Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

OXACILLIN SODIUM 1 G/10ML IJ (WET SOLR VIAL) [4305924]

Facility

$8.00

Service Code	HCPCS J2700
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: MDX Hawaii PPO	$32.01

OXACILLIN SODIUM 2 G/20ML IJ (WET SOLR VIAL) [4305926]

Facility

$33.00

Service Code	HCPCS J2700
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: MDX Hawaii PPO	$32.01

OXACILLIN SODIUM 2 G/20ML IJ (WET SOLR VIAL) [4305926]

Facility

$33.00

Service Code	HCPCS J2700
Hospital Revenue Code	636
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cash Price	$19.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.82
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$20.79
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: UnitedHealthcare Medicaid	$19.80
Rate for Payer: University Health Alliance Commercial	$24.05

OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION [99612]

Facility

$105.00

Service Code	HCPCS J9263
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$101.85
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$271.80
Rate for Payer: Cash Price	$271.80
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cash Price	$50.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Western Management Group Commercial	$99.75
Rate for Payer: Hawaii Western Management Group Commercial	$342.00
Rate for Payer: Hawaii Western Management Group Commercial	$430.35
Rate for Payer: Hawaii Western Management Group Commercial	$79.80
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: Health Management Network Commercial	$385.05
Rate for Payer: Health Management Network Commercial	$89.25
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Kaiser Permanente Commercial	$285.39
Rate for Payer: Kaiser Permanente Commercial	$226.80
Rate for Payer: Kaiser Permanente Commercial	$66.15
Rate for Payer: Kaiser Permanente Commercial	$52.92
Rate for Payer: Kaiser Permanente Medicaid	$183.60
Rate for Payer: Kaiser Permanente Medicaid	$53.55
Rate for Payer: Kaiser Permanente Medicaid	$231.03
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: MDX Hawaii PPO	$439.41
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: MDX Hawaii PPO	$349.20
Rate for Payer: MDX Hawaii PPO	$101.85
Rate for Payer: UnitedHealthcare Medicaid	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$216.00
Rate for Payer: UnitedHealthcare Medicaid	$271.80
Rate for Payer: UnitedHealthcare Medicaid	$50.40
Rate for Payer: University Health Alliance Commercial	$76.53
Rate for Payer: University Health Alliance Commercial	$262.40
Rate for Payer: University Health Alliance Commercial	$61.23
Rate for Payer: University Health Alliance Commercial	$330.19

OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION [99612]

Facility

$105.00

Service Code	HCPCS J9263
Hospital Revenue Code	250
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$101.85
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$271.80
Rate for Payer: Cash Price	$50.40
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Health Management Network Commercial	$89.25
Rate for Payer: Health Management Network Commercial	$385.05
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: MDX Hawaii PPO	$349.20
Rate for Payer: MDX Hawaii PPO	$439.41
Rate for Payer: MDX Hawaii PPO	$101.85

OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [99610]

Facility

$105.00

Service Code	HCPCS J9263
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$101.85
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Western Management Group Commercial	$171.00
Rate for Payer: Hawaii Western Management Group Commercial	$99.75
Rate for Payer: Health Management Network Commercial	$89.25
Rate for Payer: Health Management Network Commercial	$153.00
Rate for Payer: Kaiser Permanente Commercial	$66.15
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$91.80
Rate for Payer: Kaiser Permanente Medicaid	$53.55
Rate for Payer: MDX Hawaii PPO	$174.60
Rate for Payer: MDX Hawaii PPO	$101.85
Rate for Payer: UnitedHealthcare Medicaid	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$108.00
Rate for Payer: University Health Alliance Commercial	$76.53
Rate for Payer: University Health Alliance Commercial	$131.20

OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [99610]

Facility

$105.00

Service Code	HCPCS J9263
Hospital Revenue Code	250
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$101.85
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Health Management Network Commercial	$153.00
Rate for Payer: Health Management Network Commercial	$89.25
Rate for Payer: MDX Hawaii PPO	$174.60
Rate for Payer: MDX Hawaii PPO	$101.85

OX ANAT BRG SIZE 4 PMA 159548

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OX ANAT BRG SIZE 4 PMA 159548

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXF ANAT BRG LT GL SZ-3 159554

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXF ANAT BRG LT GL SZ-3 159554

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXF ANAT BRG LT LG5 PMA 159556

Facility

$2,649.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,350.99
Max. Negotiated Rate	$2,569.53
Rate for Payer: Cash Price	$1,589.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,854.30
Rate for Payer: Health Management Network Commercial	$2,251.65
Rate for Payer: Kaiser Permanente Commercial	$1,668.87
Rate for Payer: Kaiser Permanente Medicaid	$1,350.99
Rate for Payer: MDX Hawaii PPO	$2,569.53
Rate for Payer: University Health Alliance Commercial	$1,483.44

OXF ANAT BRG LT LG5 PMA 159556

Facility

$2,649.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,483.44
Max. Negotiated Rate	$2,569.53
Rate for Payer: Cash Price	$1,589.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,854.30
Rate for Payer: Health Management Network Commercial	$2,251.65
Rate for Payer: MDX Hawaii PPO	$2,569.53
Rate for Payer: University Health Alliance Commercial	$1,483.44

OXF ANAT BRG RT LG SZ9 159588

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

OXF ANAT BRG RT LG SZ9 159588

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,453.50
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$1,795.50
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

OXFANAT BRG RT MD SZ 6 159578

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXFANAT BRG RT MD SZ 6 159578

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXF ANAT BRG RT SM3 PMA 159568

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,453.50
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$1,795.50
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

OXF ANAT BRG RT SM3 PMA 159568

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

OXFORD ANAT BRG RT LG SZ3

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXFORD ANAT BRG RT LG SZ3

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXFORD BEARING LT MD 6MM

Facility

$2,649.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,483.44
Max. Negotiated Rate	$2,569.53
Rate for Payer: Cash Price	$1,589.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,854.30
Rate for Payer: Health Management Network Commercial	$2,251.65
Rate for Payer: MDX Hawaii PPO	$2,569.53
Rate for Payer: University Health Alliance Commercial	$1,483.44

OXFORD BEARING LT MD 6MM

Facility

$2,649.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,350.99
Max. Negotiated Rate	$2,569.53
Rate for Payer: Cash Price	$1,589.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,854.30
Rate for Payer: Health Management Network Commercial	$2,251.65
Rate for Payer: Kaiser Permanente Commercial	$1,668.87
Rate for Payer: Kaiser Permanente Medicaid	$1,350.99
Rate for Payer: MDX Hawaii PPO	$2,569.53
Rate for Payer: University Health Alliance Commercial	$1,483.44

OXFORD BEARING MD 3MM #159575

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXFORD BEARING MD 3MM #159575

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

Know your out-of-pocket cost for care.

All Charges