Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

FIBERTAK 1.3MM SUTAPE AR-3602

Facility

$1,587.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$888.72
Max. Negotiated Rate	$1,539.39
Rate for Payer: Cash Price	$952.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,110.90
Rate for Payer: Health Management Network Commercial	$1,348.95
Rate for Payer: MDX Hawaii PPO	$1,539.39
Rate for Payer: University Health Alliance Commercial	$888.72

FIBERTAK 1.3MM SUTAPE AR-3602

Facility

$1,587.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$809.37
Max. Negotiated Rate	$1,539.39
Rate for Payer: Cash Price	$952.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,110.90
Rate for Payer: Health Management Network Commercial	$1,348.95
Rate for Payer: Kaiser Permanente Commercial	$999.81
Rate for Payer: Kaiser Permanente Medicaid	$809.37
Rate for Payer: MDX Hawaii PPO	$1,539.39
Rate for Payer: University Health Alliance Commercial	$888.72

FIBERTAK 1.3 SUTAPE AR-3602-2

Facility

$1,295.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$725.20
Max. Negotiated Rate	$1,256.15
Rate for Payer: Cash Price	$777.00
Rate for Payer: Hawaii Western Management Group Commercial	$906.50
Rate for Payer: Health Management Network Commercial	$1,100.75
Rate for Payer: MDX Hawaii PPO	$1,256.15
Rate for Payer: University Health Alliance Commercial	$725.20

FIBERTAK 1.3 SUTAPE AR-3602-2

Facility

$1,295.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$660.45
Max. Negotiated Rate	$1,256.15
Rate for Payer: Cash Price	$777.00
Rate for Payer: Hawaii Western Management Group Commercial	$906.50
Rate for Payer: Health Management Network Commercial	$1,100.75
Rate for Payer: Kaiser Permanente Commercial	$815.85
Rate for Payer: Kaiser Permanente Medicaid	$660.45
Rate for Payer: MDX Hawaii PPO	$1,256.15
Rate for Payer: University Health Alliance Commercial	$725.20

FIBERTAK BICEPS SYS AR-3670

Facility

$1,969.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,004.19
Max. Negotiated Rate	$1,909.93
Rate for Payer: Cash Price	$1,181.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,378.30
Rate for Payer: Health Management Network Commercial	$1,673.65
Rate for Payer: Kaiser Permanente Commercial	$1,240.47
Rate for Payer: Kaiser Permanente Medicaid	$1,004.19
Rate for Payer: MDX Hawaii PPO	$1,909.93
Rate for Payer: University Health Alliance Commercial	$1,102.64

FIBERTAK BICEPS SYS AR-3670

Facility

$1,969.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,102.64
Max. Negotiated Rate	$1,909.93
Rate for Payer: Cash Price	$1,181.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,378.30
Rate for Payer: Health Management Network Commercial	$1,673.65
Rate for Payer: MDX Hawaii PPO	$1,909.93
Rate for Payer: University Health Alliance Commercial	$1,102.64

FIBERTAK SUT ANC KIT AR-3600DC

Facility

$731.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$621.35
Max. Negotiated Rate	$709.07
Rate for Payer: Cash Price	$438.60
Rate for Payer: Health Management Network Commercial	$621.35
Rate for Payer: MDX Hawaii PPO	$709.07

FIBERTAK SUT ANC KIT AR-3600DC

Facility

$731.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$372.81
Max. Negotiated Rate	$709.07
Rate for Payer: Cash Price	$438.60
Rate for Payer: Hawaii Western Management Group Commercial	$694.45
Rate for Payer: Health Management Network Commercial	$621.35
Rate for Payer: Kaiser Permanente Commercial	$460.53
Rate for Payer: Kaiser Permanente Medicaid	$372.81
Rate for Payer: MDX Hawaii PPO	$709.07
Rate for Payer: University Health Alliance Commercial	$532.83

FIBERTAK SUTURE AR-3600-2

Facility

$1,701.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$867.51
Max. Negotiated Rate	$1,649.97
Rate for Payer: Cash Price	$1,020.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,190.70
Rate for Payer: Health Management Network Commercial	$1,445.85
Rate for Payer: Kaiser Permanente Commercial	$1,071.63
Rate for Payer: Kaiser Permanente Medicaid	$867.51
Rate for Payer: MDX Hawaii PPO	$1,649.97
Rate for Payer: University Health Alliance Commercial	$952.56

