Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

MYNX CONTROL VENOUS 6F-12F

Facility

$945.00

Service Code	HCPCS C1760
Hospital Revenue Code	272
Min. Negotiated Rate	$481.95
Max. Negotiated Rate	$916.65
Rate for Payer: Cash Price	$567.00
Rate for Payer: Hawaii Western Management Group Commercial	$897.75
Rate for Payer: Health Management Network Commercial	$803.25
Rate for Payer: Kaiser Permanente Commercial	$595.35
Rate for Payer: Kaiser Permanente Medicaid	$481.95
Rate for Payer: MDX Hawaii PPO	$916.65
Rate for Payer: University Health Alliance Commercial	$688.81

MYOCARDIAL BIOPSY FORCEPS

Facility

$2,299.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,172.49
Max. Negotiated Rate	$2,230.03
Rate for Payer: Cash Price	$1,379.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,184.05
Rate for Payer: Health Management Network Commercial	$1,954.15
Rate for Payer: Kaiser Permanente Commercial	$1,448.37
Rate for Payer: Kaiser Permanente Medicaid	$1,172.49
Rate for Payer: MDX Hawaii PPO	$2,230.03
Rate for Payer: University Health Alliance Commercial	$1,675.74

MYOCARDIAL BIOPSY FORCEPS

Facility

$2,299.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,954.15
Max. Negotiated Rate	$2,230.03
Rate for Payer: Cash Price	$1,379.40
Rate for Payer: Health Management Network Commercial	$1,954.15
Rate for Payer: MDX Hawaii PPO	$2,230.03

MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; ABDOMINAL APPROACH

Facility

$8,270.00

Service Code	CPT 58140
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03

MYOSURE POLYP RMVL SIMPLIFIED

Facility

$2,085.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,772.25
Max. Negotiated Rate	$2,022.45
Rate for Payer: Cash Price	$1,251.00
Rate for Payer: Health Management Network Commercial	$1,772.25
Rate for Payer: MDX Hawaii PPO	$2,022.45

MYOSURE POLYP RMVL SIMPLIFIED

Facility

$2,085.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,063.35
Max. Negotiated Rate	$2,022.45
Rate for Payer: Cash Price	$1,251.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,980.75
Rate for Payer: Health Management Network Commercial	$1,772.25
Rate for Payer: Kaiser Permanente Commercial	$1,313.55
Rate for Payer: Kaiser Permanente Medicaid	$1,063.35
Rate for Payer: MDX Hawaii PPO	$2,022.45
Rate for Payer: University Health Alliance Commercial	$1,519.76

MYOSURE TISSUE REMOVAL SIMPLIF

Facility

$2,590.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$2,201.50
Max. Negotiated Rate	$2,512.30
Rate for Payer: Cash Price	$1,554.00
Rate for Payer: Health Management Network Commercial	$2,201.50
Rate for Payer: MDX Hawaii PPO	$2,512.30

MYOSURE TISSUE REMOVAL SIMPLIF

Facility

$2,590.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,320.90
Max. Negotiated Rate	$2,512.30
Rate for Payer: Cash Price	$1,554.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,460.50
Rate for Payer: Health Management Network Commercial	$2,201.50
Rate for Payer: Kaiser Permanente Commercial	$1,631.70
Rate for Payer: Kaiser Permanente Medicaid	$1,320.90
Rate for Payer: MDX Hawaii PPO	$2,512.30
Rate for Payer: University Health Alliance Commercial	$1,887.85

MYRIAD MATRIX 5X5 SR02LG0505US

Facility

$861.00

Service Code	HCPCS A2032
Hospital Revenue Code	636
Min. Negotiated Rate	$731.85
Max. Negotiated Rate	$835.17
Rate for Payer: Cash Price	$516.60
Rate for Payer: Health Management Network Commercial	$731.85
Rate for Payer: MDX Hawaii PPO	$835.17

MYRIAD MATRIX 5X5 SR02LG0505US

Facility

$861.00

Service Code	HCPCS A2032
Hospital Revenue Code	636
Min. Negotiated Rate	$439.11
Max. Negotiated Rate	$835.17
Rate for Payer: Cash Price	$516.60
Rate for Payer: Hawaii Western Management Group Commercial	$817.95
Rate for Payer: Health Management Network Commercial	$731.85
Rate for Payer: Kaiser Permanente Commercial	$542.43
Rate for Payer: Kaiser Permanente Medicaid	$439.11
Rate for Payer: MDX Hawaii PPO	$835.17
Rate for Payer: UnitedHealthcare Medicaid	$516.60
Rate for Payer: University Health Alliance Commercial	$627.58

