Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

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

FOGARTY DBL SAFEJAW INSERT 33M

Facility

$90.00

Hospital Revenue Code	272
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$54.00
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: MDX Hawaii PPO	$87.30

FOGARTY DBL SAFEJAW INSERT 33M

Facility

$90.00

Hospital Revenue Code	272
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$54.00
Rate for Payer: Hawaii Western Management Group Commercial	$85.50
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$45.90
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: University Health Alliance Commercial	$65.60

FOGARTY DBL SAFEJAW INSERT SE

Facility

$111.00

Hospital Revenue Code	272
Min. Negotiated Rate	$94.35
Max. Negotiated Rate	$107.67
Rate for Payer: Cash Price	$66.60
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: MDX Hawaii PPO	$107.67

FOGARTY DBL SAFEJAW INSERT SE

Facility

$111.00

Hospital Revenue Code	272
Min. Negotiated Rate	$56.61
Max. Negotiated Rate	$107.67
Rate for Payer: Cash Price	$66.60
Rate for Payer: Hawaii Western Management Group Commercial	$105.45
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: Kaiser Permanente Commercial	$69.93
Rate for Payer: Kaiser Permanente Medicaid	$56.61
Rate for Payer: MDX Hawaii PPO	$107.67
Rate for Payer: University Health Alliance Commercial	$80.91

FOLIC ACID 1 MG TABLET [3233]

Facility

$2.00

Service Code	NDC 69315012701
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

FOLIC ACID 1 MG TABLET [3233]

Facility

$1.00

Service Code	NDC 60687068101
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

FOLIC ACID 1 MG TABLET [3233]

Facility

$1.00

Service Code	NDC 60687068111
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

FOLIC ACID 1 MG TABLET [3233]

Facility

$1.00

Service Code	NDC 60687068101
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

FOLIC ACID 1 MG TABLET [3233]

Facility

$1.00

Service Code	NDC 60687068111
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

FOLIC ACID 1 MG TABLET [3233]

Facility

$2.00

Service Code	NDC 69315012701
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]

Facility

$4.00

Service Code	HCPCS J1808
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$92.40
Rate for Payer: Cash Price	$138.60
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: Health Management Network Commercial	$196.35
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$149.38
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: MDX Hawaii PPO	$224.07

FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [22185]

Facility

$2,578.00

Service Code	HCPCS J1451
Hospital Revenue Code	250
Min. Negotiated Rate	$2,191.30
Max. Negotiated Rate	$2,500.66
Rate for Payer: Cash Price	$1,546.80
Rate for Payer: Cash Price	$1,380.00
Rate for Payer: Health Management Network Commercial	$1,955.00
Rate for Payer: Health Management Network Commercial	$2,191.30
Rate for Payer: MDX Hawaii PPO	$2,231.00
Rate for Payer: MDX Hawaii PPO	$2,500.66

FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE [108029]

Facility

$131.00

Service Code	HCPCS J1652
Hospital Revenue Code	250
Min. Negotiated Rate	$111.35
Max. Negotiated Rate	$127.07
Rate for Payer: Cash Price	$78.60
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: MDX Hawaii PPO	$127.07

FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE [108029]

Facility

$131.00

Service Code	HCPCS J1652
Hospital Revenue Code	636
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$127.07
Rate for Payer: Cash Price	$78.60
Rate for Payer: Cash Price	$78.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.72
Rate for Payer: Hawaii Western Management Group Commercial	$124.45
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Kaiser Permanente Commercial	$82.53
Rate for Payer: Kaiser Permanente Medicaid	$66.81
Rate for Payer: MDX Hawaii PPO	$127.07
Rate for Payer: UnitedHealthcare Medicaid	$78.60
Rate for Payer: University Health Alliance Commercial	$95.49

FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE [32215]

Facility

$82.00

Service Code	HCPCS J1652
Hospital Revenue Code	250
Min. Negotiated Rate	$69.70
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$49.20
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: MDX Hawaii PPO	$79.54

FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE [32215]

Facility

$82.00

Service Code	HCPCS J1652
Hospital Revenue Code	636
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$49.20
Rate for Payer: Cash Price	$49.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.72
Rate for Payer: Hawaii Western Management Group Commercial	$77.90
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Kaiser Permanente Commercial	$51.66
Rate for Payer: Kaiser Permanente Medicaid	$41.82
Rate for Payer: MDX Hawaii PPO	$79.54
Rate for Payer: UnitedHealthcare Medicaid	$49.20
Rate for Payer: University Health Alliance Commercial	$59.77

FONDAPARINUX 5 MG/0.4 ML SUBCUTANEOUS SOLUTION SYRINGE [108027]

Facility

$193.00

Service Code	HCPCS J1652
Hospital Revenue Code	636
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$187.21
Rate for Payer: Cash Price	$115.80
Rate for Payer: Cash Price	$115.80
Rate for Payer: Cash Price	$122.40
Rate for Payer: Cash Price	$122.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.72
Rate for Payer: Hawaii Medical Service Association ABD	$0.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.72
Rate for Payer: Hawaii Western Management Group Commercial	$183.35
Rate for Payer: Hawaii Western Management Group Commercial	$193.80
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Kaiser Permanente Commercial	$121.59
Rate for Payer: Kaiser Permanente Commercial	$128.52
Rate for Payer: Kaiser Permanente Medicaid	$104.04
Rate for Payer: Kaiser Permanente Medicaid	$98.43
Rate for Payer: MDX Hawaii PPO	$197.88
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: UnitedHealthcare Medicaid	$115.80
Rate for Payer: UnitedHealthcare Medicaid	$122.40
Rate for Payer: University Health Alliance Commercial	$140.68
Rate for Payer: University Health Alliance Commercial	$148.70

