Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION [113082]

Facility

$9.00

Service Code	NDC 00487278401
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION [113082]

Facility

$9.00

Service Code	NDC 00487590199
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

RADIAL RELOAD MEDIUM THICK

Facility

$1,302.00

Hospital Revenue Code	272
Min. Negotiated Rate	$664.02
Max. Negotiated Rate	$1,262.94
Rate for Payer: Cash Price	$781.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,236.90
Rate for Payer: Health Management Network Commercial	$1,106.70
Rate for Payer: Kaiser Permanente Commercial	$820.26
Rate for Payer: Kaiser Permanente Medicaid	$664.02
Rate for Payer: MDX Hawaii PPO	$1,262.94
Rate for Payer: University Health Alliance Commercial	$949.03

RADIAL RELOAD MEDIUM THICK

Facility

$1,302.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,106.70
Max. Negotiated Rate	$1,262.94
Rate for Payer: Cash Price	$781.20
Rate for Payer: Health Management Network Commercial	$1,106.70
Rate for Payer: MDX Hawaii PPO	$1,262.94

RADIOFREQUENCY ABLATION, NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)

Facility

$2,837.00

Service Code	CPT 64625
Hospital Revenue Code	361
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$2,306.84
Rate for Payer: AlohaCare Medicare	$2,306.84
Rate for Payer: Devoted Health Medicare	$2,537.52
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,306.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$2,306.84
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,306.84
Rate for Payer: Ohana Health Plan Medicaid	$2,537.52
Rate for Payer: Ohana Health Plan Medicare	$2,306.84
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,306.84

RADIOGRAPHIC CHARMS 10MM

Facility

$122.00

Hospital Revenue Code	272
Min. Negotiated Rate	$103.70
Max. Negotiated Rate	$118.34
Rate for Payer: Cash Price	$73.20
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: MDX Hawaii PPO	$118.34

RADIOGRAPHIC CHARMS 10MM

Facility

$122.00

Hospital Revenue Code	272
Min. Negotiated Rate	$62.22
Max. Negotiated Rate	$118.34
Rate for Payer: Cash Price	$73.20
Rate for Payer: Hawaii Western Management Group Commercial	$115.90
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: Kaiser Permanente Commercial	$76.86
Rate for Payer: Kaiser Permanente Medicaid	$62.22
Rate for Payer: MDX Hawaii PPO	$118.34
Rate for Payer: University Health Alliance Commercial	$88.93

RADIOTHERAPY

Facility

$9,922.44

Service Code	APR-DRG 6923
Min. Negotiated Rate	$9,922.44
Max. Negotiated Rate	$9,922.44
Rate for Payer: AlohaCare Medicaid	$9,922.44
Rate for Payer: Hawaii Medical Service Association ABD	$9,922.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,922.44
Rate for Payer: Kaiser Permanente Medicaid	$9,922.44
Rate for Payer: Ohana Health Plan Medicaid	$9,922.44
Rate for Payer: UnitedHealthcare Medicaid	$9,922.44

RADIOTHERAPY

Facility

$6,799.99

Service Code	APR-DRG 6922
Min. Negotiated Rate	$6,799.99
Max. Negotiated Rate	$6,799.99
Rate for Payer: AlohaCare Medicaid	$6,799.99
Rate for Payer: Hawaii Medical Service Association ABD	$6,799.99
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,799.99
Rate for Payer: Kaiser Permanente Medicaid	$6,799.99
Rate for Payer: Ohana Health Plan Medicaid	$6,799.99
Rate for Payer: UnitedHealthcare Medicaid	$6,799.99

RADIOTHERAPY

Facility

$3,969.11

Service Code	APR-DRG 6921
Min. Negotiated Rate	$3,969.11
Max. Negotiated Rate	$3,969.11
Rate for Payer: AlohaCare Medicaid	$3,969.11
Rate for Payer: Hawaii Medical Service Association ABD	$3,969.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,969.11
Rate for Payer: Kaiser Permanente Medicaid	$3,969.11
Rate for Payer: Ohana Health Plan Medicaid	$3,969.11
Rate for Payer: UnitedHealthcare Medicaid	$3,969.11

RADIOTHERAPY

Facility

$46,738.88

Service Code	MSDRG 849
Min. Negotiated Rate	$17,786.98
Max. Negotiated Rate	$46,738.88
Rate for Payer: AlohaCare Medicare	$30,818.53
Rate for Payer: Devoted Health Medicare	$33,900.38
Rate for Payer: Hawaii Medical Service Association Commercial	$17,786.98
Rate for Payer: Hawaii Medical Service Association Medicare	$30,818.53
Rate for Payer: Humana Medicare	$30,818.53
Rate for Payer: Kaiser Permanente Commercial	$46,738.88
Rate for Payer: Kaiser Permanente Medicare	$30,818.53
Rate for Payer: Ohana Health Plan Medicare	$30,818.53
Rate for Payer: UnitedHealthcare Medicare	$30,818.53

RADIOTHERAPY

Facility

$19,568.31

Service Code	APR-DRG 6924
Min. Negotiated Rate	$19,568.31
Max. Negotiated Rate	$19,568.31
Rate for Payer: AlohaCare Medicaid	$19,568.31
Rate for Payer: Hawaii Medical Service Association ABD	$19,568.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19,568.31
Rate for Payer: Kaiser Permanente Medicaid	$19,568.31
Rate for Payer: Ohana Health Plan Medicaid	$19,568.31
Rate for Payer: UnitedHealthcare Medicaid	$19,568.31