FIBERTAK SUTURE AR-3600-2

Facility

$1,701.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$952.56
Max. Negotiated Rate	$1,649.97
Rate for Payer: Cash Price	$1,020.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,190.70
Rate for Payer: Health Management Network Commercial	$1,445.85
Rate for Payer: MDX Hawaii PPO	$1,649.97
Rate for Payer: University Health Alliance Commercial	$952.56

FIBER TAPE CERCLAGE AR-7268

Facility

$1,746.00

Hospital Revenue Code	278
Min. Negotiated Rate	$977.76
Max. Negotiated Rate	$1,693.62
Rate for Payer: Cash Price	$1,047.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,222.20
Rate for Payer: Health Management Network Commercial	$1,484.10
Rate for Payer: MDX Hawaii PPO	$1,693.62
Rate for Payer: University Health Alliance Commercial	$977.76

FIBER TAPE CERCLAGE AR-7268

Facility

$1,746.00

Hospital Revenue Code	278
Min. Negotiated Rate	$890.46
Max. Negotiated Rate	$1,693.62
Rate for Payer: Cash Price	$1,047.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,222.20
Rate for Payer: Health Management Network Commercial	$1,484.10
Rate for Payer: Kaiser Permanente Commercial	$1,099.98
Rate for Payer: Kaiser Permanente Medicaid	$890.46
Rate for Payer: MDX Hawaii PPO	$1,693.62
Rate for Payer: University Health Alliance Commercial	$977.76

FIBER WIRE 5 / 7 METRIC 38"

Facility

$167.00

Hospital Revenue Code	272
Min. Negotiated Rate	$85.17
Max. Negotiated Rate	$161.99
Rate for Payer: Cash Price	$100.20
Rate for Payer: Hawaii Western Management Group Commercial	$158.65
Rate for Payer: Health Management Network Commercial	$141.95
Rate for Payer: Kaiser Permanente Commercial	$105.21
Rate for Payer: Kaiser Permanente Medicaid	$85.17
Rate for Payer: MDX Hawaii PPO	$161.99
Rate for Payer: University Health Alliance Commercial	$121.73

FIBER WIRE 5 / 7 METRIC 38"

Facility

$167.00

Hospital Revenue Code	272
Min. Negotiated Rate	$141.95
Max. Negotiated Rate	$161.99
Rate for Payer: Cash Price	$100.20
Rate for Payer: Health Management Network Commercial	$141.95
Rate for Payer: MDX Hawaii PPO	$161.99

FIBRIN SEALANT 4.8X4.8

Facility

$1,547.00

Hospital Revenue Code	272
Min. Negotiated Rate	$788.97
Max. Negotiated Rate	$1,500.59
Rate for Payer: Cash Price	$928.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,469.65
Rate for Payer: Health Management Network Commercial	$1,314.95
Rate for Payer: Kaiser Permanente Commercial	$974.61
Rate for Payer: Kaiser Permanente Medicaid	$788.97
Rate for Payer: MDX Hawaii PPO	$1,500.59
Rate for Payer: University Health Alliance Commercial	$1,127.61

FIBRIN SEALANT 4.8X4.8

Facility

$1,547.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,314.95
Max. Negotiated Rate	$1,500.59
Rate for Payer: Cash Price	$928.20
Rate for Payer: Health Management Network Commercial	$1,314.95
Rate for Payer: MDX Hawaii PPO	$1,500.59

FIBRIN SEALANT 9.5X4.8

Facility

$1,507.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,280.95
Max. Negotiated Rate	$1,461.79
Rate for Payer: Cash Price	$904.20
Rate for Payer: Health Management Network Commercial	$1,280.95
Rate for Payer: MDX Hawaii PPO	$1,461.79

FIBRIN SEALANT 9.5X4.8

Facility

$1,507.00

Hospital Revenue Code	272
Min. Negotiated Rate	$768.57
Max. Negotiated Rate	$1,461.79
Rate for Payer: Cash Price	$904.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,431.65
Rate for Payer: Health Management Network Commercial	$1,280.95
Rate for Payer: Kaiser Permanente Commercial	$949.41
Rate for Payer: Kaiser Permanente Medicaid	$768.57
Rate for Payer: MDX Hawaii PPO	$1,461.79
Rate for Payer: University Health Alliance Commercial	$1,098.45

