Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

ROSUVASTATIN 40 MG TABLET [35136]

Facility

$6.00

Service Code	NDC 50268071115
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

ROTATIONAL THROMBECTOMY 6FX65

Facility

$6,710.00

Service Code	HCPCS C1724
Hospital Revenue Code	272
Min. Negotiated Rate	$5,703.50
Max. Negotiated Rate	$6,508.70
Rate for Payer: Cash Price	$4,026.00
Rate for Payer: Health Management Network Commercial	$5,703.50
Rate for Payer: MDX Hawaii PPO	$6,508.70

ROTATIONAL THROMBECTOMY 6FX65

Facility

$6,710.00

Service Code	HCPCS C1724
Hospital Revenue Code	272
Min. Negotiated Rate	$3,422.10
Max. Negotiated Rate	$6,508.70
Rate for Payer: Cash Price	$4,026.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,374.50
Rate for Payer: Health Management Network Commercial	$5,703.50
Rate for Payer: Kaiser Permanente Commercial	$4,227.30
Rate for Payer: Kaiser Permanente Medicaid	$3,422.10
Rate for Payer: MDX Hawaii PPO	$6,508.70
Rate for Payer: University Health Alliance Commercial	$4,890.92

ROTATIONAL THROMBECTOMY 7FX65

Facility

$6,710.00

Service Code	HCPCS C1724
Hospital Revenue Code	272
Min. Negotiated Rate	$3,422.10
Max. Negotiated Rate	$6,508.70
Rate for Payer: Cash Price	$4,026.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,374.50
Rate for Payer: Health Management Network Commercial	$5,703.50
Rate for Payer: Kaiser Permanente Commercial	$4,227.30
Rate for Payer: Kaiser Permanente Medicaid	$3,422.10
Rate for Payer: MDX Hawaii PPO	$6,508.70
Rate for Payer: University Health Alliance Commercial	$4,890.92

ROTATIONAL THROMBECTOMY 7FX65

Facility

$6,710.00

Service Code	HCPCS C1724
Hospital Revenue Code	272
Min. Negotiated Rate	$5,703.50
Max. Negotiated Rate	$6,508.70
Rate for Payer: Cash Price	$4,026.00
Rate for Payer: Health Management Network Commercial	$5,703.50
Rate for Payer: MDX Hawaii PPO	$6,508.70

ROTICULATOR 30.2-0 GRY END GIA

Facility

$698.00

Hospital Revenue Code	272
Min. Negotiated Rate	$355.98
Max. Negotiated Rate	$677.06
Rate for Payer: Cash Price	$418.80
Rate for Payer: Hawaii Western Management Group Commercial	$663.10
Rate for Payer: Health Management Network Commercial	$593.30
Rate for Payer: Kaiser Permanente Commercial	$439.74
Rate for Payer: Kaiser Permanente Medicaid	$355.98
Rate for Payer: MDX Hawaii PPO	$677.06
Rate for Payer: University Health Alliance Commercial	$508.77

ROTICULATOR 30.2-0 GRY END GIA

Facility

$698.00

Hospital Revenue Code	272
Min. Negotiated Rate	$593.30
Max. Negotiated Rate	$677.06
Rate for Payer: Cash Price	$418.80
Rate for Payer: Health Management Network Commercial	$593.30
Rate for Payer: MDX Hawaii PPO	$677.06

ROTIGOTINE 4 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH [82101]

Facility

$87.00

Service Code	NDC 50474080403
Hospital Revenue Code	637
Min. Negotiated Rate	$44.37
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Hawaii Western Management Group Commercial	$82.65
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$54.81
Rate for Payer: Kaiser Permanente Medicaid	$44.37
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: University Health Alliance Commercial	$63.41

ROTIGOTINE 4 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH [82101]

Facility

$87.00

Service Code	NDC 50474080403
Hospital Revenue Code	250
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: MDX Hawaii PPO	$84.39

ROUND GIGLI SAW BLADE 12

Facility

$144.00

Hospital Revenue Code	272
Min. Negotiated Rate	$73.44
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$86.40
Rate for Payer: Hawaii Western Management Group Commercial	$136.80
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Kaiser Permanente Commercial	$90.72
Rate for Payer: Kaiser Permanente Medicaid	$73.44
Rate for Payer: MDX Hawaii PPO	$139.68
Rate for Payer: University Health Alliance Commercial	$104.96

