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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

FEBUXOSTAT 40 MG TABLET [97133]

Facility

IP

$30.00

Service Code	NDC 33342027407
Hospital Revenue Code	250
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$27.00
Rate for Payer: MDX Hawaii PPO	$29.10

FEBUXOSTAT 40 MG TABLET [97133]

Facility

OP

$30.00

Service Code	NDC 33342027407
Hospital Revenue Code	637
Min. Negotiated Rate	$15.00
Max. Negotiated Rate	$29.10
Rate for Payer: AlohaCare Medicaid	$15.00
Rate for Payer: AlohaCare Medicare	$22.80
Rate for Payer: Cash Price	$18.00
Rate for Payer: Devoted Health Medicare	$25.20
Rate for Payer: Hawaii Medical Service Association Medicare	$22.80
Rate for Payer: Hawaii Western Management Group Commercial	$28.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Humana Medicare	$22.80
Rate for Payer: Kaiser Permanente Commercial	$27.00
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: Kaiser Permanente Medicare	$22.80
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: Ohana Health Plan Medicaid	$22.80
Rate for Payer: Ohana Health Plan Medicare	$22.80
Rate for Payer: UnitedHealthcare Medicare	$22.80
Rate for Payer: University Health Alliance Commercial	$21.87

FEBUXOSTAT 40 MG TABLET [97133]

Facility

IP

$31.00

Service Code	NDC 62332019030
Hospital Revenue Code	250
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: MDX Hawaii PPO	$30.07

FEBUXOSTAT 40 MG TABLET [97133]

Facility

IP

$34.00

Service Code	NDC 64764091830
Hospital Revenue Code	250
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$20.40
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98

FEBUXOSTAT 40 MG TABLET [97133]

Facility

OP

$31.00

Service Code	NDC 62332019030
Hospital Revenue Code	637
Min. Negotiated Rate	$15.50
Max. Negotiated Rate	$30.07
Rate for Payer: AlohaCare Medicaid	$15.50
Rate for Payer: AlohaCare Medicare	$23.56
Rate for Payer: Cash Price	$18.60
Rate for Payer: Devoted Health Medicare	$26.04
Rate for Payer: Hawaii Medical Service Association Medicare	$23.56
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Humana Medicare	$23.56
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicare	$23.56
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: Ohana Health Plan Medicaid	$23.56
Rate for Payer: Ohana Health Plan Medicare	$23.56
Rate for Payer: UnitedHealthcare Medicare	$23.56
Rate for Payer: University Health Alliance Commercial	$22.60

FEBUXOSTAT 40 MG TABLET [97133]

Facility

OP

$34.00

Service Code	NDC 64764091830
Hospital Revenue Code	637
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$32.98
Rate for Payer: AlohaCare Medicaid	$17.00
Rate for Payer: AlohaCare Medicare	$25.84
Rate for Payer: Cash Price	$20.40
Rate for Payer: Devoted Health Medicare	$28.56
Rate for Payer: Hawaii Medical Service Association Medicare	$25.84
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Humana Medicare	$25.84
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: Kaiser Permanente Medicare	$25.84
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: Ohana Health Plan Medicaid	$25.84
Rate for Payer: Ohana Health Plan Medicare	$25.84
Rate for Payer: UnitedHealthcare Medicare	$25.84
Rate for Payer: University Health Alliance Commercial	$24.78

FEBUXOSTAT 80 MG TABLET [97134]

Facility

IP

$31.00

Service Code	NDC 62332019130
Hospital Revenue Code	250
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: MDX Hawaii PPO	$30.07

FEBUXOSTAT 80 MG TABLET [97134]

Facility

OP

$31.00

Service Code	NDC 62332019130
Hospital Revenue Code	637
Min. Negotiated Rate	$15.50
Max. Negotiated Rate	$30.07
Rate for Payer: AlohaCare Medicaid	$15.50
Rate for Payer: AlohaCare Medicare	$23.56
Rate for Payer: Cash Price	$18.60
Rate for Payer: Devoted Health Medicare	$26.04
Rate for Payer: Hawaii Medical Service Association Medicare	$23.56
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Humana Medicare	$23.56
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicare	$23.56
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: Ohana Health Plan Medicaid	$23.56
Rate for Payer: Ohana Health Plan Medicare	$23.56
Rate for Payer: UnitedHealthcare Medicare	$23.56
Rate for Payer: University Health Alliance Commercial	$22.60

