Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

MODULAR HIP STEM 6276-1-023

Facility

$8,879.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,972.24
Max. Negotiated Rate	$8,612.63
Rate for Payer: Cash Price	$5,327.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,215.30
Rate for Payer: Health Management Network Commercial	$7,547.15
Rate for Payer: MDX Hawaii PPO	$8,612.63
Rate for Payer: University Health Alliance Commercial	$4,972.24

MODULAR HIP STEM 6276-1-023

Facility

$8,879.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,528.29
Max. Negotiated Rate	$8,612.63
Rate for Payer: Cash Price	$5,327.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,215.30
Rate for Payer: Health Management Network Commercial	$7,547.15
Rate for Payer: Kaiser Permanente Commercial	$5,593.77
Rate for Payer: Kaiser Permanente Medicaid	$4,528.29
Rate for Payer: MDX Hawaii PPO	$8,612.63
Rate for Payer: University Health Alliance Commercial	$4,972.24

MODULAR RADIAL HEAD 11-210044

Facility

$4,280.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,182.80
Max. Negotiated Rate	$4,151.60
Rate for Payer: Cash Price	$2,568.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,996.00
Rate for Payer: Health Management Network Commercial	$3,638.00
Rate for Payer: Kaiser Permanente Commercial	$2,696.40
Rate for Payer: Kaiser Permanente Medicaid	$2,182.80
Rate for Payer: MDX Hawaii PPO	$4,151.60
Rate for Payer: University Health Alliance Commercial	$2,396.80

MODULAR RADIAL HEAD 11-210044

Facility

$4,280.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,396.80
Max. Negotiated Rate	$4,151.60
Rate for Payer: Cash Price	$2,568.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,996.00
Rate for Payer: Health Management Network Commercial	$3,638.00
Rate for Payer: MDX Hawaii PPO	$4,151.60
Rate for Payer: University Health Alliance Commercial	$2,396.80

MODULAR RADIAL STEM 11-210063

Facility

$4,280.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,396.80
Max. Negotiated Rate	$4,151.60
Rate for Payer: Cash Price	$2,568.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,996.00
Rate for Payer: Health Management Network Commercial	$3,638.00
Rate for Payer: MDX Hawaii PPO	$4,151.60
Rate for Payer: University Health Alliance Commercial	$2,396.80

MODULAR RADIAL STEM 11-210063

Facility

$4,280.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,182.80
Max. Negotiated Rate	$4,151.60
Rate for Payer: Cash Price	$2,568.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,996.00
Rate for Payer: Health Management Network Commercial	$3,638.00
Rate for Payer: Kaiser Permanente Commercial	$2,696.40
Rate for Payer: Kaiser Permanente Medicaid	$2,182.80
Rate for Payer: MDX Hawaii PPO	$4,151.60
Rate for Payer: University Health Alliance Commercial	$2,396.80

MODULE TL DYNA 54-24100

Facility

$1,400.00

Hospital Revenue Code	272
Min. Negotiated Rate	$714.00
Max. Negotiated Rate	$1,358.00
Rate for Payer: Cash Price	$840.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,330.00
Rate for Payer: Health Management Network Commercial	$1,190.00
Rate for Payer: Kaiser Permanente Commercial	$882.00
Rate for Payer: Kaiser Permanente Medicaid	$714.00
Rate for Payer: MDX Hawaii PPO	$1,358.00
Rate for Payer: University Health Alliance Commercial	$1,020.46

MODULE TL DYNA 54-24100

Facility

$1,400.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,190.00
Max. Negotiated Rate	$1,358.00
Rate for Payer: Cash Price	$840.00
Rate for Payer: Health Management Network Commercial	$1,190.00
Rate for Payer: MDX Hawaii PPO	$1,358.00

