Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 15221
Hospital Revenue Code	360
Min. Negotiated Rate	$65.26
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$65.26

FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, TRUNK; 20 SQ CM OR LESS

Facility

$6,743.44

Service Code	CPT 15200
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45
Rate for Payer: University Health Alliance Commercial	$6,743.44

FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, TRUNK; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 15201
Hospital Revenue Code	360
Min. Negotiated Rate	$72.61
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$72.61

FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE [187815]

Facility

$300.00

Service Code	HCPCS J9395
Hospital Revenue Code	250
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: MDX Hawaii PPO	$145.50

FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE [187815]

Facility

$150.00

Service Code	HCPCS J9395
Hospital Revenue Code	636
Min. Negotiated Rate	$6.98
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Hawaii Medical Service Association ABD	$6.98
Rate for Payer: Hawaii Medical Service Association ABD	$6.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.98
Rate for Payer: Hawaii Western Management Group Commercial	$142.50
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: Kaiser Permanente Commercial	$94.50
Rate for Payer: Kaiser Permanente Medicaid	$76.50
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: MDX Hawaii PPO	$145.50
Rate for Payer: UnitedHealthcare Medicaid	$90.00
Rate for Payer: UnitedHealthcare Medicaid	$180.00
Rate for Payer: University Health Alliance Commercial	$218.67
Rate for Payer: University Health Alliance Commercial	$109.33

FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]

Facility

$13.00

Service Code	HCPCS J1938
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$15.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Hawaii Western Management Group Commercial	$23.75
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$8.19
Rate for Payer: Kaiser Permanente Commercial	$11.34
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Commercial	$15.75
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Commercial	$7.56
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: UnitedHealthcare Medicaid	$7.80
Rate for Payer: UnitedHealthcare Medicaid	$6.60
Rate for Payer: UnitedHealthcare Medicaid	$7.20
Rate for Payer: UnitedHealthcare Medicaid	$3.00
Rate for Payer: UnitedHealthcare Medicaid	$15.00
Rate for Payer: University Health Alliance Commercial	$3.64
Rate for Payer: University Health Alliance Commercial	$13.12
Rate for Payer: University Health Alliance Commercial	$9.48
Rate for Payer: University Health Alliance Commercial	$8.02
Rate for Payer: University Health Alliance Commercial	$18.22
Rate for Payer: University Health Alliance Commercial	$8.75

FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]

Facility

$13.00

Service Code	HCPCS J1938
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$15.00
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: MDX Hawaii PPO	$17.46

FUROSEMIDE 10 MG/ML ORAL SOLUTION [3292]

Facility

$45.00

Service Code	NDC 00054329450
Hospital Revenue Code	250
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$27.00
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: MDX Hawaii PPO	$43.65

FUROSEMIDE 10 MG/ML ORAL SOLUTION [3292]

Facility

$28.00

Service Code	NDC 00054329446
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

FUROSEMIDE 10 MG/ML ORAL SOLUTION [3292]

Facility

$28.00

Service Code	NDC 00054329446
Hospital Revenue Code	637
Min. Negotiated Rate	$14.28
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
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: University Health Alliance Commercial	$20.41

FUROSEMIDE 10 MG/ML ORAL SOLUTION [3292]

Facility

$45.00

Service Code	NDC 00054329450
Hospital Revenue Code	637
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$27.00
Rate for Payer: Hawaii Western Management Group Commercial	$42.75
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$28.35
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: University Health Alliance Commercial	$32.80

FUROSEMIDE 20 MG TABLET [3294]

Facility

$1.00

Service Code	NDC 00904717761
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

FUROSEMIDE 20 MG TABLET [3294]

Facility

$1.00

Service Code	NDC 00904717761
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

FUROSEMIDE 40 MG TABLET [3295]

Facility

$1.00

Service Code	NDC 69315011701
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

FUROSEMIDE 40 MG TABLET [3295]

Facility

$1.00

Service Code	NDC 00904717861
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

FUROSEMIDE 40 MG TABLET [3295]

Facility

$1.00

Service Code	NDC 69315011701
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

FUROSEMIDE 40 MG TABLET [3295]

Facility

$1.00

Service Code	NDC 00904717861
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

FUROSEMIDE 80 MG TABLET [3296]

Facility

$2.00

Service Code	NDC 69315011801
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

FUROSEMIDE 80 MG TABLET [3296]

Facility

$2.00

Service Code	NDC 69315011801
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

FUROSEMIDE 80 MG TABLET [3296]

Facility

$6.00

Service Code	NDC 00054830125
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

FUROSEMIDE 80 MG TABLET [3296]

Facility

$6.00

Service Code	NDC 00054830125
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

FUROSEMIDE TABLETS (LASIX) 20 MG (TAKE HOME) [4080362]

Facility

$15.00

Service Code	NDC 00004080150
Hospital Revenue Code	253
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

FUROSEMIDE TABLETS (LASIX) 20 MG (TAKE HOME) [4080362]

Facility

$15.00

Service Code	NDC 00004080150
Hospital Revenue Code	253
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

FUSION CUP 10 HOLE 18MM FC10

Facility

$2,780.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,556.80
Max. Negotiated Rate	$2,696.60
Rate for Payer: Cash Price	$1,668.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,946.00
Rate for Payer: Health Management Network Commercial	$2,363.00
Rate for Payer: MDX Hawaii PPO	$2,696.60
Rate for Payer: University Health Alliance Commercial	$1,556.80

FUSION CUP 10 HOLE 18MM FC10

Facility

$2,780.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,417.80
Max. Negotiated Rate	$2,696.60
Rate for Payer: Cash Price	$1,668.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,946.00
Rate for Payer: Health Management Network Commercial	$2,363.00
Rate for Payer: Kaiser Permanente Commercial	$1,751.40
Rate for Payer: Kaiser Permanente Medicaid	$1,417.80
Rate for Payer: MDX Hawaii PPO	$2,696.60
Rate for Payer: University Health Alliance Commercial	$1,556.80

Know your out-of-pocket cost for care.

All Charges