Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TENO BIO-COMP AR-1662BCC-7

Facility

$1,866.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,044.96
Max. Negotiated Rate	$1,810.02
Rate for Payer: Cash Price	$1,119.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,306.20
Rate for Payer: Health Management Network Commercial	$1,586.10
Rate for Payer: MDX Hawaii PPO	$1,810.02
Rate for Payer: University Health Alliance Commercial	$1,044.96

TENO BIO-COMP AR-1662BCC-7

Facility

$1,866.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$951.66
Max. Negotiated Rate	$1,810.02
Rate for Payer: Cash Price	$1,119.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,306.20
Rate for Payer: Health Management Network Commercial	$1,586.10
Rate for Payer: Kaiser Permanente Commercial	$1,175.58
Rate for Payer: Kaiser Permanente Medicaid	$951.66
Rate for Payer: MDX Hawaii PPO	$1,810.02
Rate for Payer: University Health Alliance Commercial	$1,044.96

TENODESIS OF LONG TENDON OF BICEPS

Facility

$13,778.00

Service Code	CPT 23430
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
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	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$10,679.55

TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON

Facility

$6,743.44

Service Code	CPT 26445
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$6,743.44

TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA

Facility

$4,251.90

Service Code	CPT 27606
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$4,251.90
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$4,035.20

TERAZOSIN 1 MG CAPSULE [14550]

Facility

$6.00

Service Code	NDC 50268076411
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

TERAZOSIN 1 MG CAPSULE [14550]

Facility

$6.00

Service Code	NDC 59746038306
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

TERAZOSIN 1 MG CAPSULE [14550]

Facility

$6.00

Service Code	NDC 59746038306
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

TERAZOSIN 1 MG CAPSULE [14550]

Facility

$6.00

Service Code	NDC 50268076411
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

TERAZOSIN 2 MG CAPSULE [14551]

Facility

$6.00

Service Code	NDC 59746038406
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

TERAZOSIN 2 MG CAPSULE [14551]

Facility

$6.00

Service Code	NDC 59746038406
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

TERAZOSIN 5 MG CAPSULE [14553]

Facility

$6.00

Service Code	NDC 50268076615
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

TERAZOSIN 5 MG CAPSULE [14553]

Facility

$6.00

Service Code	NDC 59746038506
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

TERAZOSIN 5 MG CAPSULE [14553]

Facility

$6.00

Service Code	NDC 59746038506
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

TERAZOSIN 5 MG CAPSULE [14553]

Facility

$6.00

Service Code	NDC 50268076615
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION [11507]

Facility

$60.00

Service Code	HCPCS J3105
Hospital Revenue Code	250
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: MDX Hawaii PPO	$16.49

TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION [11507]

Facility

$17.00

Service Code	HCPCS J3105
Hospital Revenue Code	636
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Cash Price	$10.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Hawaii Medical Service Association ABD	$2.74
Rate for Payer: Hawaii Medical Service Association ABD	$2.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.74
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$10.71
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: UnitedHealthcare Medicaid	$10.20
Rate for Payer: UnitedHealthcare Medicaid	$36.00
Rate for Payer: University Health Alliance Commercial	$12.39
Rate for Payer: University Health Alliance Commercial	$43.73

TESTES PROCEDURES WITH CC/MCC

Facility

$53,118.27

Service Code	MSDRG 711
Min. Negotiated Rate	$23,701.68
Max. Negotiated Rate	$53,118.27
Rate for Payer: AlohaCare Medicare	$23,701.68
Rate for Payer: Devoted Health Medicare	$26,071.85
Rate for Payer: Hawaii Medical Service Association Commercial	$53,118.27
Rate for Payer: Hawaii Medical Service Association Medicare	$23,701.68
Rate for Payer: Humana Medicare	$23,701.68
Rate for Payer: Kaiser Permanente Commercial	$35,945.55
Rate for Payer: Kaiser Permanente Medicare	$23,701.68
Rate for Payer: Ohana Health Plan Medicare	$23,701.68
Rate for Payer: UnitedHealthcare Medicare	$23,701.68

