Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

SOFT TISSUE PROCEDURES WITH MCC

Facility

$54,592.80

Service Code	MSDRG 500
Min. Negotiated Rate	$35,997.24
Max. Negotiated Rate	$54,592.80
Rate for Payer: AlohaCare Medicare	$35,997.24
Rate for Payer: Devoted Health Medicare	$39,596.96
Rate for Payer: Hawaii Medical Service Association Commercial	$47,512.83
Rate for Payer: Hawaii Medical Service Association Medicare	$35,997.24
Rate for Payer: Humana Medicare	$35,997.24
Rate for Payer: Kaiser Permanente Commercial	$54,592.80
Rate for Payer: Kaiser Permanente Medicare	$35,997.24
Rate for Payer: Ohana Health Plan Medicare	$35,997.24
Rate for Payer: UnitedHealthcare Medicare	$35,997.24

SOFT TISSUE PROCEDURES WITHOUT CC/MCC

Facility

$23,440.96

Service Code	MSDRG 502
Min. Negotiated Rate	$15,308.61
Max. Negotiated Rate	$23,440.96
Rate for Payer: AlohaCare Medicare	$15,308.61
Rate for Payer: Devoted Health Medicare	$16,839.47
Rate for Payer: Hawaii Medical Service Association Commercial	$23,440.96
Rate for Payer: Hawaii Medical Service Association Medicare	$15,308.61
Rate for Payer: Humana Medicare	$15,308.61
Rate for Payer: Kaiser Permanente Commercial	$23,216.78
Rate for Payer: Kaiser Permanente Medicare	$15,308.61
Rate for Payer: Ohana Health Plan Medicare	$15,308.61
Rate for Payer: UnitedHealthcare Medicare	$15,308.61

SOFT-VU MPA 5FX65

Facility

$145.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$87.00
Rate for Payer: Hawaii Western Management Group Commercial	$137.75
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$91.35
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: University Health Alliance Commercial	$105.69

SOFT-VU MPA 5FX65

Facility

$145.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$87.00
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: MDX Hawaii PPO	$140.65

SOLN LIFT AGENT 5ML

Facility

$200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: University Health Alliance Commercial	$145.78

SOLN LIFT AGENT 5ML

Facility

$200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: MDX Hawaii PPO	$194.00

SOLUTION 1.5% 2L PD

Facility

$163.00

Hospital Revenue Code	272
Min. Negotiated Rate	$138.55
Max. Negotiated Rate	$158.11
Rate for Payer: Cash Price	$97.80
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: MDX Hawaii PPO	$158.11

SOLUTION 1.5% 2L PD

Facility

$163.00

Hospital Revenue Code	272
Min. Negotiated Rate	$83.13
Max. Negotiated Rate	$158.11
Rate for Payer: Cash Price	$97.80
Rate for Payer: Hawaii Western Management Group Commercial	$154.85
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Kaiser Permanente Commercial	$102.69
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: University Health Alliance Commercial	$118.81

SOLUTION 2.5% 2L PD

Facility

$188.00

Hospital Revenue Code	272
Min. Negotiated Rate	$159.80
Max. Negotiated Rate	$182.36
Rate for Payer: Cash Price	$112.80
Rate for Payer: Health Management Network Commercial	$159.80
Rate for Payer: MDX Hawaii PPO	$182.36

SOLUTION 2.5% 2L PD

Facility

$188.00

Hospital Revenue Code	272
Min. Negotiated Rate	$95.88
Max. Negotiated Rate	$182.36
Rate for Payer: Cash Price	$112.80
Rate for Payer: Hawaii Western Management Group Commercial	$178.60
Rate for Payer: Health Management Network Commercial	$159.80
Rate for Payer: Kaiser Permanente Commercial	$118.44
Rate for Payer: Kaiser Permanente Medicaid	$95.88
Rate for Payer: MDX Hawaii PPO	$182.36
Rate for Payer: University Health Alliance Commercial	$137.03

SOLUTION 4.25% 2L PD

Facility

$148.00

Hospital Revenue Code	272
Min. Negotiated Rate	$125.80
Max. Negotiated Rate	$143.56
Rate for Payer: Cash Price	$88.80
Rate for Payer: Health Management Network Commercial	$125.80
Rate for Payer: MDX Hawaii PPO	$143.56

