPO	$771.15

CARBON FBR ROD 8.0X400 395.797

Facility

$795.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$675.75
Max. Negotiated Rate	$771.15
Rate for Payer: Cash Price	$477.00
Rate for Payer: Health Management Network Commercial	$675.75
Rate for Payer: MDX Hawaii PPO	$771.15

CARBON FBR ROD 8.0X400 395.797

Facility

$795.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$405.45
Max. Negotiated Rate	$771.15
Rate for Payer: Cash Price	$477.00
Rate for Payer: Hawaii Western Management Group Commercial	$755.25
Rate for Payer: Health Management Network Commercial	$675.75
Rate for Payer: Kaiser Permanente Commercial	$500.85
Rate for Payer: Kaiser Permanente Medicaid	$405.45
Rate for Payer: MDX Hawaii PPO	$771.15
Rate for Payer: University Health Alliance Commercial	$579.48

CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]

Facility

$249.00

Service Code	HCPCS J9045
Hospital Revenue Code	250
Min. Negotiated Rate	$211.65
Max. Negotiated Rate	$241.53
Rate for Payer: Cash Price	$149.40
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cash Price	$126.60
Rate for Payer: Cash Price	$53.40
Rate for Payer: Cash Price	$118.80
Rate for Payer: Cash Price	$181.20
Rate for Payer: Health Management Network Commercial	$179.35
Rate for Payer: Health Management Network Commercial	$168.30
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Health Management Network Commercial	$211.65
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$256.70
Rate for Payer: MDX Hawaii PPO	$241.53
Rate for Payer: MDX Hawaii PPO	$192.06
Rate for Payer: MDX Hawaii PPO	$204.67
Rate for Payer: MDX Hawaii PPO	$292.94
Rate for Payer: MDX Hawaii PPO	$55.29
Rate for Payer: MDX Hawaii PPO	$86.33

CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]

Facility

$57.00

Service Code	HCPCS J9045
Hospital Revenue Code	636
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$55.29
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cash Price	$126.60
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cash Price	$149.40
Rate for Payer: Cash Price	$53.40
Rate for Payer: Cash Price	$53.40
Rate for Payer: Cash Price	$126.60
Rate for Payer: Cash Price	$118.80
Rate for Payer: Cash Price	$149.40
Rate for Payer: Cash Price	$118.80
Rate for Payer: Cash Price	$181.20
Rate for Payer: Cash Price	$181.20
Rate for Payer: Hawaii Medical Service Association ABD	$2.11
Rate for Payer: Hawaii Medical Service Association ABD	$2.11
Rate for Payer: Hawaii Medical Service Association ABD	$2.11
Rate for Payer: Hawaii Medical Service Association ABD	$2.11
Rate for Payer: Hawaii Medical Service Association ABD	$2.11
Rate for Payer: Hawaii Medical Service Association ABD	$2.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.11
Rate for Payer: Hawaii Western Management Group Commercial	$84.55
Rate for Payer: Hawaii Western Management Group Commercial	$236.55
Rate for Payer: Hawaii Western Management Group Commercial	$54.15
Rate for Payer: Hawaii Western Management Group Commercial	$188.10
Rate for Payer: Hawaii Western Management Group Commercial	$200.45
Rate for Payer: Hawaii Western Management Group Commercial	$286.90
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$211.65
Rate for Payer: Health Management Network Commercial	$168.30
Rate for Payer: Health Management Network Commercial	$256.70
Rate for Payer: Health Management Network Commercial	$179.35
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Kaiser Permanente Commercial	$132.93
Rate for Payer: Kaiser Permanente Commercial	$156.87
Rate for Payer: Kaiser Permanente Commercial	$190.26
Rate for Payer: Kaiser Permanente Commercial	$124.74
Rate for Payer: Kaiser Permanente Commercial	$35.91
Rate for Payer: Kaiser Permanente Commercial	$56.07
Rate for Payer: Kaiser Permanente Medicaid	$100.98
Rate for Payer: Kaiser Permanente Medicaid	$107.61
Rate for Payer: Kaiser Permanente Medicaid	$126.99
Rate for Payer: Kaiser Permanente Medicaid	$45.39
Rate for Payer: Kaiser Permanente Medicaid	$154.02
Rate for Payer: Kaiser Permanente Medicaid	$29.07
Rate for Payer: MDX Hawaii PPO	$292.94
Rate for Payer: MDX Hawaii PPO	$192.06
Rate for Payer: MDX Hawaii PPO	$241.53
Rate for Payer: MDX Hawaii PPO	$204.67
Rate for Payer: MDX Hawaii PPO	$55.29
Rate for Payer: MDX Hawaii PPO	$86.33
Rate for Payer: UnitedHealthcare Medicaid	$118.80
Rate for Payer: UnitedHealthcare Medicaid	$181.20
Rate for Payer: UnitedHealthcare Medicaid	$149.40
Rate for Payer: UnitedHealthcare Medicaid	$34.20
Rate for Payer: UnitedHealthcare Medicaid	$53.40
Rate for Payer: UnitedHealthcare Medicaid	$126.60
Rate for Payer: University Health Alliance Commercial	$64.87
Rate for Payer: University Health Alliance Commercial	$153.80
Rate for Payer: University Health Alliance Commercial	$144.32
Rate for Payer: University Health Alliance Commercial	$181.50
Rate for Payer: University Health Alliance Commercial	$41.55
Rate for Payer: University Health Alliance Commercial	$220.13

CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]

Facility

$144.00

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$73.44
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$86.40
Rate for Payer: Hawaii Western Management Group Commercial	$136.80
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Kaiser Permanente Commercial	$90.72
Rate for Payer: Kaiser Permanente Medicaid	$73.44
Rate for Payer: MDX Hawaii PPO	$139.68
Rate for Payer: UnitedHealthcare Medicaid	$86.40
Rate for Payer: University Health Alliance Commercial	$104.96

CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]

Facility

$144.00

Service Code	HCPCS J3490
Hospital Revenue Code	250
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: MDX Hawaii PPO	$139.68

CARDIAC ARREST & SHOCK

Facility

$2,831.53

Service Code	APR-DRG 1962
Min. Negotiated Rate	$2,831.53
Max. Negotiated Rate	$2,831.53
Rate for Payer: AlohaCare Medicaid	$2,831.53
Rate for Payer: Hawaii Medical Service Association ABD	$2,831.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,831.53
Rate for Payer: Kaiser Permanente Medicaid	$2,831.53
Rate for Payer: Ohana Health Plan Medicaid	$2,831.53
Rate for Payer: UnitedHealthcare Medicaid	$2,831.53

CARDIAC ARREST & SHOCK

Facility

$4,216.32

Service Code	APR-DRG 1963
Min. Negotiated Rate	$4,216.32
Max. Negotiated Rate	$4,216.32
Rate for Payer: AlohaCare Medicaid	$4,216.32
Rate for Payer: Hawaii Medical Service Association ABD	$4,216.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,216.32
Rate for Payer: Kaiser Permanente Medicaid	$4,216.32
Rate for Payer: Ohana Health Plan Medicaid	$4,216.32
Rate for Payer: UnitedHealthcare Medicaid	$4,216.32

CARDIAC ARREST & SHOCK

Facility

$7,705.35

Service Code	APR-DRG 1964
Min. Negotiated Rate	$7,705.35
Max. Negotiated Rate	$7,705.35
Rate for Payer: AlohaCare Medicaid	$7,705.35
Rate for Payer: Hawaii Medical Service Association ABD	$7,705.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,705.35
Rate for Payer: Kaiser Permanente Medicaid	$7,705.35
Rate for Payer: Ohana Health Plan Medicaid	$7,705.35
Rate for Payer: UnitedHealthcare Medicaid	$7,705.35

CARDIAC ARREST & SHOCK

Facility

$2,155.12

Service Code	APR-DRG 1961
Min. Negotiated Rate	$2,155.12
Max. Negotiated Rate	$2,155.12
Rate for Payer: AlohaCare Medicaid	$2,155.12
Rate for Payer: Hawaii Medical Service Association ABD	$2,155.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,155.12
Rate for Payer: Kaiser Permanente Medicaid	$2,155.12
Rate for Payer: Ohana Health Plan Medicaid	$2,155.12
Rate for Payer: UnitedHealthcare Medicaid	$2,155.12