FIDAXOMICIN 200 MG TABLET [110360]

Facility

$469.00

Service Code	NDC 52015008001
Hospital Revenue Code	637
Min. Negotiated Rate	$239.19
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$281.40
Rate for Payer: Hawaii Western Management Group Commercial	$445.55
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Kaiser Permanente Commercial	$295.47
Rate for Payer: Kaiser Permanente Medicaid	$239.19
Rate for Payer: MDX Hawaii PPO	$454.93
Rate for Payer: University Health Alliance Commercial	$341.85

FIDAXOMICIN 200 MG TABLET [110360]

Facility

$469.00

Service Code	NDC 52015008001
Hospital Revenue Code	250
Min. Negotiated Rate	$398.65
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$281.40
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: MDX Hawaii PPO	$454.93

FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [129453]

Facility

$494.00

Service Code	HCPCS Q5101
Hospital Revenue Code	250
Min. Negotiated Rate	$419.90
Max. Negotiated Rate	$479.18
Rate for Payer: Cash Price	$296.40
Rate for Payer: Health Management Network Commercial	$419.90
Rate for Payer: MDX Hawaii PPO	$479.18

FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [129453]

Facility

$494.00

Service Code	HCPCS Q5101
Hospital Revenue Code	636
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$479.18
Rate for Payer: AlohaCare Medicaid	$0.35
Rate for Payer: AlohaCare Medicare	$0.35
Rate for Payer: Cash Price	$296.40
Rate for Payer: Cash Price	$296.40
Rate for Payer: Devoted Health Medicare	$0.39
Rate for Payer: Hawaii Medical Service Association ABD	$0.37
Rate for Payer: Hawaii Medical Service Association Commercial	$0.44
Rate for Payer: Hawaii Medical Service Association Medicare	$0.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.37
Rate for Payer: Hawaii Western Management Group Commercial	$469.30
Rate for Payer: Health Management Network Commercial	$419.90
Rate for Payer: Humana Medicare	$0.35
Rate for Payer: Kaiser Permanente Commercial	$311.22
Rate for Payer: Kaiser Permanente Medicaid	$251.94
Rate for Payer: Kaiser Permanente Medicare	$0.35
Rate for Payer: MDX Hawaii PPO	$479.18
Rate for Payer: Ohana Health Plan Medicaid	$0.39
Rate for Payer: Ohana Health Plan Medicare	$0.35
Rate for Payer: UnitedHealthcare Medicaid	$296.40
Rate for Payer: UnitedHealthcare Medicare	$0.35
Rate for Payer: University Health Alliance Commercial	$360.08

FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE [129454]

Facility

$791.00

Service Code	HCPCS Q5101
Hospital Revenue Code	636
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$767.27
Rate for Payer: AlohaCare Medicaid	$0.35
Rate for Payer: AlohaCare Medicare	$0.35
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Devoted Health Medicare	$0.39
Rate for Payer: Hawaii Medical Service Association ABD	$0.37
Rate for Payer: Hawaii Medical Service Association Commercial	$0.44
Rate for Payer: Hawaii Medical Service Association Medicare	$0.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.37
Rate for Payer: Hawaii Western Management Group Commercial	$751.45
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Humana Medicare	$0.35
Rate for Payer: Kaiser Permanente Commercial	$498.33
Rate for Payer: Kaiser Permanente Medicaid	$403.41
Rate for Payer: Kaiser Permanente Medicare	$0.35
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: Ohana Health Plan Medicaid	$0.39
Rate for Payer: Ohana Health Plan Medicare	$0.35
Rate for Payer: UnitedHealthcare Medicaid	$474.60
Rate for Payer: UnitedHealthcare Medicare	$0.35
Rate for Payer: University Health Alliance Commercial	$576.56

FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE [129454]

Facility

$791.00

Service Code	HCPCS Q5101
Hospital Revenue Code	250
Min. Negotiated Rate	$672.35
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: MDX Hawaii PPO	$767.27

FILTER LEUKOCYT PALL

Facility

$96.00

Hospital Revenue Code	272
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$57.60
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: MDX Hawaii PPO	$93.12

Know your out-of-pocket cost for care.

All Charges