MODULE TL STERILE 99-54-24100

Facility

$1,400.00

Hospital Revenue Code	272
Min. Negotiated Rate	$714.00
Max. Negotiated Rate	$1,358.00
Rate for Payer: Cash Price	$840.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,330.00
Rate for Payer: Health Management Network Commercial	$1,190.00
Rate for Payer: Kaiser Permanente Commercial	$882.00
Rate for Payer: Kaiser Permanente Medicaid	$714.00
Rate for Payer: MDX Hawaii PPO	$1,358.00
Rate for Payer: University Health Alliance Commercial	$1,020.46

MODULE TL STERILE 99-54-24100

Facility

$1,400.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,190.00
Max. Negotiated Rate	$1,358.00
Rate for Payer: Cash Price	$840.00
Rate for Payer: Health Management Network Commercial	$1,190.00
Rate for Payer: MDX Hawaii PPO	$1,358.00

MOLD CEMT HIP HEAD 60MM 431184

Facility

$3,770.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,111.20
Max. Negotiated Rate	$3,656.90
Rate for Payer: Cash Price	$2,262.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,639.00
Rate for Payer: Health Management Network Commercial	$3,204.50
Rate for Payer: MDX Hawaii PPO	$3,656.90
Rate for Payer: University Health Alliance Commercial	$2,111.20

MOLD CEMT HIP HEAD 60MM 431184

Facility

$3,770.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,922.70
Max. Negotiated Rate	$3,656.90
Rate for Payer: Cash Price	$2,262.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,639.00
Rate for Payer: Health Management Network Commercial	$3,204.50
Rate for Payer: Kaiser Permanente Commercial	$2,375.10
Rate for Payer: Kaiser Permanente Medicaid	$1,922.70
Rate for Payer: MDX Hawaii PPO	$3,656.90
Rate for Payer: University Health Alliance Commercial	$2,111.20

MOLD HIP STEM 11X200 431196

Facility

$4,720.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,407.20
Max. Negotiated Rate	$4,578.40
Rate for Payer: Cash Price	$2,832.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,304.00
Rate for Payer: Health Management Network Commercial	$4,012.00
Rate for Payer: Kaiser Permanente Commercial	$2,973.60
Rate for Payer: Kaiser Permanente Medicaid	$2,407.20
Rate for Payer: MDX Hawaii PPO	$4,578.40
Rate for Payer: University Health Alliance Commercial	$2,643.20

MOLD HIP STEM 11X200 431196

Facility

$4,720.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,643.20
Max. Negotiated Rate	$4,578.40
Rate for Payer: Cash Price	$2,832.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,304.00
Rate for Payer: Health Management Network Commercial	$4,012.00
Rate for Payer: MDX Hawaii PPO	$4,578.40
Rate for Payer: University Health Alliance Commercial	$2,643.20

MOMENTUM CRT-D IS-1/DF

Facility

$34,290.00

Service Code	HCPCS C1882
Hospital Revenue Code	275
Min. Negotiated Rate	$19,202.40
Max. Negotiated Rate	$33,261.30
Rate for Payer: Cash Price	$20,574.00
Rate for Payer: Hawaii Western Management Group Commercial	$24,003.00
Rate for Payer: Health Management Network Commercial	$29,146.50
Rate for Payer: MDX Hawaii PPO	$33,261.30
Rate for Payer: University Health Alliance Commercial	$19,202.40

MOMENTUM CRT-D IS-1/DF

Facility

$34,290.00

Service Code	HCPCS C1882
Hospital Revenue Code	275
Min. Negotiated Rate	$17,487.90
Max. Negotiated Rate	$33,261.30
Rate for Payer: Cash Price	$20,574.00
Rate for Payer: Hawaii Western Management Group Commercial	$24,003.00
Rate for Payer: Health Management Network Commercial	$29,146.50
Rate for Payer: Kaiser Permanente Commercial	$21,602.70
Rate for Payer: Kaiser Permanente Medicaid	$17,487.90
Rate for Payer: MDX Hawaii PPO	$33,261.30
Rate for Payer: University Health Alliance Commercial	$19,202.40

