Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CLINDAMYCIN HCL 300 MG CAPSULE [9621]

Facility

$5.00

Service Code	NDC 68084024401
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$4.85

CLINDAMYCIN HCL 300 MG CAPSULE [9621]

Facility

$5.00

Service Code	NDC 68084024401
Hospital Revenue Code	637
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: University Health Alliance Commercial	$3.64

CLIP 5MM ENDO

Facility

$462.00

Hospital Revenue Code	272
Min. Negotiated Rate	$392.70
Max. Negotiated Rate	$448.14
Rate for Payer: Cash Price	$277.20
Rate for Payer: Health Management Network Commercial	$392.70
Rate for Payer: MDX Hawaii PPO	$448.14

CLIP 5MM ENDO

Facility

$462.00

Hospital Revenue Code	272
Min. Negotiated Rate	$235.62
Max. Negotiated Rate	$448.14
Rate for Payer: Cash Price	$277.20
Rate for Payer: Hawaii Western Management Group Commercial	$438.90
Rate for Payer: Health Management Network Commercial	$392.70
Rate for Payer: Kaiser Permanente Commercial	$291.06
Rate for Payer: Kaiser Permanente Medicaid	$235.62
Rate for Payer: MDX Hawaii PPO	$448.14
Rate for Payer: University Health Alliance Commercial	$336.75

CLIP CLOSED GAMMA 1320-0125S

Facility

$871.00

Hospital Revenue Code	272
Min. Negotiated Rate	$740.35
Max. Negotiated Rate	$844.87
Rate for Payer: Cash Price	$522.60
Rate for Payer: Health Management Network Commercial	$740.35
Rate for Payer: MDX Hawaii PPO	$844.87

CLIP CLOSED GAMMA 1320-0125S

Facility

$871.00

Hospital Revenue Code	272
Min. Negotiated Rate	$444.21
Max. Negotiated Rate	$844.87
Rate for Payer: Cash Price	$522.60
Rate for Payer: Hawaii Western Management Group Commercial	$827.45
Rate for Payer: Health Management Network Commercial	$740.35
Rate for Payer: Kaiser Permanente Commercial	$548.73
Rate for Payer: Kaiser Permanente Medicaid	$444.21
Rate for Payer: MDX Hawaii PPO	$844.87
Rate for Payer: University Health Alliance Commercial	$634.87

CLIP DYNAMIZATION 390.032

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

CLIP DYNAMIZATION 390.032

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

CLIP II M/L ENDO

Facility

$338.00

Hospital Revenue Code	272
Min. Negotiated Rate	$172.38
Max. Negotiated Rate	$327.86
Rate for Payer: Cash Price	$202.80
Rate for Payer: Hawaii Western Management Group Commercial	$321.10
Rate for Payer: Health Management Network Commercial	$287.30
Rate for Payer: Kaiser Permanente Commercial	$212.94
Rate for Payer: Kaiser Permanente Medicaid	$172.38
Rate for Payer: MDX Hawaii PPO	$327.86
Rate for Payer: University Health Alliance Commercial	$246.37

CLIP II M/L ENDO

Facility

$338.00

Hospital Revenue Code	272
Min. Negotiated Rate	$287.30
Max. Negotiated Rate	$327.86
Rate for Payer: Cash Price	$202.80
Rate for Payer: Health Management Network Commercial	$287.30
Rate for Payer: MDX Hawaii PPO	$327.86

CLIP LIGATING SMALL LT100

Facility

$70.00

Hospital Revenue Code	272
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$67.90
Rate for Payer: Cash Price	$42.00
Rate for Payer: Hawaii Western Management Group Commercial	$66.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: Kaiser Permanente Medicaid	$35.70
Rate for Payer: MDX Hawaii PPO	$67.90
Rate for Payer: University Health Alliance Commercial	$51.02

CLIP LIGATING SMALL LT100

Facility

$70.00

Hospital Revenue Code	272
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$67.90
Rate for Payer: Cash Price	$42.00
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: MDX Hawaii PPO	$67.90

CLIP LOCKING STERILE 352.260S

Facility

$354.00

Hospital Revenue Code	272
Min. Negotiated Rate	$300.90
Max. Negotiated Rate	$343.38
Rate for Payer: Cash Price	$212.40
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: MDX Hawaii PPO	$343.38