FEEDING TUBE 18FR 0200-18

Facility

OP

$529.00

Hospital Revenue Code	272
Min. Negotiated Rate	$264.50
Max. Negotiated Rate	$513.13
Rate for Payer: AlohaCare Medicaid	$264.50
Rate for Payer: AlohaCare Medicare	$402.04
Rate for Payer: Cash Price	$317.40
Rate for Payer: Devoted Health Medicare	$444.36
Rate for Payer: Hawaii Medical Service Association Medicare	$402.04
Rate for Payer: Hawaii Western Management Group Commercial	$502.55
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: Humana Medicare	$402.04
Rate for Payer: Kaiser Permanente Commercial	$476.10
Rate for Payer: Kaiser Permanente Medicaid	$269.79
Rate for Payer: Kaiser Permanente Medicare	$402.04
Rate for Payer: MDX Hawaii PPO	$513.13
Rate for Payer: Ohana Health Plan Medicaid	$402.04
Rate for Payer: Ohana Health Plan Medicare	$402.04
Rate for Payer: UnitedHealthcare Medicare	$402.04
Rate for Payer: University Health Alliance Commercial	$385.59

FEEDING TUBE 18FR 0200-18

Facility

IP

$529.00

Hospital Revenue Code	272
Min. Negotiated Rate	$449.65
Max. Negotiated Rate	$513.13
Rate for Payer: Cash Price	$317.40
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: Kaiser Permanente Commercial	$476.10
Rate for Payer: MDX Hawaii PPO	$513.13

FEEDING TUBE 20FR 0200-20

Facility

OP

$536.00

Hospital Revenue Code	272
Min. Negotiated Rate	$268.00
Max. Negotiated Rate	$519.92
Rate for Payer: AlohaCare Medicaid	$268.00
Rate for Payer: AlohaCare Medicare	$407.36
Rate for Payer: Cash Price	$321.60
Rate for Payer: Devoted Health Medicare	$450.24
Rate for Payer: Hawaii Medical Service Association Medicare	$407.36
Rate for Payer: Hawaii Western Management Group Commercial	$509.20
Rate for Payer: Health Management Network Commercial	$455.60
Rate for Payer: Humana Medicare	$407.36
Rate for Payer: Kaiser Permanente Commercial	$482.40
Rate for Payer: Kaiser Permanente Medicaid	$273.36
Rate for Payer: Kaiser Permanente Medicare	$407.36
Rate for Payer: MDX Hawaii PPO	$519.92
Rate for Payer: Ohana Health Plan Medicaid	$407.36
Rate for Payer: Ohana Health Plan Medicare	$407.36
Rate for Payer: UnitedHealthcare Medicare	$407.36
Rate for Payer: University Health Alliance Commercial	$390.69

FEEDING TUBE 20FR 0200-20

Facility

IP

$536.00

Hospital Revenue Code	272
Min. Negotiated Rate	$455.60
Max. Negotiated Rate	$519.92
Rate for Payer: Cash Price	$321.60
Rate for Payer: Health Management Network Commercial	$455.60
Rate for Payer: Kaiser Permanente Commercial	$482.40
Rate for Payer: MDX Hawaii PPO	$519.92

FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES

Facility

IP

$18,203.14

Service Code	MSDRG 748
Min. Negotiated Rate	$18,203.14
Max. Negotiated Rate	$18,203.14
Rate for Payer: Hawaii Medical Service Association Commercial	$18,203.14

FEM CNL PRESS MED 206-566-000

Facility

OP

$138.00

Hospital Revenue Code	272
Min. Negotiated Rate	$69.00
Max. Negotiated Rate	$133.86
Rate for Payer: AlohaCare Medicaid	$69.00
Rate for Payer: AlohaCare Medicare	$104.88
Rate for Payer: Cash Price	$82.80
Rate for Payer: Devoted Health Medicare	$115.92
Rate for Payer: Hawaii Medical Service Association Medicare	$104.88
Rate for Payer: Hawaii Western Management Group Commercial	$131.10
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Humana Medicare	$104.88
Rate for Payer: Kaiser Permanente Commercial	$124.20
Rate for Payer: Kaiser Permanente Medicaid	$70.38
Rate for Payer: Kaiser Permanente Medicare	$104.88
Rate for Payer: MDX Hawaii PPO	$133.86
Rate for Payer: Ohana Health Plan Medicaid	$104.88
Rate for Payer: Ohana Health Plan Medicare	$104.88
Rate for Payer: UnitedHealthcare Medicare	$104.88
Rate for Payer: University Health Alliance Commercial	$100.59

FEM CNL PRESS MED 206-566-000

Facility

IP

$138.00

Hospital Revenue Code	272
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$133.86
Rate for Payer: Cash Price	$82.80
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Kaiser Permanente Commercial	$124.20
Rate for Payer: MDX Hawaii PPO	$133.86