RALOXIFENE 60 MG TABLET [22143]

Facility

$22.00

Service Code	NDC 65862070930
Hospital Revenue Code	250
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: MDX Hawaii PPO	$21.34

RALOXIFENE 60 MG TABLET [22143]

Facility

$22.00

Service Code	NDC 43598050530
Hospital Revenue Code	250
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: MDX Hawaii PPO	$21.34

RALOXIFENE 60 MG TABLET [22143]

Facility

$22.00

Service Code	NDC 43598050530
Hospital Revenue Code	637
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Kaiser Permanente Commercial	$13.86
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: University Health Alliance Commercial	$16.04

RALOXIFENE 60 MG TABLET [22143]

Facility

$22.00

Service Code	NDC 65862070930
Hospital Revenue Code	637
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Kaiser Permanente Commercial	$13.86
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: University Health Alliance Commercial	$16.04

RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION [125686]

Facility

$13,508.00

Service Code	HCPCS J9308
Hospital Revenue Code	250
Min. Negotiated Rate	$11,481.80
Max. Negotiated Rate	$13,102.76
Rate for Payer: Cash Price	$8,104.80
Rate for Payer: Cash Price	$1,621.20
Rate for Payer: Health Management Network Commercial	$2,296.70
Rate for Payer: Health Management Network Commercial	$11,481.80
Rate for Payer: MDX Hawaii PPO	$13,102.76
Rate for Payer: MDX Hawaii PPO	$2,620.94

RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION [125686]

Facility

$13,508.00

Service Code	HCPCS J9308
Hospital Revenue Code	636
Min. Negotiated Rate	$74.45
Max. Negotiated Rate	$13,102.76
Rate for Payer: AlohaCare Medicaid	$75.47
Rate for Payer: AlohaCare Medicaid	$75.47
Rate for Payer: AlohaCare Medicare	$75.47
Rate for Payer: AlohaCare Medicare	$75.47
Rate for Payer: Cash Price	$8,104.80
Rate for Payer: Cash Price	$1,621.20
Rate for Payer: Cash Price	$1,621.20
Rate for Payer: Cash Price	$8,104.80
Rate for Payer: Devoted Health Medicare	$83.02
Rate for Payer: Devoted Health Medicare	$83.02
Rate for Payer: Hawaii Medical Service Association ABD	$74.45
Rate for Payer: Hawaii Medical Service Association ABD	$74.45
Rate for Payer: Hawaii Medical Service Association Commercial	$94.34
Rate for Payer: Hawaii Medical Service Association Commercial	$94.34
Rate for Payer: Hawaii Medical Service Association Medicare	$75.47
Rate for Payer: Hawaii Medical Service Association Medicare	$75.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$74.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$74.45
Rate for Payer: Hawaii Western Management Group Commercial	$2,566.90
Rate for Payer: Hawaii Western Management Group Commercial	$12,832.60
Rate for Payer: Health Management Network Commercial	$11,481.80
Rate for Payer: Health Management Network Commercial	$2,296.70
Rate for Payer: Humana Medicare	$75.47
Rate for Payer: Humana Medicare	$75.47
Rate for Payer: Kaiser Permanente Commercial	$8,510.04
Rate for Payer: Kaiser Permanente Commercial	$1,702.26
Rate for Payer: Kaiser Permanente Medicaid	$1,378.02
Rate for Payer: Kaiser Permanente Medicaid	$6,889.08
Rate for Payer: Kaiser Permanente Medicare	$75.47
Rate for Payer: Kaiser Permanente Medicare	$75.47
Rate for Payer: MDX Hawaii PPO	$13,102.76
Rate for Payer: MDX Hawaii PPO	$2,620.94
Rate for Payer: Ohana Health Plan Medicaid	$83.02
Rate for Payer: Ohana Health Plan Medicaid	$83.02
Rate for Payer: Ohana Health Plan Medicare	$75.47
Rate for Payer: Ohana Health Plan Medicare	$75.47
Rate for Payer: UnitedHealthcare Medicaid	$1,621.20
Rate for Payer: UnitedHealthcare Medicaid	$8,104.80
Rate for Payer: UnitedHealthcare Medicare	$75.47
Rate for Payer: UnitedHealthcare Medicare	$75.47
Rate for Payer: University Health Alliance Commercial	$1,969.49
Rate for Payer: University Health Alliance Commercial	$9,845.98

RANGER DCB 4X100X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,890.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: MDX Hawaii PPO	$3,298.00

RANGER DCB 4X100X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,734.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,230.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$2,478.26

RANGER DCB 4X150X150

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,734.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,230.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$2,478.26

RANGER DCB 4X150X150

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,890.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: MDX Hawaii PPO	$3,298.00

RANGER DCB 4X40X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,890.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: MDX Hawaii PPO	$3,298.00

RANGER DCB 4X40X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,734.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,230.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$2,478.26

RANGER DCB 4X60X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,734.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,230.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$2,478.26

Know your out-of-pocket cost for care.

All Charges