Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TRI HA ACETAB 64MM 542-11-64H

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,965.14
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$3,662.82
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 64MM 542-11-64H

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 66MM 542-11-66I

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,965.14
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$3,662.82
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 66MM 542-11-66I

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 68MM 542-11-68I

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 68MM 542-11-68I

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,965.14
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$3,662.82
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 70MM 542-11-70J

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,965.14
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$3,662.82
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 70MM 542-11-70J

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 72MM 542-11-72J

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,965.14
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$3,662.82
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 72MM 542-11-72J

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRIHEXYPHENIDYL 2 MG TABLET [8166]

Facility

$1.00

Service Code	NDC 00591533501
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

TRIHEXYPHENIDYL 2 MG TABLET [8166]

Facility

$1.00

Service Code	NDC 00591533501
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

TRI-LUMEN FILTER ASM-EVAC1-BI

Facility

$420.00

Hospital Revenue Code	272
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$407.40
Rate for Payer: Cash Price	$252.00
Rate for Payer: Hawaii Western Management Group Commercial	$399.00
Rate for Payer: Health Management Network Commercial	$357.00
Rate for Payer: Kaiser Permanente Commercial	$264.60
Rate for Payer: Kaiser Permanente Medicaid	$214.20
Rate for Payer: MDX Hawaii PPO	$407.40
Rate for Payer: University Health Alliance Commercial	$306.14

TRI-LUMEN FILTER ASM-EVAC1-BI

Facility

$420.00

Hospital Revenue Code	272
Min. Negotiated Rate	$357.00
Max. Negotiated Rate	$407.40
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Management Network Commercial	$357.00
Rate for Payer: MDX Hawaii PPO	$407.40

TRIMETHOPRIM 100 MG TABLET [8182]

Facility

$9.00

Service Code	NDC 70954054110
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

TRIMETHOPRIM 100 MG TABLET [8182]

Facility

$9.00

Service Code	NDC 75907004301
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

TRIMETHOPRIM 100 MG TABLET [8182]

Facility

$9.00

Service Code	NDC 70954054110
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

TRIMETHOPRIM 100 MG TABLET [8182]

Facility

$9.00

Service Code	NDC 75907004301
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

TRIPORT CANNU 2 4X22 PAL-402LS

Facility

$300.00

Hospital Revenue Code	272
Min. Negotiated Rate	$153.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: University Health Alliance Commercial	$218.67

TRIPORT CANNU 2 4X22 PAL-402LS

Facility

$300.00

Hospital Revenue Code	272
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: MDX Hawaii PPO	$291.00

TRIPORT HELIXED 5X22 PAL-507LS

Facility

$300.00

Hospital Revenue Code	272
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: MDX Hawaii PPO	$291.00

TRIPORT HELIXED 5X22 PAL-507LS

Facility

$300.00

Hospital Revenue Code	272
Min. Negotiated Rate	$153.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: University Health Alliance Commercial	$218.67

TRITANIUM CUP 50MM 502-03-50D

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,816.64
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

TRITANIUM CUP 50MM 502-03-50D

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,654.44
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Kaiser Permanente Commercial	$2,043.72
Rate for Payer: Kaiser Permanente Medicaid	$1,654.44
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

TRITANIUM CUP 52MM 502-03-52D

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,816.64
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

Know your out-of-pocket cost for care.

All Charges