Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

FLUPHENAZINE 5 MG TABLET [3221]

Facility

$18.00

Service Code	NDC 60687074911
Hospital Revenue Code	250
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$17.46

FLUPHENAZINE 5 MG TABLET [3221]

Facility

$18.00

Service Code	NDC 60687074901
Hospital Revenue Code	250
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$17.46

FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION [3215]

Facility

$465.00

Service Code	HCPCS J2680
Hospital Revenue Code	250
Min. Negotiated Rate	$395.25
Max. Negotiated Rate	$451.05
Rate for Payer: Cash Price	$279.00
Rate for Payer: Cash Price	$217.80
Rate for Payer: Health Management Network Commercial	$308.55
Rate for Payer: Health Management Network Commercial	$395.25
Rate for Payer: MDX Hawaii PPO	$352.11
Rate for Payer: MDX Hawaii PPO	$451.05

FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION [3215]

Facility

$465.00

Service Code	HCPCS J2680
Hospital Revenue Code	636
Min. Negotiated Rate	$7.53
Max. Negotiated Rate	$451.05
Rate for Payer: Cash Price	$279.00
Rate for Payer: Cash Price	$217.80
Rate for Payer: Cash Price	$279.00
Rate for Payer: Cash Price	$217.80
Rate for Payer: Hawaii Medical Service Association ABD	$7.53
Rate for Payer: Hawaii Medical Service Association ABD	$7.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.53
Rate for Payer: Hawaii Western Management Group Commercial	$344.85
Rate for Payer: Hawaii Western Management Group Commercial	$441.75
Rate for Payer: Health Management Network Commercial	$395.25
Rate for Payer: Health Management Network Commercial	$308.55
Rate for Payer: Kaiser Permanente Commercial	$292.95
Rate for Payer: Kaiser Permanente Commercial	$228.69
Rate for Payer: Kaiser Permanente Medicaid	$185.13
Rate for Payer: Kaiser Permanente Medicaid	$237.15
Rate for Payer: MDX Hawaii PPO	$451.05
Rate for Payer: MDX Hawaii PPO	$352.11
Rate for Payer: UnitedHealthcare Medicaid	$217.80
Rate for Payer: UnitedHealthcare Medicaid	$279.00
Rate for Payer: University Health Alliance Commercial	$338.94
Rate for Payer: University Health Alliance Commercial	$264.59

FLURBIPROFEN 0.03 % EYE DROPS [10080]

Facility

$108.00

Service Code	NDC 69292072225
Hospital Revenue Code	637
Min. Negotiated Rate	$55.08
Max. Negotiated Rate	$104.76
Rate for Payer: Cash Price	$64.80
Rate for Payer: Hawaii Western Management Group Commercial	$102.60
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Kaiser Permanente Commercial	$68.04
Rate for Payer: Kaiser Permanente Medicaid	$55.08
Rate for Payer: MDX Hawaii PPO	$104.76
Rate for Payer: University Health Alliance Commercial	$78.72

FLURBIPROFEN 0.03 % EYE DROPS [10080]

Facility

$108.00

Service Code	NDC 69292072225
Hospital Revenue Code	250
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$104.76
Rate for Payer: Cash Price	$64.80
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: MDX Hawaii PPO	$104.76

FLUTED DISP PIN 7650-2038A

Facility

$1,542.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$786.42
Max. Negotiated Rate	$1,495.74
Rate for Payer: Cash Price	$925.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,464.90
Rate for Payer: Health Management Network Commercial	$1,310.70
Rate for Payer: Kaiser Permanente Commercial	$971.46
Rate for Payer: Kaiser Permanente Medicaid	$786.42
Rate for Payer: MDX Hawaii PPO	$1,495.74
Rate for Payer: University Health Alliance Commercial	$1,123.96

FLUTED DISP PIN 7650-2038A

Facility

$1,542.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$1,310.70
Max. Negotiated Rate	$1,495.74
Rate for Payer: Cash Price	$925.20
Rate for Payer: Health Management Network Commercial	$1,310.70
Rate for Payer: MDX Hawaii PPO	$1,495.74

FLUTED STEM 5565-S-013

Facility

$2,421.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,234.71
Max. Negotiated Rate	$2,348.37
Rate for Payer: Cash Price	$1,452.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,694.70
Rate for Payer: Health Management Network Commercial	$2,057.85
Rate for Payer: Kaiser Permanente Commercial	$1,525.23
Rate for Payer: Kaiser Permanente Medicaid	$1,234.71
Rate for Payer: MDX Hawaii PPO	$2,348.37
Rate for Payer: University Health Alliance Commercial	$1,355.76

FLUTED STEM 5565-S-013

Facility

$2,421.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,355.76
Max. Negotiated Rate	$2,348.37
Rate for Payer: Cash Price	$1,452.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,694.70
Rate for Payer: Health Management Network Commercial	$2,057.85
Rate for Payer: MDX Hawaii PPO	$2,348.37
Rate for Payer: University Health Alliance Commercial	$1,355.76

FLUTED STEM 5565-S-022

Facility

$2,421.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,355.76
Max. Negotiated Rate	$2,348.37
Rate for Payer: Cash Price	$1,452.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,694.70
Rate for Payer: Health Management Network Commercial	$2,057.85
Rate for Payer: MDX Hawaii PPO	$2,348.37
Rate for Payer: University Health Alliance Commercial	$1,355.76