ROUND GIGLI SAW BLADE 12

Facility

$144.00

Hospital Revenue Code	272
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: MDX Hawaii PPO	$139.68

ROUND SILICONE GS10621-620HP

Facility

$694.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$388.64
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$416.40
Rate for Payer: Hawaii Western Management Group Commercial	$485.80
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: University Health Alliance Commercial	$388.64

ROUND SILICONE GS10621-620HP

Facility

$694.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$353.94
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$416.40
Rate for Payer: Hawaii Western Management Group Commercial	$485.80
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Kaiser Permanente Commercial	$437.22
Rate for Payer: Kaiser Permanente Medicaid	$353.94
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: University Health Alliance Commercial	$388.64

ROUND SILICONE GS10621-625MP

Facility

$694.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$388.64
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$416.40
Rate for Payer: Hawaii Western Management Group Commercial	$485.80
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: University Health Alliance Commercial	$388.64

ROUND SILICONE GS10621-625MP

Facility

$694.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$353.94
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$416.40
Rate for Payer: Hawaii Western Management Group Commercial	$485.80
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Kaiser Permanente Commercial	$437.22
Rate for Payer: Kaiser Permanente Medicaid	$353.94
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: University Health Alliance Commercial	$388.64

ROUTER QC 130MM #332.062

Facility

$945.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$803.25
Max. Negotiated Rate	$916.65
Rate for Payer: Cash Price	$567.00
Rate for Payer: Health Management Network Commercial	$803.25
Rate for Payer: MDX Hawaii PPO	$916.65

ROUTER QC 130MM #332.062

Facility

$945.00

Service Code	HCPCS C1889
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

RSA GLENOID 28MM 5572-2802

Facility

$4,400.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

RSA GLENOID 28MM 5572-2802

Facility

$4,400.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,244.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$2,772.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

RSA HUMERAL CUP 5570-3602

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

RSA HUMERAL CUP 5570-3602

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,040.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$2,520.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

RUMI INTRAUTERINE 6CM UMW676

Facility

$309.00

Hospital Revenue Code	272
Min. Negotiated Rate	$157.59
Max. Negotiated Rate	$299.73
Rate for Payer: Cash Price	$185.40
Rate for Payer: Hawaii Western Management Group Commercial	$293.55
Rate for Payer: Health Management Network Commercial	$262.65
Rate for Payer: Kaiser Permanente Commercial	$194.67
Rate for Payer: Kaiser Permanente Medicaid	$157.59
Rate for Payer: MDX Hawaii PPO	$299.73
Rate for Payer: University Health Alliance Commercial	$225.23

RUMI INTRAUTERINE 6CM UMW676

Facility

$309.00

Hospital Revenue Code	272
Min. Negotiated Rate	$262.65
Max. Negotiated Rate	$299.73
Rate for Payer: Cash Price	$185.40
Rate for Payer: Health Management Network Commercial	$262.65
Rate for Payer: MDX Hawaii PPO	$299.73

RUMI KOH EFFCIENT 3.0 KCRUMI30

Facility

$553.00

Hospital Revenue Code	272
Min. Negotiated Rate	$282.03
Max. Negotiated Rate	$536.41
Rate for Payer: Cash Price	$331.80
Rate for Payer: Hawaii Western Management Group Commercial	$525.35
Rate for Payer: Health Management Network Commercial	$470.05
Rate for Payer: Kaiser Permanente Commercial	$348.39
Rate for Payer: Kaiser Permanente Medicaid	$282.03
Rate for Payer: MDX Hawaii PPO	$536.41
Rate for Payer: University Health Alliance Commercial	$403.08

RUMI KOH EFFCIENT 3.0 KCRUMI30

Facility

$553.00

Hospital Revenue Code	272
Min. Negotiated Rate	$470.05
Max. Negotiated Rate	$536.41
Rate for Payer: Cash Price	$331.80
Rate for Payer: Health Management Network Commercial	$470.05
Rate for Payer: MDX Hawaii PPO	$536.41

Know your out-of-pocket cost for care.

All Charges