Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PSN POLY PLY 42-5400-000-29

Facility

$1,500.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$840.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: University Health Alliance Commercial	$840.00

PSN TIB 5D SZ-D RT 42532006702

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,456.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

PSN TIB 5D SZ-D RT 42532006702

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,326.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Kaiser Permanente Commercial	$1,638.00
Rate for Payer: Kaiser Permanente Medicaid	$1,326.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

PSN TIB STEM LT 42-5320-075-01

Facility

$2,600.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,456.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

PSN TIB STEM LT 42-5320-075-01

Facility

$2,600.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,326.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Kaiser Permanente Commercial	$1,638.00
Rate for Payer: Kaiser Permanente Medicaid	$1,326.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

PSN TIB STEM RT 42-5320-075-02

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

PSN TIB STEM RT 42-5320-075-02

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

PSN TIB ST LEFT 42-5320-067-01

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,326.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Kaiser Permanente Commercial	$1,638.00
Rate for Payer: Kaiser Permanente Medicaid	$1,326.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

PSN TIB ST LEFT 42-5320-067-01

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,456.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

PSN TIB STM 5 DEG SZ C R

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,456.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

PSN TIB STM 5 DEG SZ C R

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,326.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Kaiser Permanente Commercial	$1,638.00
Rate for Payer: Kaiser Permanente Medicaid	$1,326.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

PSYCHOSES

Facility

$24,094.80

Service Code	MSDRG 885
Min. Negotiated Rate	$15,887.57
Max. Negotiated Rate	$24,094.80
Rate for Payer: AlohaCare Medicare	$15,887.57
Rate for Payer: Devoted Health Medicare	$17,476.33
Rate for Payer: Hawaii Medical Service Association Commercial	$16,136.89
Rate for Payer: Hawaii Medical Service Association Medicare	$15,887.57
Rate for Payer: Humana Medicare	$15,887.57
Rate for Payer: Kaiser Permanente Commercial	$24,094.80
Rate for Payer: Kaiser Permanente Medicare	$15,887.57
Rate for Payer: Ohana Health Plan Medicare	$15,887.57
Rate for Payer: UnitedHealthcare Medicare	$15,887.57

PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [95957]

Facility

$2.00

Service Code	NDC 37000002310
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [95957]

Facility

$2.00

Service Code	NDC 37000002310
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

PULMONARY EDEMA AND RESPIRATORY FAILURE

Facility

$46,687.78

Service Code	MSDRG 189
Min. Negotiated Rate	$14,051.76
Max. Negotiated Rate	$46,687.78
Rate for Payer: AlohaCare Medicare	$14,051.76
Rate for Payer: Devoted Health Medicare	$15,456.94
Rate for Payer: Hawaii Medical Service Association Commercial	$46,687.78
Rate for Payer: Hawaii Medical Service Association Medicare	$14,051.76
Rate for Payer: Humana Medicare	$14,051.76
Rate for Payer: Kaiser Permanente Commercial	$21,310.65
Rate for Payer: Kaiser Permanente Medicare	$14,051.76
Rate for Payer: Ohana Health Plan Medicare	$14,051.76
Rate for Payer: UnitedHealthcare Medicare	$14,051.76

PULMONARY EMBOLISM

Facility

$8,446.99

Service Code	APR-DRG 1344
Min. Negotiated Rate	$8,446.99
Max. Negotiated Rate	$8,446.99
Rate for Payer: AlohaCare Medicaid	$8,446.99
Rate for Payer: Hawaii Medical Service Association ABD	$8,446.99
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,446.99
Rate for Payer: Kaiser Permanente Medicaid	$8,446.99
Rate for Payer: Ohana Health Plan Medicaid	$8,446.99
Rate for Payer: UnitedHealthcare Medicaid	$8,446.99

PULMONARY EMBOLISM

Facility

$4,276.33

Service Code	APR-DRG 1342
Min. Negotiated Rate	$4,276.33
Max. Negotiated Rate	$4,276.33
Rate for Payer: AlohaCare Medicaid	$4,276.33
Rate for Payer: Hawaii Medical Service Association ABD	$4,276.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,276.33
Rate for Payer: Kaiser Permanente Medicaid	$4,276.33
Rate for Payer: Ohana Health Plan Medicaid	$4,276.33
Rate for Payer: UnitedHealthcare Medicaid	$4,276.33

PULMONARY EMBOLISM

Facility

$5,933.11

Service Code	APR-DRG 1343
Min. Negotiated Rate	$5,933.11
Max. Negotiated Rate	$5,933.11
Rate for Payer: AlohaCare Medicaid	$5,933.11
Rate for Payer: Hawaii Medical Service Association ABD	$5,933.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,933.11
Rate for Payer: Kaiser Permanente Medicaid	$5,933.11
Rate for Payer: Ohana Health Plan Medicaid	$5,933.11
Rate for Payer: UnitedHealthcare Medicaid	$5,933.11