FLUTED STEM 5565-S-022

Facility

$2,421.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,234.71
Max. Negotiated Rate	$2,348.37
Rate for Payer: Cash Price	$1,452.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,694.70
Rate for Payer: Health Management Network Commercial	$2,057.85
Rate for Payer: Kaiser Permanente Commercial	$1,525.23
Rate for Payer: Kaiser Permanente Medicaid	$1,234.71
Rate for Payer: MDX Hawaii PPO	$2,348.37
Rate for Payer: University Health Alliance Commercial	$1,355.76

FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER [40698]

Facility

$781.00

Service Code	NDC 66993007996
Hospital Revenue Code	637
Min. Negotiated Rate	$398.31
Max. Negotiated Rate	$757.57
Rate for Payer: Cash Price	$468.60
Rate for Payer: Hawaii Western Management Group Commercial	$741.95
Rate for Payer: Health Management Network Commercial	$663.85
Rate for Payer: Kaiser Permanente Commercial	$492.03
Rate for Payer: Kaiser Permanente Medicaid	$398.31
Rate for Payer: MDX Hawaii PPO	$757.57
Rate for Payer: University Health Alliance Commercial	$569.27

FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER [40698]

Facility

$781.00

Service Code	NDC 66993007996
Hospital Revenue Code	250
Min. Negotiated Rate	$663.85
Max. Negotiated Rate	$757.57
Rate for Payer: Cash Price	$468.60
Rate for Payer: Health Management Network Commercial	$663.85
Rate for Payer: MDX Hawaii PPO	$757.57

FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]

Facility

$299.00

Service Code	NDC 60505082901
Hospital Revenue Code	637
Min. Negotiated Rate	$152.49
Max. Negotiated Rate	$290.03
Rate for Payer: Cash Price	$179.40
Rate for Payer: Hawaii Western Management Group Commercial	$284.05
Rate for Payer: Health Management Network Commercial	$254.15
Rate for Payer: Kaiser Permanente Commercial	$188.37
Rate for Payer: Kaiser Permanente Medicaid	$152.49
Rate for Payer: MDX Hawaii PPO	$290.03
Rate for Payer: University Health Alliance Commercial	$217.94

FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]

Facility

$299.00

Service Code	NDC 60505082901
Hospital Revenue Code	250
Min. Negotiated Rate	$254.15
Max. Negotiated Rate	$290.03
Rate for Payer: Cash Price	$179.40
Rate for Payer: Health Management Network Commercial	$254.15
Rate for Payer: MDX Hawaii PPO	$290.03

FLU VACCINE TS2025-26(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE [237650]

Facility

$155.00

Service Code	HCPCS 90662
Hospital Revenue Code	250
Min. Negotiated Rate	$131.75
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$93.00
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: MDX Hawaii PPO	$150.35

FLU VACCINE TS2025-26(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE [237650]

Facility

$155.00

Service Code	HCPCS 90662
Hospital Revenue Code	636
Min. Negotiated Rate	$79.05
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$93.00
Rate for Payer: Cash Price	$93.00
Rate for Payer: Hawaii Medical Service Association ABD	$83.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$83.49
Rate for Payer: Hawaii Western Management Group Commercial	$147.25
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Kaiser Permanente Commercial	$97.65
Rate for Payer: Kaiser Permanente Medicaid	$79.05
Rate for Payer: MDX Hawaii PPO	$150.35
Rate for Payer: UnitedHealthcare Medicaid	$93.00
Rate for Payer: University Health Alliance Commercial	$112.98

FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE [237654]

Facility

$62.00

Service Code	HCPCS 90656
Hospital Revenue Code	636
Min. Negotiated Rate	$22.35
Max. Negotiated Rate	$60.14
Rate for Payer: Cash Price	$37.20
Rate for Payer: Cash Price	$37.20
Rate for Payer: Hawaii Medical Service Association ABD	$22.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.35
Rate for Payer: Hawaii Western Management Group Commercial	$58.90
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Kaiser Permanente Commercial	$39.06
Rate for Payer: Kaiser Permanente Medicaid	$31.62
Rate for Payer: MDX Hawaii PPO	$60.14
Rate for Payer: UnitedHealthcare Medicaid	$37.20
Rate for Payer: University Health Alliance Commercial	$45.19

FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE [237654]

Facility

$62.00

Service Code	HCPCS 90656
Hospital Revenue Code	250
Min. Negotiated Rate	$52.70
Max. Negotiated Rate	$60.14
Rate for Payer: Cash Price	$37.20
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: MDX Hawaii PPO	$60.14

FLUVOXAMINE 100 MG TABLET [10084]

Facility

$10.00

Service Code	NDC 62559016001
Hospital Revenue Code	637
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: University Health Alliance Commercial	$7.29

FLUVOXAMINE 100 MG TABLET [10084]

Facility

$10.00

Service Code	NDC 62559016001
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: MDX Hawaii PPO	$9.70

FLUVOXAMINE 50 MG TABLET [10085]

Facility

$9.00

Service Code	NDC 62559015901
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

FLUVOXAMINE 50 MG TABLET [10085]

Facility

$9.00

Service Code	NDC 62559015901
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
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: University Health Alliance Commercial	$6.56

FLX OPTN FEM #00-5964-014-52

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,800.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

Know your out-of-pocket cost for care.

All Charges