Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

RFX HUMERAL 10X123MM 5568-0010

Facility

$8,462.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,315.62
Max. Negotiated Rate	$8,208.14
Rate for Payer: Cash Price	$5,077.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,923.40
Rate for Payer: Health Management Network Commercial	$7,192.70
Rate for Payer: Kaiser Permanente Commercial	$5,331.06
Rate for Payer: Kaiser Permanente Medicaid	$4,315.62
Rate for Payer: MDX Hawaii PPO	$8,208.14
Rate for Payer: University Health Alliance Commercial	$4,738.72

RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR

Facility

$13,778.00

Service Code	CPT 30420
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Devoted Health Medicare	$7,692.70
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,993.36
Rate for Payer: University Health Alliance Commercial	$11,157.19

RHINOPLASTY, SECONDARY; MAJOR REVISION (NASAL TIP WORK AND OSTEOTOMIES)

Facility

$16,700.00

Service Code	CPT 30450
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$16,700.00
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Devoted Health Medicare	$7,692.70
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,993.36
Rate for Payer: University Health Alliance Commercial	$16,700.00

RHINOPLASTY, SECONDARY; MINOR REVISION (SMALL AMOUNT OF NASAL TIP WORK)

Facility

$7,692.70

Service Code	CPT 30430
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,692.70
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Devoted Health Medicare	$7,692.70
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	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$6,993.36
Rate for Payer: University Health Alliance Commercial	$6,743.44

RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE [127772]

Facility

$372.00

Service Code	HCPCS J2791
Hospital Revenue Code	636
Min. Negotiated Rate	$4.97
Max. Negotiated Rate	$360.84
Rate for Payer: Cash Price	$223.20
Rate for Payer: Cash Price	$223.20
Rate for Payer: Cash Price	$184.20
Rate for Payer: Cash Price	$184.20
Rate for Payer: Hawaii Medical Service Association ABD	$4.97
Rate for Payer: Hawaii Medical Service Association ABD	$4.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.97
Rate for Payer: Hawaii Western Management Group Commercial	$291.65
Rate for Payer: Hawaii Western Management Group Commercial	$353.40
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Health Management Network Commercial	$316.20
Rate for Payer: Kaiser Permanente Commercial	$234.36
Rate for Payer: Kaiser Permanente Commercial	$193.41
Rate for Payer: Kaiser Permanente Medicaid	$189.72
Rate for Payer: Kaiser Permanente Medicaid	$156.57
Rate for Payer: MDX Hawaii PPO	$297.79
Rate for Payer: MDX Hawaii PPO	$360.84
Rate for Payer: UnitedHealthcare Medicaid	$223.20
Rate for Payer: UnitedHealthcare Medicaid	$184.20
Rate for Payer: University Health Alliance Commercial	$223.77
Rate for Payer: University Health Alliance Commercial	$271.15

RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE [127772]

Facility

$307.00

Service Code	HCPCS J2791
Hospital Revenue Code	250
Min. Negotiated Rate	$260.95
Max. Negotiated Rate	$297.79
Rate for Payer: Cash Price	$184.20
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Management Network Commercial	$316.20
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: MDX Hawaii PPO	$297.79
Rate for Payer: MDX Hawaii PPO	$360.84

RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INTRAMUSCULAR SYRINGE [127771]

Facility

$222.00

Service Code	HCPCS J2790
Hospital Revenue Code	250
Min. Negotiated Rate	$188.70
Max. Negotiated Rate	$215.34
Rate for Payer: Cash Price	$133.20
Rate for Payer: Health Management Network Commercial	$188.70
Rate for Payer: MDX Hawaii PPO	$215.34

RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INTRAMUSCULAR SYRINGE [127771]

Facility

$222.00

Service Code	HCPCS J2790
Hospital Revenue Code	636
Min. Negotiated Rate	$82.42
Max. Negotiated Rate	$215.34
Rate for Payer: Cash Price	$133.20
Rate for Payer: Cash Price	$133.20
Rate for Payer: Hawaii Medical Service Association ABD	$82.42
Rate for Payer: Hawaii Medical Service Association Non-ABD	$82.42
Rate for Payer: Hawaii Western Management Group Commercial	$210.90
Rate for Payer: Health Management Network Commercial	$188.70
Rate for Payer: Kaiser Permanente Commercial	$139.86
Rate for Payer: Kaiser Permanente Medicaid	$113.22
Rate for Payer: MDX Hawaii PPO	$215.34
Rate for Payer: UnitedHealthcare Medicaid	$133.20
Rate for Payer: University Health Alliance Commercial	$161.82

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$8.00

Service Code	NDC 60687058601
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$7.76

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$8.00

Service Code	NDC 60687058601
Hospital Revenue Code	637
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: University Health Alliance Commercial	$5.83

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$8.00

Service Code	NDC 60687058611
Hospital Revenue Code	637
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: University Health Alliance Commercial	$5.83

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$8.00

Service Code	NDC 60687058611
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$7.76

RIFAMPIN 600 MG/10ML IV (WET SOLR VIAL) [43011291]

Facility

$276.00

Service Code	NDC 63323035120
Hospital Revenue Code	250
Min. Negotiated Rate	$234.60
Max. Negotiated Rate	$267.72
Rate for Payer: Cash Price	$165.60
Rate for Payer: Health Management Network Commercial	$234.60
Rate for Payer: MDX Hawaii PPO	$267.72