MYRIAD MATRIX SR02LG1010US

Facility

$2,756.00

Service Code	HCPCS A2032
Hospital Revenue Code	636
Min. Negotiated Rate	$2,342.60
Max. Negotiated Rate	$2,673.32
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Health Management Network Commercial	$2,342.60
Rate for Payer: MDX Hawaii PPO	$2,673.32

MYRIAD MATRIX SR02LG1010US

Facility

$2,756.00

Service Code	HCPCS A2032
Hospital Revenue Code	636
Min. Negotiated Rate	$1,405.56
Max. Negotiated Rate	$2,673.32
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,618.20
Rate for Payer: Health Management Network Commercial	$2,342.60
Rate for Payer: Kaiser Permanente Commercial	$1,736.28
Rate for Payer: Kaiser Permanente Medicaid	$1,405.56
Rate for Payer: MDX Hawaii PPO	$2,673.32
Rate for Payer: UnitedHealthcare Medicaid	$1,653.60
Rate for Payer: University Health Alliance Commercial	$2,008.85

MYRIAD MATRIX SR02LG2020US

Facility

$7,350.00

Service Code	HCPCS A2032
Hospital Revenue Code	636
Min. Negotiated Rate	$3,748.50
Max. Negotiated Rate	$7,129.50
Rate for Payer: MDX Hawaii PPO	$7,129.50
Rate for Payer: Cash Price	$4,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,982.50
Rate for Payer: Health Management Network Commercial	$6,247.50
Rate for Payer: Kaiser Permanente Commercial	$4,630.50
Rate for Payer: Kaiser Permanente Medicaid	$3,748.50
Rate for Payer: UnitedHealthcare Medicaid	$4,410.00
Rate for Payer: University Health Alliance Commercial	$5,357.41

MYRIAD MATRIX SR02LG2020US

Facility

$7,350.00

Service Code	HCPCS A2032
Hospital Revenue Code	636
Min. Negotiated Rate	$6,247.50
Max. Negotiated Rate	$7,129.50
Rate for Payer: Cash Price	$4,410.00
Rate for Payer: Health Management Network Commercial	$6,247.50
Rate for Payer: MDX Hawaii PPO	$7,129.50

MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION REQUIRING GENERAL ANESTHESIA

Facility

$6,743.44

Service Code	CPT 69421
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$3,916.70
Rate for Payer: AlohaCare Medicare	$3,916.70
Rate for Payer: Devoted Health Medicare	$4,308.37
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,916.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,916.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,916.70
Rate for Payer: Ohana Health Plan Medicaid	$4,308.37
Rate for Payer: Ohana Health Plan Medicare	$3,916.70
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,916.70
Rate for Payer: University Health Alliance Commercial	$6,743.44

NADOLOL 20 MG TABLET [5330]

Facility

$13.00

Service Code	NDC 60687030295
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: MDX Hawaii PPO	$12.61

NADOLOL 20 MG TABLET [5330]

Facility

$13.00

Service Code	NDC 00904707007
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: MDX Hawaii PPO	$12.61

NADOLOL 20 MG TABLET [5330]

Facility

$13.00

Service Code	NDC 60687030225
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: MDX Hawaii PPO	$12.61

NADOLOL 20 MG TABLET [5330]

Facility

$13.00

Service Code	NDC 60687030295
Hospital Revenue Code	637
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$8.19
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: University Health Alliance Commercial	$9.48

NADOLOL 20 MG TABLET [5330]

Facility

$13.00

Service Code	NDC 00904707007
Hospital Revenue Code	637
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$8.19
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: University Health Alliance Commercial	$9.48

NADOLOL 20 MG TABLET [5330]

Facility

$13.00

Service Code	NDC 60687030225
Hospital Revenue Code	637
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$8.19
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: University Health Alliance Commercial	$9.48

NAIL 011X400 125° 3525-1400S

Facility

$6,402.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,265.02
Max. Negotiated Rate	$6,209.94
Rate for Payer: Cash Price	$3,841.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,481.40
Rate for Payer: Health Management Network Commercial	$5,441.70
Rate for Payer: Kaiser Permanente Commercial	$4,033.26
Rate for Payer: Kaiser Permanente Medicaid	$3,265.02
Rate for Payer: MDX Hawaii PPO	$6,209.94
Rate for Payer: University Health Alliance Commercial	$3,585.12

NAIL 011X400 125° 3525-1400S

Facility

$6,402.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,585.12
Max. Negotiated Rate	$6,209.94
Rate for Payer: Cash Price	$3,841.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,481.40
Rate for Payer: Health Management Network Commercial	$5,441.70
Rate for Payer: MDX Hawaii PPO	$6,209.94
Rate for Payer: University Health Alliance Commercial	$3,585.12

NAIL 10MM CANN LF 04.033.067S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

NAIL 10MM CANN LF 04.033.067S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

Know your out-of-pocket cost for care.

All Charges