Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

WARFARIN 3 MG TABLET [19433]

Facility

$3.00

Service Code	NDC 65162076410
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

WARFARIN 5 MG TABLET [8751]

Facility

$3.00

Service Code	NDC 00832121601
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: University Health Alliance Commercial	$2.19

WARFARIN 5 MG TABLET [8751]

Facility

$3.00

Service Code	NDC 00832121689
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

WARFARIN 5 MG TABLET [8751]

Facility

$3.00

Service Code	NDC 00832121689
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: University Health Alliance Commercial	$2.19

WARFARIN 5 MG TABLET [8751]

Facility

$3.00

Service Code	NDC 00832121601
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

WASHER 2.5MM THREAD 131220025

Facility

$488.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$248.88
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$292.80
Rate for Payer: Hawaii Western Management Group Commercial	$341.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Kaiser Permanente Commercial	$307.44
Rate for Payer: Kaiser Permanente Medicaid	$248.88
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: University Health Alliance Commercial	$273.28

WASHER 2.5MM THREAD 131220025

Facility

$488.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$273.28
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$292.80
Rate for Payer: Hawaii Western Management Group Commercial	$341.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: University Health Alliance Commercial	$273.28

WASHER 3.0MM CANN TH 219.89

Facility

$621.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$347.76
Max. Negotiated Rate	$602.37
Rate for Payer: Cash Price	$372.60
Rate for Payer: Hawaii Western Management Group Commercial	$434.70
Rate for Payer: Health Management Network Commercial	$527.85
Rate for Payer: MDX Hawaii PPO	$602.37
Rate for Payer: University Health Alliance Commercial	$347.76

WASHER 3.0MM CANN TH 219.89

Facility

$621.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$316.71
Max. Negotiated Rate	$602.37
Rate for Payer: Cash Price	$372.60
Rate for Payer: Hawaii Western Management Group Commercial	$434.70
Rate for Payer: Health Management Network Commercial	$527.85
Rate for Payer: Kaiser Permanente Commercial	$391.23
Rate for Payer: Kaiser Permanente Medicaid	$316.71
Rate for Payer: MDX Hawaii PPO	$602.37
Rate for Payer: University Health Alliance Commercial	$347.76

WASHER 3.5/4.0MM 337-3599

Facility

$294.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$149.94
Max. Negotiated Rate	$285.18
Rate for Payer: Cash Price	$176.40
Rate for Payer: Hawaii Western Management Group Commercial	$205.80
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: Kaiser Permanente Commercial	$185.22
Rate for Payer: Kaiser Permanente Medicaid	$149.94
Rate for Payer: MDX Hawaii PPO	$285.18
Rate for Payer: University Health Alliance Commercial	$164.64

WASHER 3.5/4.0MM 337-3599

Facility

$294.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$164.64
Max. Negotiated Rate	$285.18
Rate for Payer: Cash Price	$176.40
Rate for Payer: Hawaii Western Management Group Commercial	$205.80
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: MDX Hawaii PPO	$285.18
Rate for Payer: University Health Alliance Commercial	$164.64

WASHER 619905

Facility

$177.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$90.27
Max. Negotiated Rate	$171.69
Rate for Payer: Cash Price	$106.20
Rate for Payer: Hawaii Western Management Group Commercial	$123.90
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Kaiser Permanente Commercial	$111.51
Rate for Payer: Kaiser Permanente Medicaid	$90.27
Rate for Payer: MDX Hawaii PPO	$171.69
Rate for Payer: University Health Alliance Commercial	$99.12

WASHER 619905

Facility

$177.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$99.12
Max. Negotiated Rate	$171.69
Rate for Payer: Cash Price	$106.20
Rate for Payer: Hawaii Western Management Group Commercial	$123.90
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: MDX Hawaii PPO	$171.69
Rate for Payer: University Health Alliance Commercial	$99.12

WASHER 619920

Facility

$207.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$115.92
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$124.20
Rate for Payer: Hawaii Western Management Group Commercial	$144.90
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: University Health Alliance Commercial	$115.92

WASHER 619920

Facility

$207.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$105.57
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$124.20
Rate for Payer: Hawaii Western Management Group Commercial	$144.90
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$130.41
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: University Health Alliance Commercial	$115.92