RIFAMPIN 600 MG/10ML IV (WET SOLR VIAL) [43011291]

Facility

$161.00

Service Code	NDC 00068059701
Hospital Revenue Code	250
Min. Negotiated Rate	$136.85
Max. Negotiated Rate	$156.17
Rate for Payer: Cash Price	$96.60
Rate for Payer: Cash Price	$193.20
Rate for Payer: Health Management Network Commercial	$273.70
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: MDX Hawaii PPO	$312.34
Rate for Payer: MDX Hawaii PPO	$156.17

RIFAMPIN 600 MG INTRAVENOUS SOLUTION [11291]

Facility

$276.00

Service Code	HCPCS J2804
Hospital Revenue Code	250
Min. Negotiated Rate	$234.60
Max. Negotiated Rate	$267.72
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cash Price	$193.20
Rate for Payer: Health Management Network Commercial	$273.70
Rate for Payer: Health Management Network Commercial	$234.60
Rate for Payer: MDX Hawaii PPO	$312.34
Rate for Payer: MDX Hawaii PPO	$267.72

RIFAXIMIN 550 MG TABLET [104604]

Facility

$139.00

Service Code	NDC 65649030303
Hospital Revenue Code	250
Min. Negotiated Rate	$118.15
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$83.40
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: MDX Hawaii PPO	$134.83

RIFAXIMIN 550 MG TABLET [104604]

Facility

$139.00

Service Code	NDC 65649030303
Hospital Revenue Code	637
Min. Negotiated Rate	$70.89
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$83.40
Rate for Payer: Hawaii Western Management Group Commercial	$132.05
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$87.57
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: University Health Alliance Commercial	$101.32

RIGIFLEX 35/10 BLN M00554510

Facility

$1,854.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$1,575.90
Max. Negotiated Rate	$1,798.38
Rate for Payer: Cash Price	$1,112.40
Rate for Payer: Health Management Network Commercial	$1,575.90
Rate for Payer: MDX Hawaii PPO	$1,798.38

RIGIFLEX 35/10 BLN M00554510

Facility

$1,854.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$945.54
Max. Negotiated Rate	$1,798.38
Rate for Payer: Cash Price	$1,112.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,761.30
Rate for Payer: Health Management Network Commercial	$1,575.90
Rate for Payer: Kaiser Permanente Commercial	$1,168.02
Rate for Payer: Kaiser Permanente Medicaid	$945.54
Rate for Payer: MDX Hawaii PPO	$1,798.38
Rate for Payer: University Health Alliance Commercial	$1,351.38

RIM PLATE 12H 0.5MM 04.503.343

Facility

$2,229.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,248.24
Max. Negotiated Rate	$2,162.13
Rate for Payer: Cash Price	$1,337.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,560.30
Rate for Payer: Health Management Network Commercial	$1,894.65
Rate for Payer: MDX Hawaii PPO	$2,162.13
Rate for Payer: University Health Alliance Commercial	$1,248.24

RIM PLATE 12H 0.5MM 04.503.343

Facility

$2,229.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,136.79
Max. Negotiated Rate	$2,162.13
Rate for Payer: Cash Price	$1,337.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,560.30
Rate for Payer: Health Management Network Commercial	$1,894.65
Rate for Payer: Kaiser Permanente Commercial	$1,404.27
Rate for Payer: Kaiser Permanente Medicaid	$1,136.79
Rate for Payer: MDX Hawaii PPO	$2,162.13
Rate for Payer: University Health Alliance Commercial	$1,248.24

RING FULL 220MM 99-56-20080

Facility

$3,506.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,980.10
Max. Negotiated Rate	$3,400.82
Rate for Payer: Cash Price	$2,103.60
Rate for Payer: Health Management Network Commercial	$2,980.10
Rate for Payer: MDX Hawaii PPO	$3,400.82

RING FULL 220MM 99-56-20080

Facility

$3,506.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,788.06
Max. Negotiated Rate	$3,400.82
Rate for Payer: Cash Price	$2,103.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,330.70
Rate for Payer: Health Management Network Commercial	$2,980.10
Rate for Payer: Kaiser Permanente Commercial	$2,208.78
Rate for Payer: Kaiser Permanente Medicaid	$1,788.06
Rate for Payer: MDX Hawaii PPO	$3,400.82
Rate for Payer: University Health Alliance Commercial	$2,555.52

RING HALF 220MM 56-11670

Facility

$2,313.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,966.05
Max. Negotiated Rate	$2,243.61
Rate for Payer: Cash Price	$1,387.80
Rate for Payer: Health Management Network Commercial	$1,966.05
Rate for Payer: MDX Hawaii PPO	$2,243.61

RING HALF 220MM 56-11670

Facility

$2,313.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,179.63
Max. Negotiated Rate	$2,243.61
Rate for Payer: Cash Price	$1,387.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,197.35
Rate for Payer: Health Management Network Commercial	$1,966.05
Rate for Payer: Kaiser Permanente Commercial	$1,457.19
Rate for Payer: Kaiser Permanente Medicaid	$1,179.63
Rate for Payer: MDX Hawaii PPO	$2,243.61
Rate for Payer: University Health Alliance Commercial	$1,685.95

Know your out-of-pocket cost for care.

All Charges