PULMONARY EMBOLISM

Facility

$3,370.97

Service Code	APR-DRG 1341
Min. Negotiated Rate	$3,370.97
Max. Negotiated Rate	$3,370.97
Rate for Payer: AlohaCare Medicaid	$3,370.97
Rate for Payer: Hawaii Medical Service Association ABD	$3,370.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,370.97
Rate for Payer: Kaiser Permanente Medicaid	$3,370.97
Rate for Payer: Ohana Health Plan Medicaid	$3,370.97
Rate for Payer: UnitedHealthcare Medicaid	$3,370.97

PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE

Facility

$31,691.40

Service Code	MSDRG 175
Min. Negotiated Rate	$15,623.69
Max. Negotiated Rate	$31,691.40
Rate for Payer: AlohaCare Medicare	$15,623.69
Rate for Payer: Devoted Health Medicare	$17,186.06
Rate for Payer: Hawaii Medical Service Association Commercial	$31,691.40
Rate for Payer: Hawaii Medical Service Association Medicare	$15,623.69
Rate for Payer: Humana Medicare	$15,623.69
Rate for Payer: Kaiser Permanente Commercial	$23,694.60
Rate for Payer: Kaiser Permanente Medicare	$15,623.69
Rate for Payer: Ohana Health Plan Medicare	$15,623.69
Rate for Payer: UnitedHealthcare Medicare	$15,623.69

PULMONARY EMBOLISM WITHOUT MCC

Facility

$31,691.40

Service Code	MSDRG 176
Min. Negotiated Rate	$9,156.28
Max. Negotiated Rate	$31,691.40
Rate for Payer: AlohaCare Medicare	$9,156.28
Rate for Payer: Devoted Health Medicare	$10,071.91
Rate for Payer: Hawaii Medical Service Association Commercial	$31,691.40
Rate for Payer: Hawaii Medical Service Association Medicare	$9,156.28
Rate for Payer: Humana Medicare	$9,156.28
Rate for Payer: Kaiser Permanente Commercial	$13,886.25
Rate for Payer: Kaiser Permanente Medicare	$9,156.28
Rate for Payer: Ohana Health Plan Medicare	$9,156.28
Rate for Payer: UnitedHealthcare Medicare	$9,156.28

PULSE GENERATOR V 3150

Facility

$43,200.00

Service Code	HCPCS C1767
Hospital Revenue Code	278
Min. Negotiated Rate	$24,192.00
Max. Negotiated Rate	$41,904.00
Rate for Payer: Cash Price	$25,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$30,240.00
Rate for Payer: Health Management Network Commercial	$36,720.00
Rate for Payer: MDX Hawaii PPO	$41,904.00
Rate for Payer: University Health Alliance Commercial	$24,192.00

PULSE GENERATOR V 3150

Facility

$43,200.00

Service Code	HCPCS C1767
Hospital Revenue Code	278
Min. Negotiated Rate	$22,032.00
Max. Negotiated Rate	$41,904.00
Rate for Payer: Cash Price	$25,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$30,240.00
Rate for Payer: Health Management Network Commercial	$36,720.00
Rate for Payer: Kaiser Permanente Commercial	$27,216.00
Rate for Payer: Kaiser Permanente Medicaid	$22,032.00
Rate for Payer: MDX Hawaii PPO	$41,904.00
Rate for Payer: University Health Alliance Commercial	$24,192.00

PUMP AMS 700 LGX 18CM

Facility

$25,458.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$12,983.58
Max. Negotiated Rate	$24,694.26
Rate for Payer: Cash Price	$15,274.80
Rate for Payer: Hawaii Western Management Group Commercial	$17,820.60
Rate for Payer: Health Management Network Commercial	$21,639.30
Rate for Payer: Kaiser Permanente Commercial	$16,038.54
Rate for Payer: Kaiser Permanente Medicaid	$12,983.58
Rate for Payer: MDX Hawaii PPO	$24,694.26
Rate for Payer: University Health Alliance Commercial	$14,256.48

PUMP AMS 700 LGX 18CM

Facility

$25,458.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$14,256.48
Max. Negotiated Rate	$24,694.26
Rate for Payer: Cash Price	$15,274.80
Rate for Payer: Hawaii Western Management Group Commercial	$17,820.60
Rate for Payer: Health Management Network Commercial	$21,639.30
Rate for Payer: MDX Hawaii PPO	$24,694.26
Rate for Payer: University Health Alliance Commercial	$14,256.48

Know your out-of-pocket cost for care.

All Charges