Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

ENOVIS SR MCP IMPLANT SIZE LG

Facility

$7,650.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,901.50
Max. Negotiated Rate	$7,420.50
Rate for Payer: Cash Price	$4,590.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,355.00
Rate for Payer: Health Management Network Commercial	$6,502.50
Rate for Payer: Kaiser Permanente Commercial	$4,819.50
Rate for Payer: Kaiser Permanente Medicaid	$3,901.50
Rate for Payer: MDX Hawaii PPO	$7,420.50
Rate for Payer: University Health Alliance Commercial	$4,284.00

ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [183776]

Facility

$28.00

Service Code	HCPCS J1650
Hospital Revenue Code	636
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Hawaii Medical Service Association ABD	$1.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.24
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: UnitedHealthcare Medicaid	$16.80
Rate for Payer: University Health Alliance Commercial	$20.41

ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [183776]

Facility

$28.00

Service Code	HCPCS J1650
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: MDX Hawaii PPO	$27.16

ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE [183777]

Facility

$34.00

Service Code	HCPCS J1650
Hospital Revenue Code	636
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$20.40
Rate for Payer: Cash Price	$20.40
Rate for Payer: Hawaii Medical Service Association ABD	$1.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.24
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$21.42
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: University Health Alliance Commercial	$24.78

ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE [183777]

Facility

$34.00

Service Code	HCPCS J1650
Hospital Revenue Code	250
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$20.40
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: MDX Hawaii PPO	$32.98

ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE [183778]

Facility

$42.00

Service Code	HCPCS J1650
Hospital Revenue Code	250
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: MDX Hawaii PPO	$40.74

ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE [183778]

Facility

$42.00

Service Code	HCPCS J1650
Hospital Revenue Code	636
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cash Price	$25.20
Rate for Payer: Hawaii Medical Service Association ABD	$1.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.24
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$26.46
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: UnitedHealthcare Medicaid	$25.20
Rate for Payer: University Health Alliance Commercial	$30.61

ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE [183772]

Facility

$9.00

Service Code	HCPCS J1650
Hospital Revenue Code	636
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Medical Service Association ABD	$1.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.24
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: UnitedHealthcare Medicaid	$5.40
Rate for Payer: University Health Alliance Commercial	$6.56

ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE [183772]

Facility

$9.00

Service Code	HCPCS J1650
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [183773]

Facility

$12.00

Service Code	HCPCS J1650
Hospital Revenue Code	250
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.20
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: MDX Hawaii PPO	$11.64

ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [183773]

Facility

$12.00

Service Code	HCPCS J1650
Hospital Revenue Code	636
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$7.20
Rate for Payer: Hawaii Medical Service Association ABD	$1.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.24
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$7.56
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: UnitedHealthcare Medicaid	$7.20
Rate for Payer: University Health Alliance Commercial	$8.75

ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE [183774]

Facility

$20.00

Service Code	HCPCS J1650
Hospital Revenue Code	636
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Hawaii Medical Service Association ABD	$1.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.24
Rate for Payer: Hawaii Western Management Group Commercial	$19.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$10.20
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: UnitedHealthcare Medicaid	$12.00
Rate for Payer: University Health Alliance Commercial	$14.58

ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE [183774]

Facility

$20.00

Service Code	HCPCS J1650
Hospital Revenue Code	250
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: MDX Hawaii PPO	$19.40

ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE [183775]

Facility

$23.00

Service Code	HCPCS J1650
Hospital Revenue Code	636
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Cash Price	$13.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Hawaii Medical Service Association ABD	$1.24
Rate for Payer: Hawaii Medical Service Association ABD	$1.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.24
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Hawaii Western Management Group Commercial	$45.60
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$14.49
Rate for Payer: Kaiser Permanente Commercial	$30.24
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: UnitedHealthcare Medicaid	$13.80
Rate for Payer: UnitedHealthcare Medicaid	$28.80
Rate for Payer: University Health Alliance Commercial	$16.76
Rate for Payer: University Health Alliance Commercial	$34.99

ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE [183775]

Facility

$48.00

Service Code	HCPCS J1650
Hospital Revenue Code	250
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$13.80
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: MDX Hawaii PPO	$22.31

ENROUTE RX BALLOON SR-5025-BC

Facility

$1,397.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$1,187.45
Max. Negotiated Rate	$1,355.09
Rate for Payer: Cash Price	$838.20
Rate for Payer: Health Management Network Commercial	$1,187.45
Rate for Payer: MDX Hawaii PPO	$1,355.09

ENROUTE RX BALLOON SR-5025-BC

Facility

$1,397.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$712.47
Max. Negotiated Rate	$1,355.09
Rate for Payer: Cash Price	$838.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,327.15
Rate for Payer: Health Management Network Commercial	$1,187.45
Rate for Payer: Kaiser Permanente Commercial	$880.11
Rate for Payer: Kaiser Permanente Medicaid	$712.47
Rate for Payer: MDX Hawaii PPO	$1,355.09
Rate for Payer: University Health Alliance Commercial	$1,018.27

ENROUTE RX BALLOON SR-5525-BC

Facility

$1,397.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$1,187.45
Max. Negotiated Rate	$1,355.09
Rate for Payer: Cash Price	$838.20
Rate for Payer: Health Management Network Commercial	$1,187.45
Rate for Payer: MDX Hawaii PPO	$1,355.09

ENROUTE RX BALLOON SR-5525-BC

Facility

$1,397.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$712.47
Max. Negotiated Rate	$1,355.09
Rate for Payer: Cash Price	$838.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,327.15
Rate for Payer: Health Management Network Commercial	$1,187.45
Rate for Payer: Kaiser Permanente Commercial	$880.11
Rate for Payer: Kaiser Permanente Medicaid	$712.47
Rate for Payer: MDX Hawaii PPO	$1,355.09
Rate for Payer: University Health Alliance Commercial	$1,018.27

ENROUTE STENT SYS SR-0830-CS

Facility

$5,400.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$3,024.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

ENROUTE STENT SYS SR-0830-CS

Facility

$5,400.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$2,754.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: Kaiser Permanente Medicaid	$2,754.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

ENROUTE TRANSCAROTD SR-0930-CS

Facility

$5,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,024.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

ENROUTE TRANSCAROTD SR-0930-CS

Facility

$5,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,754.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: Kaiser Permanente Medicaid	$2,754.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

ENROUTE TRANSCAROT SR-250-NPS

Facility

$16,590.00

Service Code	HCPCS C1884
Hospital Revenue Code	278
Min. Negotiated Rate	$9,290.40
Max. Negotiated Rate	$16,092.30
Rate for Payer: Cash Price	$9,954.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,613.00
Rate for Payer: Health Management Network Commercial	$14,101.50
Rate for Payer: MDX Hawaii PPO	$16,092.30
Rate for Payer: University Health Alliance Commercial	$9,290.40

ENROUTE TRANSCAROT SR-250-NPS

Facility

$16,590.00

Service Code	HCPCS C1884
Hospital Revenue Code	278
Min. Negotiated Rate	$8,460.90
Max. Negotiated Rate	$16,092.30
Rate for Payer: Cash Price	$9,954.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,613.00
Rate for Payer: Health Management Network Commercial	$14,101.50
Rate for Payer: Kaiser Permanente Commercial	$10,451.70
Rate for Payer: Kaiser Permanente Medicaid	$8,460.90
Rate for Payer: MDX Hawaii PPO	$16,092.30
Rate for Payer: University Health Alliance Commercial	$9,290.40

Know your out-of-pocket cost for care.

All Charges