FONDAPARINUX 5 MG/0.4 ML SUBCUTANEOUS SOLUTION SYRINGE [108027]

Facility

$204.00

Service Code	HCPCS J1652
Hospital Revenue Code	250
Min. Negotiated Rate	$173.40
Max. Negotiated Rate	$197.88
Rate for Payer: Cash Price	$122.40
Rate for Payer: Cash Price	$115.80
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: MDX Hawaii PPO	$197.88
Rate for Payer: MDX Hawaii PPO	$187.21

FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE [108028]

Facility

$131.00

Service Code	HCPCS J1652
Hospital Revenue Code	636
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$127.07
Rate for Payer: Cash Price	$78.60
Rate for Payer: Cash Price	$122.40
Rate for Payer: Cash Price	$122.40
Rate for Payer: Cash Price	$78.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.72
Rate for Payer: Hawaii Medical Service Association ABD	$0.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.72
Rate for Payer: Hawaii Western Management Group Commercial	$193.80
Rate for Payer: Hawaii Western Management Group Commercial	$124.45
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Kaiser Permanente Commercial	$82.53
Rate for Payer: Kaiser Permanente Commercial	$128.52
Rate for Payer: Kaiser Permanente Medicaid	$104.04
Rate for Payer: Kaiser Permanente Medicaid	$66.81
Rate for Payer: MDX Hawaii PPO	$197.88
Rate for Payer: MDX Hawaii PPO	$127.07
Rate for Payer: UnitedHealthcare Medicaid	$78.60
Rate for Payer: UnitedHealthcare Medicaid	$122.40
Rate for Payer: University Health Alliance Commercial	$95.49
Rate for Payer: University Health Alliance Commercial	$148.70

FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE [108028]

Facility

$131.00

Service Code	HCPCS J1652
Hospital Revenue Code	250
Min. Negotiated Rate	$111.35
Max. Negotiated Rate	$127.07
Rate for Payer: Cash Price	$78.60
Rate for Payer: Cash Price	$122.40
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: MDX Hawaii PPO	$197.88
Rate for Payer: MDX Hawaii PPO	$127.07

FOOT

Facility

$5,700.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,192.00
Max. Negotiated Rate	$5,529.00
Rate for Payer: Cash Price	$3,420.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,990.00
Rate for Payer: Health Management Network Commercial	$4,845.00
Rate for Payer: MDX Hawaii PPO	$5,529.00
Rate for Payer: University Health Alliance Commercial	$3,192.00

FOOT

Facility

$5,700.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,907.00
Max. Negotiated Rate	$5,529.00
Rate for Payer: Cash Price	$3,420.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,990.00
Rate for Payer: Health Management Network Commercial	$4,845.00
Rate for Payer: Kaiser Permanente Commercial	$3,591.00
Rate for Payer: Kaiser Permanente Medicaid	$2,907.00
Rate for Payer: MDX Hawaii PPO	$5,529.00
Rate for Payer: University Health Alliance Commercial	$3,192.00

FOOT PROCEDURES WITH CC

Facility

$32,243.70

Service Code	MSDRG 504
Min. Negotiated Rate	$21,260.76
Max. Negotiated Rate	$32,243.70
Rate for Payer: AlohaCare Medicare	$21,260.76
Rate for Payer: Devoted Health Medicare	$23,386.84
Rate for Payer: Hawaii Medical Service Association Commercial	$23,780.68
Rate for Payer: Hawaii Medical Service Association Medicare	$21,260.76
Rate for Payer: Humana Medicare	$21,260.76
Rate for Payer: Kaiser Permanente Commercial	$32,243.70
Rate for Payer: Kaiser Permanente Medicare	$21,260.76
Rate for Payer: Ohana Health Plan Medicare	$21,260.76
Rate for Payer: UnitedHealthcare Medicare	$21,260.76

FOOT PROCEDURES WITH MCC

Facility

$48,146.47

Service Code	MSDRG 503
Min. Negotiated Rate	$23,780.68
Max. Negotiated Rate	$48,146.47
Rate for Payer: AlohaCare Medicare	$31,746.69
Rate for Payer: Devoted Health Medicare	$34,921.36
Rate for Payer: Hawaii Medical Service Association Commercial	$23,780.68
Rate for Payer: Hawaii Medical Service Association Medicare	$31,746.69
Rate for Payer: Humana Medicare	$31,746.69
Rate for Payer: Kaiser Permanente Commercial	$48,146.47
Rate for Payer: Kaiser Permanente Medicare	$31,746.69
Rate for Payer: Ohana Health Plan Medicare	$31,746.69
Rate for Payer: UnitedHealthcare Medicare	$31,746.69

Know your out-of-pocket cost for care.

All Charges