Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

METRONIDAZOLE 500 MG TABLET [5016]

Facility

$4.00

Service Code	NDC 60687055011
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

METRONIDAZOLE 500 MG TABLET [5016]

Facility

$4.00

Service Code	NDC 60687055011
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.92

METRONIDAZOLE 500 MG TABLET [5016]

Facility

$4.00

Service Code	NDC 60687055001
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.92

METRONIDAZOLE TABLETS (FLAGYL) 500 MG (TAKE HOME) [4080376]

Facility

$15.00

Service Code	NDC 00004080164
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

METRONIDAZOLE TABLETS (FLAGYL) 500 MG (TAKE HOME) [4080376]

Facility

$15.00

Service Code	NDC 00004080164
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

MEXILETINE 150 MG CAPSULE [10595]

Facility

$9.00

Service Code	NDC 00093873901
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

MEXILETINE 150 MG CAPSULE [10595]

Facility

$9.00

Service Code	NDC 50742023901
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

MEXILETINE 150 MG CAPSULE [10595]

Facility

$9.00

Service Code	NDC 00093873901
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

MEXILETINE 150 MG CAPSULE [10595]

Facility

$9.00

Service Code	NDC 50742023901
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

MIC G-12 LAP INTRODUCER KIT

Facility

$877.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$745.45
Max. Negotiated Rate	$850.69
Rate for Payer: Cash Price	$526.20
Rate for Payer: Health Management Network Commercial	$745.45
Rate for Payer: MDX Hawaii PPO	$850.69

MIC G-12 LAP INTRODUCER KIT

Facility

$877.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$447.27
Max. Negotiated Rate	$850.69
Rate for Payer: Cash Price	$526.20
Rate for Payer: Hawaii Western Management Group Commercial	$833.15
Rate for Payer: Health Management Network Commercial	$745.45
Rate for Payer: Kaiser Permanente Commercial	$552.51
Rate for Payer: Kaiser Permanente Medicaid	$447.27
Rate for Payer: MDX Hawaii PPO	$850.69
Rate for Payer: University Health Alliance Commercial	$639.25

MIC G-24 LAP INTRODUCER KIT

Facility

$930.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$790.50
Max. Negotiated Rate	$902.10
Rate for Payer: Cash Price	$558.00
Rate for Payer: Health Management Network Commercial	$790.50
Rate for Payer: MDX Hawaii PPO	$902.10

MIC G-24 LAP INTRODUCER KIT

Facility

$930.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$474.30
Max. Negotiated Rate	$902.10
Rate for Payer: Cash Price	$558.00
Rate for Payer: Hawaii Western Management Group Commercial	$883.50
Rate for Payer: Health Management Network Commercial	$790.50
Rate for Payer: Kaiser Permanente Commercial	$585.90
Rate for Payer: Kaiser Permanente Medicaid	$474.30
Rate for Payer: MDX Hawaii PPO	$902.10
Rate for Payer: University Health Alliance Commercial	$677.88

MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]

Facility

$26.00

Service Code	NDC 51672200102
Hospital Revenue Code	637
Min. Negotiated Rate	$13.26
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$15.60
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$16.38
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: University Health Alliance Commercial	$18.95

MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]

Facility

$26.00

Service Code	NDC 51672200102
Hospital Revenue Code	250
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: MDX Hawaii PPO	$25.22

MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]

Facility

$10.00

Service Code	NDC 68001048145
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: MDX Hawaii PPO	$9.70

MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]

Facility

$10.00

Service Code	NDC 68001048145
Hospital Revenue Code	637
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: University Health Alliance Commercial	$7.29

MICONAZOLE NITRATE 2 % TOPICAL OINTMENT [13651]

Facility

$15.00

Service Code	NDC 13551000000
Hospital Revenue Code	250
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

MICONAZOLE NITRATE 2 % TOPICAL OINTMENT [13651]

Facility

$15.00

Service Code	NDC 13551000000
Hospital Revenue Code	637
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

MICRA AV2 US

Facility

$2,844.00

Service Code	HCPCS C1786
Hospital Revenue Code	275
Min. Negotiated Rate	$1,450.44
Max. Negotiated Rate	$2,758.68
Rate for Payer: Cash Price	$1,706.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,990.80
Rate for Payer: Health Management Network Commercial	$2,417.40
Rate for Payer: Kaiser Permanente Commercial	$1,791.72
Rate for Payer: Kaiser Permanente Medicaid	$1,450.44
Rate for Payer: MDX Hawaii PPO	$2,758.68
Rate for Payer: University Health Alliance Commercial	$1,592.64

MICRA AV2 US

Facility

$2,844.00

Service Code	HCPCS C1786
Hospital Revenue Code	275
Min. Negotiated Rate	$1,592.64
Max. Negotiated Rate	$2,758.68
Rate for Payer: Cash Price	$1,706.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,990.80
Rate for Payer: Health Management Network Commercial	$2,417.40
Rate for Payer: MDX Hawaii PPO	$2,758.68
Rate for Payer: University Health Alliance Commercial	$1,592.64

MICRA VR2 SINGLE CHAMBER

Facility

$22,820.00

Service Code	HCPCS C1786
Hospital Revenue Code	275
Min. Negotiated Rate	$11,638.20
Max. Negotiated Rate	$22,135.40
Rate for Payer: Cash Price	$13,692.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,974.00
Rate for Payer: Health Management Network Commercial	$19,397.00
Rate for Payer: Kaiser Permanente Commercial	$14,376.60
Rate for Payer: Kaiser Permanente Medicaid	$11,638.20
Rate for Payer: MDX Hawaii PPO	$22,135.40
Rate for Payer: University Health Alliance Commercial	$12,779.20

MICRA VR2 SINGLE CHAMBER

Facility

$22,820.00

Service Code	HCPCS C1786
Hospital Revenue Code	275
Min. Negotiated Rate	$12,779.20
Max. Negotiated Rate	$22,135.40
Rate for Payer: Cash Price	$13,692.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,974.00
Rate for Payer: Health Management Network Commercial	$19,397.00
Rate for Payer: MDX Hawaii PPO	$22,135.40
Rate for Payer: University Health Alliance Commercial	$12,779.20

MICROMATRIX MD 500MG MM0500

Facility

$2,419.00

Service Code	HCPCS Q4118
Hospital Revenue Code	636
Min. Negotiated Rate	$2,056.15
Max. Negotiated Rate	$2,346.43
Rate for Payer: Cash Price	$1,451.40
Rate for Payer: Health Management Network Commercial	$2,056.15
Rate for Payer: MDX Hawaii PPO	$2,346.43

MICROMATRIX MD 500MG MM0500

Facility

$2,419.00

Service Code	HCPCS Q4118
Hospital Revenue Code	636
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$2,346.43
Rate for Payer: Cash Price	$1,451.40
Rate for Payer: Cash Price	$1,451.40
Rate for Payer: Hawaii Medical Service Association ABD	$2.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.56
Rate for Payer: Hawaii Western Management Group Commercial	$2,298.05
Rate for Payer: Health Management Network Commercial	$2,056.15
Rate for Payer: Kaiser Permanente Commercial	$1,523.97
Rate for Payer: Kaiser Permanente Medicaid	$1,233.69
Rate for Payer: MDX Hawaii PPO	$2,346.43
Rate for Payer: UnitedHealthcare Medicaid	$1,451.40
Rate for Payer: University Health Alliance Commercial	$1,763.21

Know your out-of-pocket cost for care.

All Charges