Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

NORIAN DRILLABLE INJECT 10CC

Facility

$6,330.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,544.80
Max. Negotiated Rate	$6,140.10
Rate for Payer: Cash Price	$3,798.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,431.00
Rate for Payer: Health Management Network Commercial	$5,380.50
Rate for Payer: MDX Hawaii PPO	$6,140.10
Rate for Payer: University Health Alliance Commercial	$3,544.80

NORIAN DRILLABLE INJECT 10CC

Facility

$6,330.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,228.30
Max. Negotiated Rate	$6,140.10
Rate for Payer: Cash Price	$3,798.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,431.00
Rate for Payer: Health Management Network Commercial	$5,380.50
Rate for Payer: Kaiser Permanente Commercial	$3,987.90
Rate for Payer: Kaiser Permanente Medicaid	$3,228.30
Rate for Payer: MDX Hawaii PPO	$6,140.10
Rate for Payer: University Health Alliance Commercial	$3,544.80

NORMAL NEWBORN

Facility

$3,446.55

Service Code	MSDRG 795
Min. Negotiated Rate	$2,272.57
Max. Negotiated Rate	$3,446.55
Rate for Payer: AlohaCare Medicare	$2,272.57
Rate for Payer: Devoted Health Medicare	$2,499.83
Rate for Payer: Hawaii Medical Service Association Commercial	$2,742.06
Rate for Payer: Hawaii Medical Service Association Medicare	$2,272.57
Rate for Payer: Humana Medicare	$2,272.57
Rate for Payer: Kaiser Permanente Commercial	$3,446.55
Rate for Payer: Kaiser Permanente Medicare	$2,272.57
Rate for Payer: Ohana Health Plan Medicare	$2,272.57
Rate for Payer: UnitedHealthcare Medicare	$2,272.57

NORTRIPTYLINE 10 MG CAPSULE [5674]

Facility

$2.00

Service Code	NDC 60687028101
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

NORTRIPTYLINE 10 MG CAPSULE [5674]

Facility

$2.00

Service Code	NDC 60687028101
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

NORTRIPTYLINE 10 MG CAPSULE [5674]

Facility

$3.00

Service Code	NDC 75907006901
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: University Health Alliance Commercial	$2.19

NORTRIPTYLINE 10 MG CAPSULE [5674]

Facility

$3.00

Service Code	NDC 75907006901
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

NORTRIPTYLINE 25 MG CAPSULE [5675]

Facility

$3.00

Service Code	NDC 50268060415
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

NORTRIPTYLINE 25 MG CAPSULE [5675]

Facility

$6.00

Service Code	NDC 75907007001
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

NORTRIPTYLINE 25 MG CAPSULE [5675]

Facility

$3.00

Service Code	NDC 50268060415
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: University Health Alliance Commercial	$2.19

NORTRIPTYLINE 25 MG CAPSULE [5675]

Facility

$6.00

Service Code	NDC 75907007001
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

NO SCREENING PERFORMED, PARTIAL SCREENING PERFORMED OR POSITIVE SCREEN WITHOUT RECOMMENDATIONS AND REASON IS NOT GIVEN OR OTHERWISE SPECIFIED

Facility

$2,837.00

Service Code	CPT G9921
Hospital Revenue Code	360
Min. Negotiated Rate	$2,837.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00

NOVASURE DEVICE NS2013KITUS

Facility

$2,276.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,934.60
Max. Negotiated Rate	$2,207.72
Rate for Payer: Cash Price	$1,365.60
Rate for Payer: Health Management Network Commercial	$1,934.60
Rate for Payer: MDX Hawaii PPO	$2,207.72

NOVASURE DEVICE NS2013KITUS

Facility

$2,276.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,160.76
Max. Negotiated Rate	$2,207.72
Rate for Payer: Cash Price	$1,365.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,162.20
Rate for Payer: Health Management Network Commercial	$1,934.60
Rate for Payer: Kaiser Permanente Commercial	$1,433.88
Rate for Payer: Kaiser Permanente Medicaid	$1,160.76
Rate for Payer: MDX Hawaii PPO	$2,207.72
Rate for Payer: University Health Alliance Commercial	$1,658.98

NOVASURE KIT NS2007

Facility

$7,320.00

Hospital Revenue Code	272
Min. Negotiated Rate	$6,222.00
Max. Negotiated Rate	$7,100.40
Rate for Payer: Cash Price	$4,392.00
Rate for Payer: Health Management Network Commercial	$6,222.00
Rate for Payer: MDX Hawaii PPO	$7,100.40