CARDIAC ARREST, UNEXPLAINED WITH CC

Facility

$45,741.41

Service Code	MSDRG 297
Min. Negotiated Rate	$7,211.27
Max. Negotiated Rate	$45,741.41
Rate for Payer: AlohaCare Medicare	$7,211.27
Rate for Payer: Devoted Health Medicare	$7,932.40
Rate for Payer: Hawaii Medical Service Association Commercial	$45,741.41
Rate for Payer: Hawaii Medical Service Association Medicare	$7,211.27
Rate for Payer: Humana Medicare	$7,211.27
Rate for Payer: Kaiser Permanente Commercial	$10,755.38
Rate for Payer: Kaiser Permanente Medicare	$7,211.27
Rate for Payer: Ohana Health Plan Medicare	$7,211.27
Rate for Payer: UnitedHealthcare Medicare	$7,211.27

CARDIAC ARREST, UNEXPLAINED WITH MCC

Facility

$45,741.41

Service Code	MSDRG 296
Min. Negotiated Rate	$17,765.44
Max. Negotiated Rate	$45,741.41
Rate for Payer: AlohaCare Medicare	$17,765.44
Rate for Payer: Devoted Health Medicare	$19,541.98
Rate for Payer: Hawaii Medical Service Association Commercial	$45,741.41
Rate for Payer: Hawaii Medical Service Association Medicare	$17,765.44
Rate for Payer: Humana Medicare	$17,765.44
Rate for Payer: Kaiser Permanente Commercial	$26,942.78
Rate for Payer: Kaiser Permanente Medicare	$17,765.44
Rate for Payer: Ohana Health Plan Medicare	$17,765.44
Rate for Payer: UnitedHealthcare Medicare	$17,765.44

CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC

Facility

$45,741.41

Service Code	MSDRG 298
Min. Negotiated Rate	$5,176.41
Max. Negotiated Rate	$45,741.41
Rate for Payer: AlohaCare Medicare	$5,176.41
Rate for Payer: Devoted Health Medicare	$5,694.05
Rate for Payer: Hawaii Medical Service Association Commercial	$45,741.41
Rate for Payer: Hawaii Medical Service Association Medicare	$5,176.41
Rate for Payer: Humana Medicare	$5,176.41
Rate for Payer: Kaiser Permanente Commercial	$7,850.48
Rate for Payer: Kaiser Permanente Medicare	$5,176.41
Rate for Payer: Ohana Health Plan Medicare	$5,176.41
Rate for Payer: UnitedHealthcare Medicare	$5,176.41

CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC

Facility

$20,286.38

Service Code	MSDRG 309
Min. Negotiated Rate	$8,368.05
Max. Negotiated Rate	$20,286.38
Rate for Payer: AlohaCare Medicare	$8,368.05
Rate for Payer: Devoted Health Medicare	$9,204.85
Rate for Payer: Hawaii Medical Service Association Commercial	$20,286.38
Rate for Payer: Hawaii Medical Service Association Medicare	$8,368.05
Rate for Payer: Humana Medicare	$8,368.05
Rate for Payer: Kaiser Permanente Commercial	$12,690.83
Rate for Payer: Kaiser Permanente Medicare	$8,368.05
Rate for Payer: Ohana Health Plan Medicare	$8,368.05
Rate for Payer: UnitedHealthcare Medicare	$8,368.05

CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC

Facility

$21,621.01

Service Code	MSDRG 308
Min. Negotiated Rate	$13,694.59
Max. Negotiated Rate	$21,621.01
Rate for Payer: AlohaCare Medicare	$13,694.59
Rate for Payer: Devoted Health Medicare	$15,064.05
Rate for Payer: Hawaii Medical Service Association Commercial	$21,621.01
Rate for Payer: Hawaii Medical Service Association Medicare	$13,694.59
Rate for Payer: Humana Medicare	$13,694.59
Rate for Payer: Kaiser Permanente Commercial	$20,769.00
Rate for Payer: Kaiser Permanente Medicare	$13,694.59
Rate for Payer: Ohana Health Plan Medicare	$13,694.59
Rate for Payer: UnitedHealthcare Medicare	$13,694.59

Know your out-of-pocket cost for care.

All Charges