Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

RELIANCE LEAD 64CM

Facility

$6,208.00

Service Code	HCPCS C1777
Hospital Revenue Code	278
Min. Negotiated Rate	$3,166.08
Max. Negotiated Rate	$6,021.76
Rate for Payer: Cash Price	$3,724.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,345.60
Rate for Payer: Health Management Network Commercial	$5,276.80
Rate for Payer: Kaiser Permanente Commercial	$3,911.04
Rate for Payer: Kaiser Permanente Medicaid	$3,166.08
Rate for Payer: MDX Hawaii PPO	$6,021.76
Rate for Payer: University Health Alliance Commercial	$3,476.48

RELIANCE LEAD 64CM

Facility

$6,208.00

Service Code	HCPCS C1777
Hospital Revenue Code	278
Min. Negotiated Rate	$3,476.48
Max. Negotiated Rate	$6,021.76
Rate for Payer: Cash Price	$3,724.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,345.60
Rate for Payer: Health Management Network Commercial	$5,276.80
Rate for Payer: MDX Hawaii PPO	$6,021.76
Rate for Payer: University Health Alliance Commercial	$3,476.48

RELIANT STENT GRAFT BLN CATH

Facility

$1,558.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$794.58
Max. Negotiated Rate	$1,511.26
Rate for Payer: Cash Price	$934.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,480.10
Rate for Payer: Health Management Network Commercial	$1,324.30
Rate for Payer: Kaiser Permanente Commercial	$981.54
Rate for Payer: Kaiser Permanente Medicaid	$794.58
Rate for Payer: MDX Hawaii PPO	$1,511.26
Rate for Payer: University Health Alliance Commercial	$1,135.63

RELIANT STENT GRAFT BLN CATH

Facility

$1,558.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$1,324.30
Max. Negotiated Rate	$1,511.26
Rate for Payer: Cash Price	$934.80
Rate for Payer: Health Management Network Commercial	$1,324.30
Rate for Payer: MDX Hawaii PPO	$1,511.26

RELOAD 5MM JR-REL25-2.0-12

Facility

$1,278.00

Hospital Revenue Code	272
Min. Negotiated Rate	$651.78
Max. Negotiated Rate	$1,239.66
Rate for Payer: Cash Price	$766.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,214.10
Rate for Payer: Health Management Network Commercial	$1,086.30
Rate for Payer: Kaiser Permanente Commercial	$805.14
Rate for Payer: Kaiser Permanente Medicaid	$651.78
Rate for Payer: MDX Hawaii PPO	$1,239.66
Rate for Payer: University Health Alliance Commercial	$931.53

RELOAD 5MM JR-REL25-2.0-12

Facility

$1,278.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,086.30
Max. Negotiated Rate	$1,239.66
Rate for Payer: Cash Price	$766.80
Rate for Payer: Health Management Network Commercial	$1,086.30
Rate for Payer: MDX Hawaii PPO	$1,239.66

RELOAD SUREFORM 8MM BLU 48230B

Facility

$788.00

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

RELOAD SUREFORM 8MM BLU 48230B

Facility

$788.00

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

RELOAD SUREFORM 8MM WHT 48230W

Facility

$788.00

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

RELOAD SUREFORM 8MM WHT 48230W

Facility

$788.00

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

REMDESIVIR 100 MG/20ML IV (WET SOLR VIAL) [430400829]

Facility

$1,172.00

Service Code	NDC 61958290102
Hospital Revenue Code	250
Min. Negotiated Rate	$996.20
Max. Negotiated Rate	$1,136.84
Rate for Payer: Cash Price	$703.20
Rate for Payer: Cash Price	$756.00
Rate for Payer: Health Management Network Commercial	$1,071.00
Rate for Payer: Health Management Network Commercial	$996.20
Rate for Payer: MDX Hawaii PPO	$1,222.20
Rate for Payer: MDX Hawaii PPO	$1,136.84

REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION [400829]

