Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

SULFAMETH/TMP 200-40 MG/5 ML SUSPENSION (BACTRIM) (120 ML) (TAKE HOME) [4080398]

Facility

$15.00

Service Code	NDC 00004080186
Hospital Revenue Code	253
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

SULFASALAZINE 500 MG TABLET [7562]

Facility

$1.00

Service Code	NDC 59762500005
Hospital Revenue Code	637
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: University Health Alliance Commercial	$0.73

SULFASALAZINE 500 MG TABLET [7562]

Facility

$1.00

Service Code	NDC 59762500005
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: MDX Hawaii PPO	$0.97

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97343]

Facility

$36.00

Service Code	NDC 00143963805
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$34.92

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97343]

Facility

$128.00

Service Code	NDC 64679072801
Hospital Revenue Code	250
Min. Negotiated Rate	$108.80
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$76.80
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: MDX Hawaii PPO	$124.16

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97343]

Facility

$33.00

Service Code	NDC 55150017301
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: MDX Hawaii PPO	$32.01

SUNDT CAR SHNT 3.5MM/NL8505079

Facility

$2,470.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,259.70
Max. Negotiated Rate	$2,395.90
Rate for Payer: Cash Price	$1,482.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,346.50
Rate for Payer: Health Management Network Commercial	$2,099.50
Rate for Payer: Kaiser Permanente Commercial	$1,556.10
Rate for Payer: Kaiser Permanente Medicaid	$1,259.70
Rate for Payer: MDX Hawaii PPO	$2,395.90
Rate for Payer: University Health Alliance Commercial	$1,800.38

SUNDT CAR SHNT 3.5MM/NL8505079

Facility

$2,470.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$2,099.50
Max. Negotiated Rate	$2,395.90
Rate for Payer: Cash Price	$1,482.00
Rate for Payer: Health Management Network Commercial	$2,099.50
Rate for Payer: MDX Hawaii PPO	$2,395.90

SUNDT CAR SHNT 3MM/NL8505070

Facility

$2,000.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,700.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: MDX Hawaii PPO	$1,940.00

SUNDT CAR SHNT 3MM/NL8505070

Facility

$2,000.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
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	$1,900.00
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	$1,457.80

SUNDT EXT ENDART SHUNT 3MM X

Facility

$1,393.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$710.43
Max. Negotiated Rate	$1,351.21
Rate for Payer: Cash Price	$835.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,323.35
Rate for Payer: Health Management Network Commercial	$1,184.05
Rate for Payer: Kaiser Permanente Commercial	$877.59
Rate for Payer: Kaiser Permanente Medicaid	$710.43
Rate for Payer: MDX Hawaii PPO	$1,351.21
Rate for Payer: University Health Alliance Commercial	$1,015.36

SUNDT EXT ENDART SHUNT 3MM X

Facility

$1,393.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,184.05
Max. Negotiated Rate	$1,351.21
Rate for Payer: Cash Price	$835.80
Rate for Payer: Health Management Network Commercial	$1,184.05
Rate for Payer: MDX Hawaii PPO	$1,351.21

SUPERIOR CLAVICLE 8H RT 628028

Facility

$3,450.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,759.50
Max. Negotiated Rate	$3,346.50
Rate for Payer: Cash Price	$2,070.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,415.00
Rate for Payer: Health Management Network Commercial	$2,932.50
Rate for Payer: Kaiser Permanente Commercial	$2,173.50
Rate for Payer: Kaiser Permanente Medicaid	$1,759.50
Rate for Payer: MDX Hawaii PPO	$3,346.50
Rate for Payer: University Health Alliance Commercial	$1,932.00

SUPERIOR CLAVICLE 8H RT 628028

Facility

$3,450.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,932.00
Max. Negotiated Rate	$3,346.50
Rate for Payer: Cash Price	$2,070.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,415.00
Rate for Payer: Health Management Network Commercial	$2,932.50
Rate for Payer: MDX Hawaii PPO	$3,346.50
Rate for Payer: University Health Alliance Commercial	$1,932.00

SUPERSELECTIVE CATHETER PLACEMENT (ONE OR MORE SECOND ORDER OR HIGHER RENAL ARTERY BRANCHES) RENAL ARTERY AND ANY ACCESSORY RENAL ARTERY(S) FOR RENAL ANGIOGRAPHY, INCLUDING ARTERIAL PUNCTURE, CATHETERIZATION, FLUOROSCOPY, CONTRAST INJECTION(S), IMAGE POSTPROCESSING, PERMANENT RECORDING OF IMAGES, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDING PRESSURE GRADIENT MEASUREMENTS WHEN PERFORMED, AND FLUSH AORTOGRAM WHEN PERFORMED; UNILATERAL

Facility

$13,778.00

Service Code	CPT 36253
Hospital Revenue Code	361
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$6,573.58
Rate for Payer: AlohaCare Medicare	$6,573.58
Rate for Payer: Devoted Health Medicare	$7,230.94
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,573.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$6,573.58
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,573.58
Rate for Payer: Ohana Health Plan Medicaid	$7,230.94
Rate for Payer: Ohana Health Plan Medicare	$6,573.58
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,573.58

SUPPORT FOREARM RIGHT

Facility

$119.00

Service Code	HCPCS L3908
Hospital Revenue Code	274
Min. Negotiated Rate	$66.64
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Hawaii Western Management Group Commercial	$83.30
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: University Health Alliance Commercial	$66.64

SUPPORT FOREARM RIGHT

Facility

$119.00

Service Code	HCPCS L3908
Hospital Revenue Code	274
Min. Negotiated Rate	$49.46
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Cash Price	$71.40
Rate for Payer: Hawaii Western Management Group Commercial	$83.30
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Kaiser Permanente Commercial	$74.97
Rate for Payer: Kaiser Permanente Medicaid	$60.69
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: UnitedHealthcare Medicaid	$49.46
Rate for Payer: University Health Alliance Commercial	$66.64

SUREFORM 45 2.0 GRAY 48345M

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$546.67

SUREFORM 45 2.0 GRAY 48345M

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: MDX Hawaii PPO	$727.50

SUREFORM 45 2.5 WHITE 48345W

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$669.80
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: MDX Hawaii PPO	$764.36

SUREFORM 45 2.5 WHITE 48345W

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$401.88
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Hawaii Western Management Group Commercial	$748.60
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Kaiser Permanente Commercial	$496.44
Rate for Payer: Kaiser Permanente Medicaid	$401.88
Rate for Payer: MDX Hawaii PPO	$764.36
Rate for Payer: University Health Alliance Commercial	$574.37

SUREFORM 45 3.5 BLUE 48345B

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: MDX Hawaii PPO	$727.50

SUREFORM 45 3.5 BLUE 48345B

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$546.67

SUREFORM 45 4.3 GREEN 48345G

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$546.67

SUREFORM 45 4.3 GREEN 48345G

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: MDX Hawaii PPO	$727.50

Know your out-of-pocket cost for care.

All Charges