TESTES PROCEDURES WITHOUT CC/MCC

Facility

$37,588.03

Service Code	MSDRG 712
Min. Negotiated Rate	$12,508.26
Max. Negotiated Rate	$37,588.03
Rate for Payer: AlohaCare Medicare	$12,508.26
Rate for Payer: Devoted Health Medicare	$13,759.09
Rate for Payer: Hawaii Medical Service Association Commercial	$37,588.03
Rate for Payer: Hawaii Medical Service Association Medicare	$12,508.26
Rate for Payer: Humana Medicare	$12,508.26
Rate for Payer: Kaiser Permanente Commercial	$18,969.83
Rate for Payer: Kaiser Permanente Medicare	$12,508.26
Rate for Payer: Ohana Health Plan Medicare	$12,508.26
Rate for Payer: UnitedHealthcare Medicare	$12,508.26

TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [126226]

Facility

$72.00

Service Code	HCPCS J1071
Hospital Revenue Code	250
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cash Price	$34.80
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: MDX Hawaii PPO	$56.26

TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [126226]

Facility

$58.00

Service Code	HCPCS J1071
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$56.26
Rate for Payer: Cash Price	$34.80
Rate for Payer: Cash Price	$34.80
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cash Price	$43.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Western Management Group Commercial	$55.10
Rate for Payer: Hawaii Western Management Group Commercial	$68.40
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: Kaiser Permanente Commercial	$45.36
Rate for Payer: Kaiser Permanente Commercial	$36.54
Rate for Payer: Kaiser Permanente Medicaid	$29.58
Rate for Payer: Kaiser Permanente Medicaid	$36.72
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: MDX Hawaii PPO	$56.26
Rate for Payer: UnitedHealthcare Medicaid	$34.80
Rate for Payer: UnitedHealthcare Medicaid	$43.20
Rate for Payer: University Health Alliance Commercial	$52.48
Rate for Payer: University Health Alliance Commercial	$42.28

TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [203772]

Facility

$126.00

Service Code	HCPCS 90714
Hospital Revenue Code	636
Min. Negotiated Rate	$33.48
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cash Price	$75.60
Rate for Payer: Hawaii Medical Service Association ABD	$33.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$33.48
Rate for Payer: Hawaii Western Management Group Commercial	$119.70
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$79.38
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: UnitedHealthcare Medicaid	$75.60
Rate for Payer: University Health Alliance Commercial	$91.84

TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [203772]

Facility

$126.00

Service Code	HCPCS 90714
Hospital Revenue Code	250
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: MDX Hawaii PPO	$122.22

TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [180686]

Facility

$1,169.00

Service Code	HCPCS J1670
Hospital Revenue Code	250
Min. Negotiated Rate	$993.65
Max. Negotiated Rate	$1,133.93
Rate for Payer: Cash Price	$701.40
Rate for Payer: Health Management Network Commercial	$993.65
Rate for Payer: MDX Hawaii PPO	$1,133.93

TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [180686]

Facility

$1,169.00

Service Code	HCPCS J1670
Hospital Revenue Code	636
Min. Negotiated Rate	$558.12
Max. Negotiated Rate	$1,133.93
Rate for Payer: AlohaCare Medicaid	$558.12
Rate for Payer: AlohaCare Medicare	$558.12
Rate for Payer: Cash Price	$701.40
Rate for Payer: Cash Price	$701.40
Rate for Payer: Devoted Health Medicare	$613.93
Rate for Payer: Hawaii Medical Service Association ABD	$577.05
Rate for Payer: Hawaii Medical Service Association Commercial	$697.65
Rate for Payer: Hawaii Medical Service Association Medicare	$558.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$577.05
Rate for Payer: Hawaii Western Management Group Commercial	$1,110.55
Rate for Payer: Health Management Network Commercial	$993.65
Rate for Payer: Humana Medicare	$558.12
Rate for Payer: Kaiser Permanente Commercial	$736.47
Rate for Payer: Kaiser Permanente Medicaid	$596.19
Rate for Payer: Kaiser Permanente Medicare	$558.12
Rate for Payer: MDX Hawaii PPO	$1,133.93
Rate for Payer: Ohana Health Plan Medicaid	$613.93
Rate for Payer: Ohana Health Plan Medicare	$558.12
Rate for Payer: UnitedHealthcare Medicaid	$701.40
Rate for Payer: UnitedHealthcare Medicare	$558.12
Rate for Payer: University Health Alliance Commercial	$852.08

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