Facility

$1,172.00

Service Code	HCPCS J0248
Hospital Revenue Code	636
Min. Negotiated Rate	$6.73
Max. Negotiated Rate	$1,136.84
Rate for Payer: AlohaCare Medicaid	$6.90
Rate for Payer: AlohaCare Medicare	$6.90
Rate for Payer: Cash Price	$703.20
Rate for Payer: Cash Price	$703.20
Rate for Payer: Devoted Health Medicare	$7.59
Rate for Payer: Hawaii Medical Service Association ABD	$6.73
Rate for Payer: Hawaii Medical Service Association Commercial	$8.62
Rate for Payer: Hawaii Medical Service Association Medicare	$6.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.73
Rate for Payer: Hawaii Western Management Group Commercial	$1,113.40
Rate for Payer: Health Management Network Commercial	$996.20
Rate for Payer: Humana Medicare	$6.90
Rate for Payer: Kaiser Permanente Commercial	$738.36
Rate for Payer: Kaiser Permanente Medicaid	$597.72
Rate for Payer: Kaiser Permanente Medicare	$6.90
Rate for Payer: MDX Hawaii PPO	$1,136.84
Rate for Payer: Ohana Health Plan Medicaid	$7.59
Rate for Payer: Ohana Health Plan Medicare	$6.90
Rate for Payer: UnitedHealthcare Medicaid	$703.20
Rate for Payer: UnitedHealthcare Medicare	$6.90
Rate for Payer: University Health Alliance Commercial	$854.27

REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION [400829]

Facility

$1,172.00

Service Code	HCPCS J0248
Hospital Revenue Code	250
Min. Negotiated Rate	$996.20
Max. Negotiated Rate	$1,136.84
Rate for Payer: Cash Price	$703.20
Rate for Payer: Health Management Network Commercial	$996.20
Rate for Payer: MDX Hawaii PPO	$1,136.84

REMEDY STEM EST SZ 175 RSK175

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

REMEDY STEM EST SZ 175 RSK175

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

REMEDY STEM EXT SZ 100 RSK100

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

REMEDY STEM EXT SZ 100 RSK100

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

REMEDY STEM FEMORAL SZL RSKFLG

Facility

$8,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,928.00
Max. Negotiated Rate	$8,536.00
Rate for Payer: Cash Price	$5,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,160.00
Rate for Payer: Health Management Network Commercial	$7,480.00
Rate for Payer: MDX Hawaii PPO	$8,536.00
Rate for Payer: University Health Alliance Commercial	$4,928.00

REMEDY STEM FEMORAL SZL RSKFLG

Facility

$8,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,488.00
Max. Negotiated Rate	$8,536.00
Rate for Payer: Cash Price	$5,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,160.00
Rate for Payer: Health Management Network Commercial	$7,480.00
Rate for Payer: Kaiser Permanente Commercial	$5,544.00
Rate for Payer: Kaiser Permanente Medicaid	$4,488.00
Rate for Payer: MDX Hawaii PPO	$8,536.00
Rate for Payer: University Health Alliance Commercial	$4,928.00

REMEDY STEM TIBIAL SZ L RSKTLG

Facility

$8,500.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,760.00
Max. Negotiated Rate	$8,245.00
Rate for Payer: Cash Price	$5,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,950.00
Rate for Payer: Health Management Network Commercial	$7,225.00
Rate for Payer: MDX Hawaii PPO	$8,245.00
Rate for Payer: University Health Alliance Commercial	$4,760.00

REMEDY STEM TIBIAL SZ L RSKTLG

Facility

$8,500.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,335.00
Max. Negotiated Rate	$8,245.00
Rate for Payer: Cash Price	$5,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,950.00
Rate for Payer: Health Management Network Commercial	$7,225.00
Rate for Payer: Kaiser Permanente Commercial	$5,355.00
Rate for Payer: Kaiser Permanente Medicaid	$4,335.00
Rate for Payer: MDX Hawaii PPO	$8,245.00
Rate for Payer: University Health Alliance Commercial	$4,760.00

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$221.00

Service Code	NDC 00143939201
Hospital Revenue Code	250
Min. Negotiated Rate	$187.85
Max. Negotiated Rate	$214.37
Rate for Payer: Cash Price	$132.60
Rate for Payer: Health Management Network Commercial	$187.85
Rate for Payer: MDX Hawaii PPO	$214.37

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$243.00

Service Code	NDC 72078003500
Hospital Revenue Code	250
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$235.71
Rate for Payer: Cash Price	$145.80
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: MDX Hawaii PPO	$235.71

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$221.00

Service Code	NDC 00143939210
Hospital Revenue Code	250
Min. Negotiated Rate	$187.85
Max. Negotiated Rate	$214.37
Rate for Payer: Cash Price	$132.60
Rate for Payer: Health Management Network Commercial	$187.85
Rate for Payer: MDX Hawaii PPO	$214.37

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$243.00

Service Code	NDC 72078003502
Hospital Revenue Code	250
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$235.71
Rate for Payer: Cash Price	$145.80
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: MDX Hawaii PPO	$235.71

Know your out-of-pocket cost for care.

All Charges