Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS

Facility

$187,042.33

Service Code	MSDRG 870
Min. Negotiated Rate	$78,616.58
Max. Negotiated Rate	$187,042.33
Rate for Payer: AlohaCare Medicare	$78,616.58
Rate for Payer: Devoted Health Medicare	$86,478.24
Rate for Payer: Hawaii Medical Service Association Commercial	$187,042.33
Rate for Payer: Hawaii Medical Service Association Medicare	$78,616.58
Rate for Payer: Humana Medicare	$78,616.58
Rate for Payer: Kaiser Permanente Commercial	$119,228.55
Rate for Payer: Kaiser Permanente Medicare	$78,616.58
Rate for Payer: Ohana Health Plan Medicare	$78,616.58
Rate for Payer: UnitedHealthcare Medicare	$78,616.58

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC

Facility

$41,786.05

Service Code	MSDRG 871
Min. Negotiated Rate	$22,094.49
Max. Negotiated Rate	$41,786.05
Rate for Payer: AlohaCare Medicare	$22,094.49
Rate for Payer: Devoted Health Medicare	$24,303.94
Rate for Payer: Hawaii Medical Service Association Commercial	$41,786.05
Rate for Payer: Hawaii Medical Service Association Medicare	$22,094.49
Rate for Payer: Humana Medicare	$22,094.49
Rate for Payer: Kaiser Permanente Commercial	$33,508.12
Rate for Payer: Kaiser Permanente Medicare	$22,094.49
Rate for Payer: Ohana Health Plan Medicare	$22,094.49
Rate for Payer: UnitedHealthcare Medicare	$22,094.49

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC

Facility

$41,761.79

Service Code	MSDRG 872
Min. Negotiated Rate	$11,639.28
Max. Negotiated Rate	$41,761.79
Rate for Payer: AlohaCare Medicare	$11,639.28
Rate for Payer: Devoted Health Medicare	$12,803.21
Rate for Payer: Hawaii Medical Service Association Commercial	$41,761.79
Rate for Payer: Hawaii Medical Service Association Medicare	$11,639.28
Rate for Payer: Humana Medicare	$11,639.28
Rate for Payer: Kaiser Permanente Commercial	$17,651.92
Rate for Payer: Kaiser Permanente Medicare	$11,639.28
Rate for Payer: Ohana Health Plan Medicare	$11,639.28
Rate for Payer: UnitedHealthcare Medicare	$11,639.28

SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT

Facility

$10,679.55

Service Code	CPT 30520
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$3,916.70
Rate for Payer: AlohaCare Medicare	$3,916.70
Rate for Payer: Devoted Health Medicare	$4,308.37
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	$3,916.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$3,916.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,916.70
Rate for Payer: Ohana Health Plan Medicaid	$4,308.37
Rate for Payer: Ohana Health Plan Medicare	$3,916.70
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,916.70
Rate for Payer: University Health Alliance Commercial	$10,679.55

SERTRALINE 100 MG TABLET [11350]

Facility

$2.00

Service Code	NDC 60687025301
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

SERTRALINE 100 MG TABLET [11350]

Facility

$2.00

Service Code	NDC 60687025311
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

SERTRALINE 100 MG TABLET [11350]

Facility

$2.00

Service Code	NDC 60687025301
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

SERTRALINE 100 MG TABLET [11350]

Facility

$2.00

Service Code	NDC 60687025311
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

SERTRALINE 25 MG TABLET [19882]

Facility

$2.00

Service Code	NDC 60687023111
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

SERTRALINE 25 MG TABLET [19882]

Facility

$2.00

Service Code	NDC 60687023111
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

SERTRALINE 25 MG TABLET [19882]

Facility

$2.00

Service Code	NDC 60687023101
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

SERTRALINE 25 MG TABLET [19882]

Facility

$2.00

Service Code	NDC 60687023101
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

SERTRALINE 50 MG TABLET [11351]

Facility

$2.00

Service Code	NDC 60687024211
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

SERTRALINE 50 MG TABLET [11351]

