Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TICAGRELOR 90 MG TABLET [110427]

Facility

$28.00

Service Code	NDC 00186077739
Hospital Revenue Code	637
Min. Negotiated Rate	$14.28
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$17.64
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: University Health Alliance Commercial	$20.41

TI END CAP 0MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$504.00
Max. Negotiated Rate	$873.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP 0MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$459.00
Max. Negotiated Rate	$873.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: Kaiser Permanente Commercial	$567.00
Rate for Payer: Kaiser Permanente Medicaid	$459.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP 10MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$459.00
Max. Negotiated Rate	$873.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: Kaiser Permanente Commercial	$567.00
Rate for Payer: Kaiser Permanente Medicaid	$459.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP 10MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$504.00
Max. Negotiated Rate	$873.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP 15MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$459.00
Max. Negotiated Rate	$873.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: Kaiser Permanente Commercial	$567.00
Rate for Payer: Kaiser Permanente Medicaid	$459.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP 15MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$504.00
Max. Negotiated Rate	$873.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP 5MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$459.00
Max. Negotiated Rate	$873.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: Kaiser Permanente Commercial	$567.00
Rate for Payer: Kaiser Permanente Medicaid	$459.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP 5MM STRDRV T25

Facility

$900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$504.00
Max. Negotiated Rate	$873.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.00
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: University Health Alliance Commercial	$504.00

TI END CAP T40X0MM 04.003.000

Facility

$791.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$442.96
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Hawaii Western Management Group Commercial	$553.70
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: University Health Alliance Commercial	$442.96

TI END CAP T40X0MM 04.003.000

Facility

$791.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$403.41
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Hawaii Western Management Group Commercial	$553.70
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Kaiser Permanente Commercial	$498.33
Rate for Payer: Kaiser Permanente Medicaid	$403.41
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: University Health Alliance Commercial	$442.96

TI END CAP T40X10MM 04.003.002

Facility

$791.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$403.41
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Hawaii Western Management Group Commercial	$553.70
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Kaiser Permanente Commercial	$498.33
Rate for Payer: Kaiser Permanente Medicaid	$403.41
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: University Health Alliance Commercial	$442.96

TI END CAP T40X10MM 04.003.002

Facility

$791.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$442.96
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Hawaii Western Management Group Commercial	$553.70
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: University Health Alliance Commercial	$442.96

TI END CAP T40X15MM 04.003.003

Facility

$791.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$403.41
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Hawaii Western Management Group Commercial	$553.70
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Kaiser Permanente Commercial	$498.33
Rate for Payer: Kaiser Permanente Medicaid	$403.41
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: University Health Alliance Commercial	$442.96

TI END CAP T40X15MM 04.003.003

Facility

$791.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$442.96
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Hawaii Western Management Group Commercial	$553.70
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: University Health Alliance Commercial	$442.96

TI END CAP T40X20MM 04.003.004

Facility

$791.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$442.96
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Hawaii Western Management Group Commercial	$553.70
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: University Health Alliance Commercial	$442.96

TI END CAP T40X20MM 04.003.004

Facility

$791.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$403.41
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Hawaii Western Management Group Commercial	$553.70
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Kaiser Permanente Commercial	$498.33
Rate for Payer: Kaiser Permanente Medicaid	$403.41
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: University Health Alliance Commercial	$442.96

TI END CAP T40X5MM 04.003.001

Facility

$791.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$403.41
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Hawaii Western Management Group Commercial	$553.70
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Kaiser Permanente Commercial	$498.33
Rate for Payer: Kaiser Permanente Medicaid	$403.41
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: University Health Alliance Commercial	$442.96

TI END CAP T40X5MM 04.003.001

Facility

$791.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$442.96
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Hawaii Western Management Group Commercial	$553.70
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: University Health Alliance Commercial	$442.96

TIGECYCLINE 50 MG INTRAVENOUS SOLUTION [41652]