SOLUTION 4.25% 2L PD

Facility

$148.00

Hospital Revenue Code	272
Min. Negotiated Rate	$75.48
Max. Negotiated Rate	$143.56
Rate for Payer: Cash Price	$88.80
Rate for Payer: Hawaii Western Management Group Commercial	$140.60
Rate for Payer: Health Management Network Commercial	$125.80
Rate for Payer: Kaiser Permanente Commercial	$93.24
Rate for Payer: Kaiser Permanente Medicaid	$75.48
Rate for Payer: MDX Hawaii PPO	$143.56
Rate for Payer: University Health Alliance Commercial	$107.88

SOLUTION CR GREEN #5976-40-12

Facility

$2,228.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,247.68
Max. Negotiated Rate	$2,161.16
Rate for Payer: Cash Price	$1,336.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,559.60
Rate for Payer: Health Management Network Commercial	$1,893.80
Rate for Payer: MDX Hawaii PPO	$2,161.16
Rate for Payer: University Health Alliance Commercial	$1,247.68

SOLUTION CR GREEN #5976-40-12

Facility

$2,228.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,136.28
Max. Negotiated Rate	$2,161.16
Rate for Payer: Cash Price	$1,336.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,559.60
Rate for Payer: Health Management Network Commercial	$1,893.80
Rate for Payer: Kaiser Permanente Commercial	$1,403.64
Rate for Payer: Kaiser Permanente Medicaid	$1,136.28
Rate for Payer: MDX Hawaii PPO	$2,161.16
Rate for Payer: University Health Alliance Commercial	$1,247.68

SORBITOL 70 % SOLUTION [7413]

Facility

$15.00

Service Code	NDC 50030000000
Hospital Revenue Code	637
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$9.45
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: University Health Alliance Commercial	$10.93

SORBITOL 70 % SOLUTION [7413]

Facility

$15.00

Service Code	NDC 50030000000
Hospital Revenue Code	250
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: MDX Hawaii PPO	$14.55

SOTALOL 80 MG TABLET [11421]

Facility

$9.00

Service Code	NDC 00093106101
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: University Health Alliance Commercial	$6.56

SOTALOL 80 MG TABLET [11421]

Facility

$9.00

Service Code	NDC 68084065401
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

SOTALOL 80 MG TABLET [11421]

Facility

$9.00

Service Code	NDC 00093106101
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

SOTALOL 80 MG TABLET [11421]

Facility

$9.00

Service Code	NDC 68084065401
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: University Health Alliance Commercial	$6.56

SPACER FEMORAL 64MM RKFMMD

Facility

$9,460.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,297.60
Max. Negotiated Rate	$9,176.20
Rate for Payer: Cash Price	$5,676.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,622.00
Rate for Payer: Health Management Network Commercial	$8,041.00
Rate for Payer: MDX Hawaii PPO	$9,176.20
Rate for Payer: University Health Alliance Commercial	$5,297.60

SPACER FEMORAL 64MM RKFMMD

Facility

$9,460.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,824.60
Max. Negotiated Rate	$9,176.20
Rate for Payer: Cash Price	$5,676.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,622.00
Rate for Payer: Health Management Network Commercial	$8,041.00
Rate for Payer: Kaiser Permanente Commercial	$5,959.80
Rate for Payer: Kaiser Permanente Medicaid	$4,824.60
Rate for Payer: MDX Hawaii PPO	$9,176.20
Rate for Payer: University Health Alliance Commercial	$5,297.60

SPEEDBRIDGE SYS AR-8928BC-CP

Facility

$3,480.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,774.80
Max. Negotiated Rate	$3,375.60
Rate for Payer: Cash Price	$2,088.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,436.00
Rate for Payer: Health Management Network Commercial	$2,958.00
Rate for Payer: Kaiser Permanente Commercial	$2,192.40
Rate for Payer: Kaiser Permanente Medicaid	$1,774.80
Rate for Payer: MDX Hawaii PPO	$3,375.60
Rate for Payer: University Health Alliance Commercial	$1,948.80

SPEEDBRIDGE SYS AR-8928BC-CP

Facility

$3,480.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,948.80
Max. Negotiated Rate	$3,375.60
Rate for Payer: Cash Price	$2,088.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,436.00
Rate for Payer: Health Management Network Commercial	$2,958.00
Rate for Payer: MDX Hawaii PPO	$3,375.60
Rate for Payer: University Health Alliance Commercial	$1,948.80

SPEEDGRAFT JRF 10MM #SPD-001

Facility

$4,650.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$2,604.00
Max. Negotiated Rate	$4,510.50
Rate for Payer: Cash Price	$2,790.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,255.00
Rate for Payer: Health Management Network Commercial	$3,952.50
Rate for Payer: MDX Hawaii PPO	$4,510.50
Rate for Payer: University Health Alliance Commercial	$2,604.00

Know your out-of-pocket cost for care.

All Charges