Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION - INFUSION ONLY [4080508]

Facility

$83.00

Service Code	NDC 70092110436
Hospital Revenue Code	250
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$49.80
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: MDX Hawaii PPO	$80.51

FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [131632]

Facility

$15.00

Service Code	HCPCS J3010
Hospital Revenue Code	250
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Health Management Network Commercial	$89.25
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$101.85
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: MDX Hawaii PPO	$128.04

FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [131632]

Facility

$105.00

Service Code	HCPCS J3010
Hospital Revenue Code	636
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$101.85
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cash Price	$7.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.96
Rate for Payer: Hawaii Medical Service Association ABD	$0.96
Rate for Payer: Hawaii Medical Service Association ABD	$0.96
Rate for Payer: Hawaii Medical Service Association ABD	$0.96
Rate for Payer: Hawaii Medical Service Association ABD	$0.96
Rate for Payer: Hawaii Medical Service Association ABD	$0.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.96
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Hawaii Western Management Group Commercial	$99.75
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Health Management Network Commercial	$89.25
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$83.16
Rate for Payer: Kaiser Permanente Commercial	$9.45
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Commercial	$66.15
Rate for Payer: Kaiser Permanente Commercial	$7.56
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicaid	$53.55
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$101.85
Rate for Payer: UnitedHealthcare Medicaid	$79.20
Rate for Payer: UnitedHealthcare Medicaid	$6.00
Rate for Payer: UnitedHealthcare Medicaid	$5.40
Rate for Payer: UnitedHealthcare Medicaid	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$7.20
Rate for Payer: UnitedHealthcare Medicaid	$9.00
Rate for Payer: University Health Alliance Commercial	$8.75
Rate for Payer: University Health Alliance Commercial	$76.53
Rate for Payer: University Health Alliance Commercial	$96.21
Rate for Payer: University Health Alliance Commercial	$10.93
Rate for Payer: University Health Alliance Commercial	$6.56
Rate for Payer: University Health Alliance Commercial	$7.29

FERIC QUICK STAT V16-0397

Facility

$177.00

Hospital Revenue Code	272
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	$168.15
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	$129.02

FERIC QUICK STAT V16-0397

Facility

$177.00

Hospital Revenue Code	272
Min. Negotiated Rate	$150.45
Max. Negotiated Rate	$171.69
Rate for Payer: Cash Price	$106.20
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: MDX Hawaii PPO	$171.69

FERMORAL HEAD 3.5 X 28MM

Facility

$1,853.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,037.68
Max. Negotiated Rate	$1,797.41
Rate for Payer: Cash Price	$1,111.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,297.10
Rate for Payer: Health Management Network Commercial	$1,575.05
Rate for Payer: MDX Hawaii PPO	$1,797.41
Rate for Payer: University Health Alliance Commercial	$1,037.68

FERMORAL HEAD 3.5 X 28MM

Facility

$1,853.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$945.03
Max. Negotiated Rate	$1,797.41
Rate for Payer: Cash Price	$1,111.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,297.10
Rate for Payer: Health Management Network Commercial	$1,575.05
Rate for Payer: Kaiser Permanente Commercial	$1,167.39
Rate for Payer: Kaiser Permanente Medicaid	$945.03
Rate for Payer: MDX Hawaii PPO	$1,797.41
Rate for Payer: University Health Alliance Commercial	$1,037.68

FERMORAL HEAD CERAMIC 18-3675

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.76
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$1,685.88
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

FERMORAL HEAD CERAMIC 18-3675

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION [122648]

Facility

$2,900.00

Service Code	HCPCS J1439
Hospital Revenue Code	636
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$2,813.00
Rate for Payer: AlohaCare Medicaid	$1.10
Rate for Payer: AlohaCare Medicare	$1.10
Rate for Payer: Cash Price	$1,740.00
Rate for Payer: Cash Price	$1,740.00
Rate for Payer: Devoted Health Medicare	$1.21
Rate for Payer: Hawaii Medical Service Association ABD	$1.14
Rate for Payer: Hawaii Medical Service Association Commercial	$1.38
Rate for Payer: Hawaii Medical Service Association Medicare	$1.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.14
Rate for Payer: Hawaii Western Management Group Commercial	$2,755.00
Rate for Payer: Health Management Network Commercial	$2,465.00
Rate for Payer: Humana Medicare	$1.10
Rate for Payer: Kaiser Permanente Commercial	$1,827.00
Rate for Payer: Kaiser Permanente Medicaid	$1,479.00
Rate for Payer: Kaiser Permanente Medicare	$1.10
Rate for Payer: MDX Hawaii PPO	$2,813.00
Rate for Payer: Ohana Health Plan Medicaid	$1.21
Rate for Payer: Ohana Health Plan Medicare	$1.10
Rate for Payer: UnitedHealthcare Medicaid	$1,740.00
Rate for Payer: UnitedHealthcare Medicare	$1.10
Rate for Payer: University Health Alliance Commercial	$2,113.81

FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION [122648]

Facility

$2,900.00

Service Code	HCPCS J1439
Hospital Revenue Code	250
Min. Negotiated Rate	$2,465.00
Max. Negotiated Rate	$2,813.00
Rate for Payer: Cash Price	$1,740.00
Rate for Payer: Health Management Network Commercial	$2,465.00
Rate for Payer: MDX Hawaii PPO	$2,813.00

FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS [95693]

Facility

$14.00

Service Code	NDC 74805000000
Hospital Revenue Code	637
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$8.82
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: University Health Alliance Commercial	$10.20

FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS [95693]

Facility

$21.00

Service Code	NDC 01150000000
Hospital Revenue Code	637
Min. Negotiated Rate	$10.71
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$13.23
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: University Health Alliance Commercial	$15.31

FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS [95693]

Facility

$21.00

Service Code	NDC 01150000000
Hospital Revenue Code	250
Min. Negotiated Rate	$17.85
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: MDX Hawaii PPO	$20.37

FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS [95693]

Facility

$14.00

Service Code	NDC 74805000000
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: MDX Hawaii PPO	$13.58

FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID [194491]

Facility

$15.00

Service Code	NDC 00559000000
Hospital Revenue Code	250
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: MDX Hawaii PPO	$14.55

FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID [194491]

Facility

$15.00

Service Code	NDC 53005000000
Hospital Revenue Code	250
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: MDX Hawaii PPO	$14.55

FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID [194491]

Facility

$15.00

Service Code	NDC 00559000000
Hospital Revenue Code	637
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$9.45
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: University Health Alliance Commercial	$10.93

FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID [194491]

Facility

$15.00

Service Code	NDC 53005000000
Hospital Revenue Code	637
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$9.45
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: University Health Alliance Commercial	$10.93

FERROUS SULFATE 325 MG (65 MG IRON) TABLET [3074]

Facility

$1.00

Service Code	NDC 59161000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: University Health Alliance Commercial	$0.73

FERROUS SULFATE 325 MG (65 MG IRON) TABLET [3074]

Facility

$1.00

Service Code	NDC 59161000000
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: MDX Hawaii PPO	$0.97

FEVER AND INFLAMMATORY CONDITIONS

Facility

$23,101.23

Service Code	MSDRG 864
Min. Negotiated Rate	$10,096.93
Max. Negotiated Rate	$23,101.23
Rate for Payer: AlohaCare Medicare	$10,096.93
Rate for Payer: Devoted Health Medicare	$11,106.62
Rate for Payer: Hawaii Medical Service Association Commercial	$23,101.23
Rate for Payer: Hawaii Medical Service Association Medicare	$10,096.93
Rate for Payer: Humana Medicare	$10,096.93
Rate for Payer: Kaiser Permanente Commercial	$15,312.83
Rate for Payer: Kaiser Permanente Medicare	$10,096.93
Rate for Payer: Ohana Health Plan Medicare	$10,096.93
Rate for Payer: UnitedHealthcare Medicare	$10,096.93

FEVER & INFLAMMATORY CONDITIONS

Facility

$2,162.30

Service Code	APR-DRG 7221
Min. Negotiated Rate	$2,162.30
Max. Negotiated Rate	$2,162.30
Rate for Payer: AlohaCare Medicaid	$2,162.30
Rate for Payer: Hawaii Medical Service Association ABD	$2,162.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,162.30
Rate for Payer: Kaiser Permanente Medicaid	$2,162.30
Rate for Payer: Ohana Health Plan Medicaid	$2,162.30
Rate for Payer: UnitedHealthcare Medicaid	$2,162.30

FEVER & INFLAMMATORY CONDITIONS

Facility

$4,083.25

Service Code	APR-DRG 7223
Min. Negotiated Rate	$4,083.25
Max. Negotiated Rate	$4,083.25
Rate for Payer: AlohaCare Medicaid	$4,083.25
Rate for Payer: Hawaii Medical Service Association ABD	$4,083.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,083.25
Rate for Payer: Kaiser Permanente Medicaid	$4,083.25
Rate for Payer: Ohana Health Plan Medicaid	$4,083.25
Rate for Payer: UnitedHealthcare Medicaid	$4,083.25

FEVER & INFLAMMATORY CONDITIONS

Facility

$3,008.95

Service Code	APR-DRG 7222
Min. Negotiated Rate	$3,008.95
Max. Negotiated Rate	$3,008.95
Rate for Payer: AlohaCare Medicaid	$3,008.95
Rate for Payer: Hawaii Medical Service Association ABD	$3,008.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,008.95
Rate for Payer: Kaiser Permanente Medicaid	$3,008.95
Rate for Payer: Ohana Health Plan Medicaid	$3,008.95
Rate for Payer: UnitedHealthcare Medicaid	$3,008.95

Know your out-of-pocket cost for care.

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