Facility

$189.00

Service Code	HCPCS J3243
Hospital Revenue Code	636
Min. Negotiated Rate	$3.18
Max. Negotiated Rate	$183.33
Rate for Payer: Cash Price	$113.40
Rate for Payer: Cash Price	$141.00
Rate for Payer: Cash Price	$168.60
Rate for Payer: Cash Price	$113.40
Rate for Payer: Cash Price	$141.00
Rate for Payer: Cash Price	$168.60
Rate for Payer: Hawaii Medical Service Association ABD	$3.18
Rate for Payer: Hawaii Medical Service Association ABD	$3.18
Rate for Payer: Hawaii Medical Service Association ABD	$3.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.18
Rate for Payer: Hawaii Western Management Group Commercial	$223.25
Rate for Payer: Hawaii Western Management Group Commercial	$179.55
Rate for Payer: Hawaii Western Management Group Commercial	$266.95
Rate for Payer: Health Management Network Commercial	$238.85
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Health Management Network Commercial	$199.75
Rate for Payer: Kaiser Permanente Commercial	$177.03
Rate for Payer: Kaiser Permanente Commercial	$148.05
Rate for Payer: Kaiser Permanente Commercial	$119.07
Rate for Payer: Kaiser Permanente Medicaid	$96.39
Rate for Payer: Kaiser Permanente Medicaid	$143.31
Rate for Payer: Kaiser Permanente Medicaid	$119.85
Rate for Payer: MDX Hawaii PPO	$272.57
Rate for Payer: MDX Hawaii PPO	$227.95
Rate for Payer: MDX Hawaii PPO	$183.33
Rate for Payer: UnitedHealthcare Medicaid	$113.40
Rate for Payer: UnitedHealthcare Medicaid	$141.00
Rate for Payer: UnitedHealthcare Medicaid	$168.60
Rate for Payer: University Health Alliance Commercial	$171.29
Rate for Payer: University Health Alliance Commercial	$137.76
Rate for Payer: University Health Alliance Commercial	$204.82

TIGECYCLINE 50 MG INTRAVENOUS SOLUTION [41652]

Facility

$281.00

Service Code	HCPCS J3243
Hospital Revenue Code	250
Min. Negotiated Rate	$238.85
Max. Negotiated Rate	$272.57
Rate for Payer: Cash Price	$168.60
Rate for Payer: Cash Price	$113.40
Rate for Payer: Cash Price	$141.00
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Health Management Network Commercial	$199.75
Rate for Payer: Health Management Network Commercial	$238.85
Rate for Payer: MDX Hawaii PPO	$183.33
Rate for Payer: MDX Hawaii PPO	$272.57
Rate for Payer: MDX Hawaii PPO	$227.95

TIGHTROPE ABS 14MM AR-1588TB-1

Facility

$1,071.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$546.21
Max. Negotiated Rate	$1,038.87
Rate for Payer: Cash Price	$642.60
Rate for Payer: Hawaii Western Management Group Commercial	$749.70
Rate for Payer: Health Management Network Commercial	$910.35
Rate for Payer: Kaiser Permanente Commercial	$674.73
Rate for Payer: Kaiser Permanente Medicaid	$546.21
Rate for Payer: MDX Hawaii PPO	$1,038.87
Rate for Payer: University Health Alliance Commercial	$599.76

TIGHTROPE ABS 14MM AR-1588TB-1

Facility

$1,071.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$599.76
Max. Negotiated Rate	$1,038.87
Rate for Payer: Cash Price	$642.60
Rate for Payer: Hawaii Western Management Group Commercial	$749.70
Rate for Payer: Health Management Network Commercial	$910.35
Rate for Payer: MDX Hawaii PPO	$1,038.87
Rate for Payer: University Health Alliance Commercial	$599.76

TIGHTROPE ABS 8X12 AR-1588TB

Facility

$769.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$392.19
Max. Negotiated Rate	$745.93
Rate for Payer: Cash Price	$461.40
Rate for Payer: Hawaii Western Management Group Commercial	$538.30
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Kaiser Permanente Commercial	$484.47
Rate for Payer: Kaiser Permanente Medicaid	$392.19
Rate for Payer: MDX Hawaii PPO	$745.93
Rate for Payer: University Health Alliance Commercial	$430.64

TIGHTROPE ABS 8X12 AR-1588TB

Facility

$769.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$430.64
Max. Negotiated Rate	$745.93
Rate for Payer: Cash Price	$461.40
Rate for Payer: Hawaii Western Management Group Commercial	$538.30
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: MDX Hawaii PPO	$745.93
Rate for Payer: University Health Alliance Commercial	$430.64

Know your out-of-pocket cost for care.

All Charges