WASHER 6.5MM 219.972

Facility

$176.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$89.76
Max. Negotiated Rate	$170.72
Rate for Payer: Cash Price	$105.60
Rate for Payer: Hawaii Western Management Group Commercial	$123.20
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: Kaiser Permanente Commercial	$110.88
Rate for Payer: Kaiser Permanente Medicaid	$89.76
Rate for Payer: MDX Hawaii PPO	$170.72
Rate for Payer: University Health Alliance Commercial	$98.56

WASHER 6.5MM 219.972

Facility

$176.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$98.56
Max. Negotiated Rate	$170.72
Rate for Payer: Cash Price	$105.60
Rate for Payer: Hawaii Western Management Group Commercial	$123.20
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: MDX Hawaii PPO	$170.72
Rate for Payer: University Health Alliance Commercial	$98.56

WASHER 7.0MM 219.98

Facility

$166.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$84.66
Max. Negotiated Rate	$161.02
Rate for Payer: Cash Price	$99.60
Rate for Payer: Hawaii Western Management Group Commercial	$116.20
Rate for Payer: Health Management Network Commercial	$141.10
Rate for Payer: Kaiser Permanente Commercial	$104.58
Rate for Payer: Kaiser Permanente Medicaid	$84.66
Rate for Payer: MDX Hawaii PPO	$161.02
Rate for Payer: University Health Alliance Commercial	$92.96

WASHER 7.0MM 219.98

Facility

$166.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$92.96
Max. Negotiated Rate	$161.02
Rate for Payer: Cash Price	$99.60
Rate for Payer: Hawaii Western Management Group Commercial	$116.20
Rate for Payer: Health Management Network Commercial	$141.10
Rate for Payer: MDX Hawaii PPO	$161.02
Rate for Payer: University Health Alliance Commercial	$92.96

WASHER 7.0MM SS AR-8870W

Facility

$169.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$94.64
Max. Negotiated Rate	$163.93
Rate for Payer: Cash Price	$101.40
Rate for Payer: Hawaii Western Management Group Commercial	$118.30
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: MDX Hawaii PPO	$163.93
Rate for Payer: University Health Alliance Commercial	$94.64

WASHER 7.0MM SS AR-8870W

Facility

$169.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$86.19
Max. Negotiated Rate	$163.93
Rate for Payer: Cash Price	$101.40
Rate for Payer: Hawaii Western Management Group Commercial	$118.30
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Kaiser Permanente Commercial	$106.47
Rate for Payer: Kaiser Permanente Medicaid	$86.19
Rate for Payer: MDX Hawaii PPO	$163.93
Rate for Payer: University Health Alliance Commercial	$94.64

WASHER 8X4.0MM 7112-0006

Facility

$360.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$183.60
Max. Negotiated Rate	$349.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Hawaii Western Management Group Commercial	$252.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: Kaiser Permanente Commercial	$226.80
Rate for Payer: Kaiser Permanente Medicaid	$183.60
Rate for Payer: MDX Hawaii PPO	$349.20
Rate for Payer: University Health Alliance Commercial	$201.60

WASHER 8X4.0MM 7112-0006

Facility

$360.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$201.60
Max. Negotiated Rate	$349.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Hawaii Western Management Group Commercial	$252.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: MDX Hawaii PPO	$349.20
Rate for Payer: University Health Alliance Commercial	$201.60

WASHER AR-7000-15

Facility

$334.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$170.34
Max. Negotiated Rate	$323.98
Rate for Payer: Cash Price	$200.40
Rate for Payer: Hawaii Western Management Group Commercial	$233.80
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: Kaiser Permanente Commercial	$210.42
Rate for Payer: Kaiser Permanente Medicaid	$170.34
Rate for Payer: MDX Hawaii PPO	$323.98
Rate for Payer: University Health Alliance Commercial	$187.04

WASHER AR-7000-15

Facility

$334.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$187.04
Max. Negotiated Rate	$323.98
Rate for Payer: Cash Price	$200.40
Rate for Payer: Hawaii Western Management Group Commercial	$233.80
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: MDX Hawaii PPO	$323.98
Rate for Payer: University Health Alliance Commercial	$187.04

Know your out-of-pocket cost for care.

All Charges