CLIP LOCKING STERILE 352.260S

Facility

$354.00

Hospital Revenue Code	272
Min. Negotiated Rate	$180.54
Max. Negotiated Rate	$343.38
Rate for Payer: Cash Price	$212.40
Rate for Payer: Hawaii Western Management Group Commercial	$336.30
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Kaiser Permanente Commercial	$223.02
Rate for Payer: Kaiser Permanente Medicaid	$180.54
Rate for Payer: MDX Hawaii PPO	$343.38
Rate for Payer: University Health Alliance Commercial	$258.03

CLIP QUICK PRO

Facility

$1,278.00

Hospital Revenue Code	272
Min. Negotiated Rate	$651.78
Max. Negotiated Rate	$1,239.66
Rate for Payer: Cash Price	$766.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,214.10
Rate for Payer: Health Management Network Commercial	$1,086.30
Rate for Payer: Kaiser Permanente Commercial	$805.14
Rate for Payer: Kaiser Permanente Medicaid	$651.78
Rate for Payer: MDX Hawaii PPO	$1,239.66
Rate for Payer: University Health Alliance Commercial	$931.53

CLIP QUICK PRO

Facility

$1,278.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,086.30
Max. Negotiated Rate	$1,239.66
Rate for Payer: Cash Price	$766.80
Rate for Payer: Health Management Network Commercial	$1,086.30
Rate for Payer: MDX Hawaii PPO	$1,239.66

CLIP RESOLUTION 235CM

Facility

$821.00

Hospital Revenue Code	272
Min. Negotiated Rate	$697.85
Max. Negotiated Rate	$796.37
Rate for Payer: Cash Price	$492.60
Rate for Payer: Health Management Network Commercial	$697.85
Rate for Payer: MDX Hawaii PPO	$796.37

CLIP RESOLUTION 235CM

Facility

$821.00

Hospital Revenue Code	272
Min. Negotiated Rate	$418.71
Max. Negotiated Rate	$796.37
Rate for Payer: Cash Price	$492.60
Rate for Payer: Hawaii Western Management Group Commercial	$779.95
Rate for Payer: Health Management Network Commercial	$697.85
Rate for Payer: Kaiser Permanente Commercial	$517.23
Rate for Payer: Kaiser Permanente Medicaid	$418.71
Rate for Payer: MDX Hawaii PPO	$796.37
Rate for Payer: University Health Alliance Commercial	$598.43

CLIPS HEMOLOK MED

Facility

$67.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$37.52
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$40.20
Rate for Payer: Hawaii Western Management Group Commercial	$46.90
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: University Health Alliance Commercial	$37.52

CLIPS HEMOLOK MED

Facility

$67.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$34.17
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$40.20
Rate for Payer: Hawaii Western Management Group Commercial	$46.90
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Kaiser Permanente Commercial	$42.21
Rate for Payer: Kaiser Permanente Medicaid	$34.17
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: University Health Alliance Commercial	$37.52

CLIP SUTURE LAPRA-TY

Facility

$1,569.00

Hospital Revenue Code	272
Min. Negotiated Rate	$800.19
Max. Negotiated Rate	$1,521.93
Rate for Payer: Cash Price	$941.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,490.55
Rate for Payer: Health Management Network Commercial	$1,333.65
Rate for Payer: Kaiser Permanente Commercial	$988.47
Rate for Payer: Kaiser Permanente Medicaid	$800.19
Rate for Payer: MDX Hawaii PPO	$1,521.93
Rate for Payer: University Health Alliance Commercial	$1,143.64

CLIP SUTURE LAPRA-TY

Facility

$1,569.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,333.65
Max. Negotiated Rate	$1,521.93
Rate for Payer: Cash Price	$941.40
Rate for Payer: Health Management Network Commercial	$1,333.65
Rate for Payer: MDX Hawaii PPO	$1,521.93

CLONAZEPAM 0.5 MG TABLET [9637]

Facility

$3.00

Service Code	NDC 60687086101
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

CLONAZEPAM 0.5 MG TABLET [9637]

Facility

$3.00

Service Code	NDC 60687086111
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

CLONAZEPAM 0.5 MG TABLET [9637]

Facility

$3.00

Service Code	NDC 60687054401
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

Know your out-of-pocket cost for care.

All Charges