Facility

$2.00

Service Code	NDC 60687024211
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

SERTRALINE 50 MG TABLET [11351]

Facility

$2.00

Service Code	NDC 60687024201
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

SERTRALINE 50 MG TABLET [11351]

Facility

$2.00

Service Code	NDC 60687024201
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

SET BANDER URETHERAL 6X75

Facility

$389.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$217.84
Max. Negotiated Rate	$377.33
Rate for Payer: Cash Price	$233.40
Rate for Payer: Hawaii Western Management Group Commercial	$272.30
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: MDX Hawaii PPO	$377.33
Rate for Payer: University Health Alliance Commercial	$217.84

SET BANDER URETHERAL 6X75

Facility

$389.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$198.39
Max. Negotiated Rate	$377.33
Rate for Payer: Cash Price	$233.40
Rate for Payer: Hawaii Western Management Group Commercial	$272.30
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Kaiser Permanente Commercial	$245.07
Rate for Payer: Kaiser Permanente Medicaid	$198.39
Rate for Payer: MDX Hawaii PPO	$377.33
Rate for Payer: University Health Alliance Commercial	$217.84

SET BLADDER EVACUATOR

Facility

$116.00

Hospital Revenue Code	272
Min. Negotiated Rate	$98.60
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: MDX Hawaii PPO	$112.52

SET BLADDER EVACUATOR

Facility

$116.00

Hospital Revenue Code	272
Min. Negotiated Rate	$59.16
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Hawaii Western Management Group Commercial	$110.20
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: Kaiser Permanente Commercial	$73.08
Rate for Payer: Kaiser Permanente Medicaid	$59.16
Rate for Payer: MDX Hawaii PPO	$112.52
Rate for Payer: University Health Alliance Commercial	$84.55

SET COMMON DUCT EXPLORATION

Facility

$2,020.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$1,030.20
Max. Negotiated Rate	$1,959.40
Rate for Payer: Cash Price	$1,212.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,919.00
Rate for Payer: Health Management Network Commercial	$1,717.00
Rate for Payer: Kaiser Permanente Commercial	$1,272.60
Rate for Payer: Kaiser Permanente Medicaid	$1,030.20
Rate for Payer: MDX Hawaii PPO	$1,959.40
Rate for Payer: University Health Alliance Commercial	$1,472.38

SET COMMON DUCT EXPLORATION

Facility

$2,020.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$1,717.00
Max. Negotiated Rate	$1,959.40
Rate for Payer: Cash Price	$1,212.00
Rate for Payer: Health Management Network Commercial	$1,717.00
Rate for Payer: MDX Hawaii PPO	$1,959.40

SET CRYOTHERAPY

Facility

$4,343.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$2,214.93
Max. Negotiated Rate	$4,212.71
Rate for Payer: Cash Price	$2,605.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,125.85
Rate for Payer: Health Management Network Commercial	$3,691.55
Rate for Payer: Kaiser Permanente Commercial	$2,736.09
Rate for Payer: Kaiser Permanente Medicaid	$2,214.93
Rate for Payer: MDX Hawaii PPO	$4,212.71
Rate for Payer: University Health Alliance Commercial	$3,165.61

SET CRYOTHERAPY

Facility

$4,343.00

Service Code	HCPCS C2618
Hospital Revenue Code	272
Min. Negotiated Rate	$3,691.55
Max. Negotiated Rate	$4,212.71
Rate for Payer: Cash Price	$2,605.80
Rate for Payer: Health Management Network Commercial	$3,691.55
Rate for Payer: MDX Hawaii PPO	$4,212.71

SET IRRIG SIMPULSE SYSTEM

Facility

$210.00

Hospital Revenue Code	272
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$203.70
Rate for Payer: Cash Price	$126.00
Rate for Payer: Hawaii Western Management Group Commercial	$199.50
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: Kaiser Permanente Medicaid	$107.10
Rate for Payer: MDX Hawaii PPO	$203.70
Rate for Payer: University Health Alliance Commercial	$153.07

Know your out-of-pocket cost for care.

All Charges