FEM HEAD 36/+0 00-8775-036-02

Facility

IP

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,456.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

FEM HEAD 36/+0 00-8775-036-02

Facility

OP

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,300.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: AlohaCare Medicaid	$1,300.00
Rate for Payer: AlohaCare Medicare	$1,976.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Devoted Health Medicare	$2,184.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,976.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Humana Medicare	$1,976.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: Kaiser Permanente Medicaid	$1,326.00
Rate for Payer: Kaiser Permanente Medicare	$1,976.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: Ohana Health Plan Medicaid	$1,976.00
Rate for Payer: Ohana Health Plan Medicare	$1,976.00
Rate for Payer: UnitedHealthcare Medicare	$1,976.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

FEM HEAD 40/+0 00-8775-040-02

Facility

IP

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,456.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

FEM HEAD 40/+0 00-8775-040-02

Facility

OP

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,300.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: AlohaCare Medicaid	$1,300.00
Rate for Payer: AlohaCare Medicare	$1,976.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Devoted Health Medicare	$2,184.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,976.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Humana Medicare	$1,976.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: Kaiser Permanente Medicaid	$1,326.00
Rate for Payer: Kaiser Permanente Medicare	$1,976.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: Ohana Health Plan Medicaid	$1,976.00
Rate for Payer: Ohana Health Plan Medicare	$1,976.00
Rate for Payer: UnitedHealthcare Medicare	$1,976.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

FEM HED 36/-3.5 00-8775-036-01

Facility

OP

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,300.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: AlohaCare Medicaid	$1,300.00
Rate for Payer: AlohaCare Medicare	$1,976.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Devoted Health Medicare	$2,184.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,976.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Humana Medicare	$1,976.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: Kaiser Permanente Medicaid	$1,326.00
Rate for Payer: Kaiser Permanente Medicare	$1,976.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: Ohana Health Plan Medicaid	$1,976.00
Rate for Payer: Ohana Health Plan Medicare	$1,976.00
Rate for Payer: UnitedHealthcare Medicare	$1,976.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

FEM HED 36/-3.5 00-8775-036-01

Facility

IP

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,456.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Kaiser Permanente Commercial	$2,340.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

FEM KNE SZ:D/RT 00-5956-014-02

Facility

OP

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,500.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: AlohaCare Medicaid	$2,500.00
Rate for Payer: AlohaCare Medicare	$3,800.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Devoted Health Medicare	$4,200.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Humana Medicare	$3,800.00
Rate for Payer: Kaiser Permanente Commercial	$4,500.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: Kaiser Permanente Medicare	$3,800.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: Ohana Health Plan Medicaid	$3,800.00
Rate for Payer: Ohana Health Plan Medicare	$3,800.00
Rate for Payer: UnitedHealthcare Medicare	$3,800.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

FEM KNE SZ:D/RT 00-5956-014-02

Facility

IP

$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: Kaiser Permanente Commercial	$4,500.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

FEMORAL #6 RETAIN 5517-F-602

Facility

IP

$5,947.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,330.32
Max. Negotiated Rate	$5,768.59
Rate for Payer: Cash Price	$3,568.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,162.90
Rate for Payer: Health Management Network Commercial	$5,054.95
Rate for Payer: Kaiser Permanente Commercial	$5,352.30
Rate for Payer: MDX Hawaii PPO	$5,768.59
Rate for Payer: University Health Alliance Commercial	$3,330.32

FEMORAL #6 RETAIN 5517-F-602

Facility

OP

$5,947.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,973.50
Max. Negotiated Rate	$5,768.59
Rate for Payer: AlohaCare Medicaid	$2,973.50
Rate for Payer: AlohaCare Medicare	$4,519.72
Rate for Payer: Cash Price	$3,568.20
Rate for Payer: Devoted Health Medicare	$4,995.48
Rate for Payer: Hawaii Medical Service Association Medicare	$4,519.72
Rate for Payer: Hawaii Western Management Group Commercial	$4,162.90
Rate for Payer: Health Management Network Commercial	$5,054.95
Rate for Payer: Humana Medicare	$4,519.72
Rate for Payer: Kaiser Permanente Commercial	$5,352.30
Rate for Payer: Kaiser Permanente Medicaid	$3,032.97
Rate for Payer: Kaiser Permanente Medicare	$4,519.72
Rate for Payer: MDX Hawaii PPO	$5,768.59
Rate for Payer: Ohana Health Plan Medicaid	$4,519.72
Rate for Payer: Ohana Health Plan Medicare	$4,519.72
Rate for Payer: UnitedHealthcare Medicare	$4,519.72
Rate for Payer: University Health Alliance Commercial	$3,330.32

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