NOVASURE KIT NS2007

Facility

$7,320.00

Hospital Revenue Code	272
Min. Negotiated Rate	$3,733.20
Max. Negotiated Rate	$7,100.40
Rate for Payer: Cash Price	$4,392.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,954.00
Rate for Payer: Health Management Network Commercial	$6,222.00
Rate for Payer: Kaiser Permanente Commercial	$4,611.60
Rate for Payer: Kaiser Permanente Medicaid	$3,733.20
Rate for Payer: MDX Hawaii PPO	$7,100.40
Rate for Payer: University Health Alliance Commercial	$5,335.55

NOVASURE KIT #NSV5KITUS-003

Facility

$2,692.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,372.92
Max. Negotiated Rate	$2,611.24
Rate for Payer: Cash Price	$1,615.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,557.40
Rate for Payer: Health Management Network Commercial	$2,288.20
Rate for Payer: Kaiser Permanente Commercial	$1,695.96
Rate for Payer: Kaiser Permanente Medicaid	$1,372.92
Rate for Payer: MDX Hawaii PPO	$2,611.24
Rate for Payer: University Health Alliance Commercial	$1,962.20

NOVASURE KIT #NSV5KITUS-003

Facility

$2,692.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$2,288.20
Max. Negotiated Rate	$2,611.24
Rate for Payer: Cash Price	$1,615.20
Rate for Payer: Health Management Network Commercial	$2,288.20
Rate for Payer: MDX Hawaii PPO	$2,611.24

NUCLEUS TI6AI1V SIZE 3 DWG403

Facility

$14,872.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,328.32
Max. Negotiated Rate	$14,425.84
Rate for Payer: Cash Price	$8,923.20
Rate for Payer: Hawaii Western Management Group Commercial	$10,410.40
Rate for Payer: Health Management Network Commercial	$12,641.20
Rate for Payer: MDX Hawaii PPO	$14,425.84
Rate for Payer: University Health Alliance Commercial	$8,328.32

NUCLEUS TI6AI1V SIZE 3 DWG403

Facility

$14,872.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$7,584.72
Max. Negotiated Rate	$14,425.84
Rate for Payer: Cash Price	$8,923.20
Rate for Payer: Hawaii Western Management Group Commercial	$10,410.40
Rate for Payer: Health Management Network Commercial	$12,641.20
Rate for Payer: Kaiser Permanente Commercial	$9,369.36
Rate for Payer: Kaiser Permanente Medicaid	$7,584.72
Rate for Payer: MDX Hawaii PPO	$14,425.84
Rate for Payer: University Health Alliance Commercial	$8,328.32

NUCLEUS TI6AI4V SIZE 1

Facility

$11,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,586.72
Max. Negotiated Rate	$11,409.14
Rate for Payer: Cash Price	$7,057.20
Rate for Payer: Hawaii Western Management Group Commercial	$8,233.40
Rate for Payer: Health Management Network Commercial	$9,997.70
Rate for Payer: MDX Hawaii PPO	$11,409.14
Rate for Payer: University Health Alliance Commercial	$6,586.72

NUCLEUS TI6AI4V SIZE 1

Facility

$11,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,998.62
Max. Negotiated Rate	$11,409.14
Rate for Payer: Cash Price	$7,057.20
Rate for Payer: Hawaii Western Management Group Commercial	$8,233.40
Rate for Payer: Health Management Network Commercial	$9,997.70
Rate for Payer: Kaiser Permanente Commercial	$7,410.06
Rate for Payer: Kaiser Permanente Medicaid	$5,998.62
Rate for Payer: MDX Hawaii PPO	$11,409.14
Rate for Payer: University Health Alliance Commercial	$6,586.72

NUCLEUS Ti6AI4V SZ 2 DWG402

Facility

$11,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,998.62
Max. Negotiated Rate	$11,409.14
Rate for Payer: Cash Price	$7,057.20
Rate for Payer: Hawaii Western Management Group Commercial	$8,233.40
Rate for Payer: Health Management Network Commercial	$9,997.70
Rate for Payer: Kaiser Permanente Commercial	$7,410.06
Rate for Payer: Kaiser Permanente Medicaid	$5,998.62
Rate for Payer: MDX Hawaii PPO	$11,409.14
Rate for Payer: University Health Alliance Commercial	$6,586.72

NUCLEUS Ti6AI4V SZ 2 DWG402

Facility

$11,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,586.72
Max. Negotiated Rate	$11,409.14
Rate for Payer: Cash Price	$7,057.20
Rate for Payer: Hawaii Western Management Group Commercial	$8,233.40
Rate for Payer: Health Management Network Commercial	$9,997.70
Rate for Payer: MDX Hawaii PPO	$11,409.14
Rate for Payer: University Health Alliance Commercial	$6,586.72

NURSE VISIT ONLY - FACILITY ONLY

Facility

$513.00

Service Code	HCPCS G0463
Hospital Charge Code	761G046302
Hospital Revenue Code	761
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$307.80
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: MDX Hawaii PPO	$497.61

Know your out-of-pocket cost for care.

All Charges