Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

MEDIAL MALLEOLAR SLED

Facility

$2,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$1,122.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,090.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$1,386.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: University Health Alliance Commercial	$1,603.58

MEDIAL MALLEOLAR SLED

Facility

$2,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$1,870.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: MDX Hawaii PPO	$2,134.00

MEDICAL BACK PROBLEMS WITH MCC

Facility

$28,912.72

Service Code	MSDRG 551
Min. Negotiated Rate	$14,996.39
Max. Negotiated Rate	$28,912.72
Rate for Payer: AlohaCare Medicare	$19,064.39
Rate for Payer: Devoted Health Medicare	$20,970.83
Rate for Payer: Hawaii Medical Service Association Commercial	$14,996.39
Rate for Payer: Hawaii Medical Service Association Medicare	$19,064.39
Rate for Payer: Humana Medicare	$19,064.39
Rate for Payer: Kaiser Permanente Commercial	$28,912.72
Rate for Payer: Kaiser Permanente Medicare	$19,064.39
Rate for Payer: Ohana Health Plan Medicare	$19,064.39
Rate for Payer: UnitedHealthcare Medicare	$19,064.39

MEDICAL BACK PROBLEMS WITHOUT MCC

Facility

$16,582.42

Service Code	MSDRG 552
Min. Negotiated Rate	$10,934.08
Max. Negotiated Rate	$16,582.42
Rate for Payer: AlohaCare Medicare	$10,934.08
Rate for Payer: Devoted Health Medicare	$12,027.49
Rate for Payer: Hawaii Medical Service Association Commercial	$14,996.39
Rate for Payer: Hawaii Medical Service Association Medicare	$10,934.08
Rate for Payer: Humana Medicare	$10,934.08
Rate for Payer: Kaiser Permanente Commercial	$16,582.42
Rate for Payer: Kaiser Permanente Medicare	$10,934.08
Rate for Payer: Ohana Health Plan Medicare	$10,934.08
Rate for Payer: UnitedHealthcare Medicare	$10,934.08

MEDL MALLE SLED 35MM MMSLED-35

Facility

$2,895.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,621.20
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

MEDL MALLE SLED 35MM MMSLED-35

Facility

$2,895.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.45
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: Kaiser Permanente Commercial	$1,823.85
Rate for Payer: Kaiser Permanente Medicaid	$1,476.45
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

MEDL MALLE SLED 42MM MMSLED-42

Facility

$2,895.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,621.20
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

MEDL MALLE SLED 42MM MMSLED-42

Facility

$2,895.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.45
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: Kaiser Permanente Commercial	$1,823.85
Rate for Payer: Kaiser Permanente Medicaid	$1,476.45
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

MEDL MALLE SLED WASHER MMSLEDW

Facility

$788.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$401.88
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Hawaii Western Management Group Commercial	$551.60
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Kaiser Permanente Commercial	$496.44
Rate for Payer: Kaiser Permanente Medicaid	$401.88
Rate for Payer: MDX Hawaii PPO	$764.36
Rate for Payer: University Health Alliance Commercial	$441.28

MEDL MALLE SLED WASHER MMSLEDW

Facility

$788.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$441.28
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Hawaii Western Management Group Commercial	$551.60
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: MDX Hawaii PPO	$764.36
Rate for Payer: University Health Alliance Commercial	$441.28

MEDROXYPROGESTERONE 10 MG TABLET [4854]

Facility

$2.00

Service Code	NDC 00555077902
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

MEDROXYPROGESTERONE 10 MG TABLET [4854]

Facility

$2.00

Service Code	NDC 00555077902
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

MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION [19736]

Facility

$104.00

Service Code	HCPCS J1050
Hospital Revenue Code	250
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$117.60
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Health Management Network Commercial	$166.60
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: MDX Hawaii PPO	$190.12

MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE [134069]

Facility

$168.00

Service Code	HCPCS J1050
Hospital Revenue Code	250
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$103.80
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: MDX Hawaii PPO	$167.81

MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE [134069]

Facility

$173.00

Service Code	HCPCS J1050
Hospital Revenue Code	636
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$167.81
Rate for Payer: Cash Price	$103.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$103.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.57
Rate for Payer: Hawaii Medical Service Association ABD	$0.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.57
Rate for Payer: Hawaii Western Management Group Commercial	$159.60
Rate for Payer: Hawaii Western Management Group Commercial	$164.35
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Kaiser Permanente Commercial	$105.84
Rate for Payer: Kaiser Permanente Commercial	$108.99
Rate for Payer: Kaiser Permanente Medicaid	$88.23
Rate for Payer: Kaiser Permanente Medicaid	$85.68
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: MDX Hawaii PPO	$167.81
Rate for Payer: UnitedHealthcare Medicaid	$100.80
Rate for Payer: UnitedHealthcare Medicaid	$103.80
Rate for Payer: University Health Alliance Commercial	$122.46
Rate for Payer: University Health Alliance Commercial	$126.10

MEDROXYPROGESTERONE 2.5 MG TABLET [4855]

Facility

$2.00

Service Code	NDC 00555087202
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

MEDROXYPROGESTERONE 2.5 MG TABLET [4855]

Facility

$2.00

Service Code	NDC 00555087202
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

MEDULLARY XCHANGE TUBE 355.006

Facility

$356.00

Hospital Revenue Code	272
Min. Negotiated Rate	$302.60
Max. Negotiated Rate	$345.32
Rate for Payer: Cash Price	$213.60
Rate for Payer: Health Management Network Commercial	$302.60
Rate for Payer: MDX Hawaii PPO	$345.32

MEDULLARY XCHANGE TUBE 355.006

Facility

$356.00

Hospital Revenue Code	272
Min. Negotiated Rate	$181.56
Max. Negotiated Rate	$345.32
Rate for Payer: Cash Price	$213.60
Rate for Payer: Hawaii Western Management Group Commercial	$338.20
Rate for Payer: Health Management Network Commercial	$302.60
Rate for Payer: Kaiser Permanente Commercial	$224.28
Rate for Payer: Kaiser Permanente Medicaid	$181.56
Rate for Payer: MDX Hawaii PPO	$345.32
Rate for Payer: University Health Alliance Commercial	$259.49

MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION [76824]

Facility

$20.00

Service Code	NDC 68094006359
Hospital Revenue Code	250
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: MDX Hawaii PPO	$19.40

MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION [76824]

Facility

$22.00

Service Code	NDC 69339016016
Hospital Revenue Code	250
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: MDX Hawaii PPO	$21.34

MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION [76824]

Facility

$20.00

Service Code	NDC 68094006359
Hospital Revenue Code	637
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Hawaii Western Management Group Commercial	$19.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$10.20
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: University Health Alliance Commercial	$14.58

MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION [76824]

Facility

$22.00

Service Code	NDC 69339016016
Hospital Revenue Code	637
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Kaiser Permanente Commercial	$13.86
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: University Health Alliance Commercial	$16.04

MEGESTROL 40 MG TABLET [4871]

Facility

$6.00

Service Code	NDC 00555060702
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

MEGESTROL 40 MG TABLET [4871]

Facility

$6.00

Service Code	NDC 00555060702
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

Know your out-of-pocket cost for care.

All Charges