MOMENTUM EL ICD R

Facility

$29,192.00

Service Code	HCPCS C1721
Hospital Revenue Code	275
Min. Negotiated Rate	$14,887.92
Max. Negotiated Rate	$28,316.24
Rate for Payer: Cash Price	$17,515.20
Rate for Payer: Hawaii Western Management Group Commercial	$20,434.40
Rate for Payer: Health Management Network Commercial	$24,813.20
Rate for Payer: Kaiser Permanente Commercial	$18,390.96
Rate for Payer: Kaiser Permanente Medicaid	$14,887.92
Rate for Payer: MDX Hawaii PPO	$28,316.24
Rate for Payer: University Health Alliance Commercial	$16,347.52

MOMENTUM EL ICD R

Facility

$29,192.00

Service Code	HCPCS C1721
Hospital Revenue Code	275
Min. Negotiated Rate	$16,347.52
Max. Negotiated Rate	$28,316.24
Rate for Payer: Cash Price	$17,515.20
Rate for Payer: Hawaii Western Management Group Commercial	$20,434.40
Rate for Payer: Health Management Network Commercial	$24,813.20
Rate for Payer: MDX Hawaii PPO	$28,316.24
Rate for Payer: University Health Alliance Commercial	$16,347.52

MOMENTUM EL ICD VR

Facility

$24,586.00

Service Code	HCPCS C1722
Hospital Revenue Code	275
Min. Negotiated Rate	$12,538.86
Max. Negotiated Rate	$23,848.42
Rate for Payer: Cash Price	$14,751.60
Rate for Payer: Hawaii Western Management Group Commercial	$17,210.20
Rate for Payer: Health Management Network Commercial	$20,898.10
Rate for Payer: Kaiser Permanente Commercial	$15,489.18
Rate for Payer: Kaiser Permanente Medicaid	$12,538.86
Rate for Payer: MDX Hawaii PPO	$23,848.42
Rate for Payer: University Health Alliance Commercial	$13,768.16

MOMENTUM EL ICD VR

Facility

$24,586.00

Service Code	HCPCS C1722
Hospital Revenue Code	275
Min. Negotiated Rate	$13,768.16
Max. Negotiated Rate	$23,848.42
Rate for Payer: Cash Price	$14,751.60
Rate for Payer: Hawaii Western Management Group Commercial	$17,210.20
Rate for Payer: Health Management Network Commercial	$20,898.10
Rate for Payer: MDX Hawaii PPO	$23,848.42
Rate for Payer: University Health Alliance Commercial	$13,768.16

MONTELUKAST 10 MG TABLET [22509]

Facility

$2.00

Service Code	NDC 00904680861
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

MONTELUKAST 10 MG TABLET [22509]

Facility

$2.00

Service Code	NDC 00904680861
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

MONTELUKAST 10 MG TABLET [22509]

Facility

$20.00

Service Code	NDC 68084087501
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

MONTELUKAST 10 MG TABLET [22509]

Facility

$20.00

Service Code	NDC 68084087501
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

MORCELLS MYRIAD PW02NA0500

Facility

$2,013.00

Service Code	HCPCS A2033
Hospital Revenue Code	636
Min. Negotiated Rate	$1,026.63
Max. Negotiated Rate	$1,952.61
Rate for Payer: Cash Price	$1,207.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,912.35
Rate for Payer: Health Management Network Commercial	$1,711.05
Rate for Payer: Kaiser Permanente Commercial	$1,268.19
Rate for Payer: Kaiser Permanente Medicaid	$1,026.63
Rate for Payer: MDX Hawaii PPO	$1,952.61
Rate for Payer: UnitedHealthcare Medicaid	$1,207.80
Rate for Payer: University Health Alliance Commercial	$1,467.28

Know your out-of-pocket cost for care.

All Charges