Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

UHR BIPOLAR 28X52MM UH1-52-28

Facility

$2,433.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,362.48
Max. Negotiated Rate	$2,360.01
Rate for Payer: Cash Price	$1,459.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,703.10
Rate for Payer: Health Management Network Commercial	$2,068.05
Rate for Payer: MDX Hawaii PPO	$2,360.01
Rate for Payer: University Health Alliance Commercial	$1,362.48

UHR BIPOLAR 28X53MM UH1-53-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$1,517.04
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X53MM UH1-53-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X54MM UH1-54-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$1,517.04
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X54MM UH1-54-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X55MM UH1-55-28

Facility

$2,433.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,240.83
Max. Negotiated Rate	$2,360.01
Rate for Payer: Cash Price	$1,459.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,703.10
Rate for Payer: Health Management Network Commercial	$2,068.05
Rate for Payer: Kaiser Permanente Commercial	$1,532.79
Rate for Payer: Kaiser Permanente Medicaid	$1,240.83
Rate for Payer: MDX Hawaii PPO	$2,360.01
Rate for Payer: University Health Alliance Commercial	$1,362.48

UHR BIPOLAR 28X55MM UH1-55-28

Facility

$2,433.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,362.48
Max. Negotiated Rate	$2,360.01
Rate for Payer: Cash Price	$1,459.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,703.10
Rate for Payer: Health Management Network Commercial	$2,068.05
Rate for Payer: MDX Hawaii PPO	$2,360.01
Rate for Payer: University Health Alliance Commercial	$1,362.48

UHR BIPOLAR 28X56MM UH1-56-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X56MM UH1-56-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$1,517.04
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X58MM UH1-58-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$1,517.04
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X58MM UH1-58-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X61MM UH1-61-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: Kaiser Permanente Commercial	$1,517.04
Rate for Payer: Kaiser Permanente Medicaid	$1,228.08
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

UHR BIPOLAR 28X61MM UH1-61-28

Facility

$2,408.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,348.48
Max. Negotiated Rate	$2,335.76
Rate for Payer: Cash Price	$1,444.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,685.60
Rate for Payer: Health Management Network Commercial	$2,046.80
Rate for Payer: MDX Hawaii PPO	$2,335.76
Rate for Payer: University Health Alliance Commercial	$1,348.48

ULNAR CAP COCR + UHMWPE SMALL

Facility

$2,838.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$1,589.28
Max. Negotiated Rate	$2,752.86
Rate for Payer: Cash Price	$1,702.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,986.60
Rate for Payer: Health Management Network Commercial	$2,412.30
Rate for Payer: MDX Hawaii PPO	$2,752.86
Rate for Payer: University Health Alliance Commercial	$1,589.28

ULNAR CAP COCR + UHMWPE SMALL

Facility

$2,838.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$1,447.38
Max. Negotiated Rate	$2,752.86
Rate for Payer: Cash Price	$1,702.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,986.60
Rate for Payer: Health Management Network Commercial	$2,412.30
Rate for Payer: Kaiser Permanente Commercial	$1,787.94
Rate for Payer: Kaiser Permanente Medicaid	$1,447.38
Rate for Payer: MDX Hawaii PPO	$2,752.86
Rate for Payer: University Health Alliance Commercial	$1,589.28

ULNAR SLED 38MM US.38

Facility

$1,593.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$812.43
Max. Negotiated Rate	$1,545.21
Rate for Payer: Cash Price	$955.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,115.10
Rate for Payer: Health Management Network Commercial	$1,354.05
Rate for Payer: Kaiser Permanente Commercial	$1,003.59
Rate for Payer: Kaiser Permanente Medicaid	$812.43
Rate for Payer: MDX Hawaii PPO	$1,545.21
Rate for Payer: University Health Alliance Commercial	$892.08

ULNAR SLED 38MM US.38

Facility

$1,593.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$892.08
Max. Negotiated Rate	$1,545.21
Rate for Payer: Cash Price	$955.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,115.10
Rate for Payer: Health Management Network Commercial	$1,354.05
Rate for Payer: MDX Hawaii PPO	$1,545.21
Rate for Payer: University Health Alliance Commercial	$892.08

ULTIMUM EV HEMOSTASIS INTRO 16

Facility

$288.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$146.88
Max. Negotiated Rate	$279.36
Rate for Payer: Cash Price	$172.80
Rate for Payer: Hawaii Western Management Group Commercial	$273.60
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: Kaiser Permanente Commercial	$181.44
Rate for Payer: Kaiser Permanente Medicaid	$146.88
Rate for Payer: MDX Hawaii PPO	$279.36
Rate for Payer: University Health Alliance Commercial	$209.92

ULTIMUM EV HEMOSTASIS INTRO 16

Facility

$288.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$244.80
Max. Negotiated Rate	$279.36
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: MDX Hawaii PPO	$279.36

ULTRASLING IV SMALL 11-0445-2

Facility

$239.00

Service Code	HCPCS L3670
Hospital Revenue Code	274
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$231.83
Rate for Payer: Cash Price	$143.40
Rate for Payer: Cash Price	$143.40
Rate for Payer: Hawaii Western Management Group Commercial	$167.30
Rate for Payer: Health Management Network Commercial	$203.15
Rate for Payer: Kaiser Permanente Commercial	$150.57
Rate for Payer: Kaiser Permanente Medicaid	$121.89
Rate for Payer: MDX Hawaii PPO	$231.83
Rate for Payer: UnitedHealthcare Medicaid	$84.70
Rate for Payer: University Health Alliance Commercial	$133.84

ULTRASLING IV SMALL 11-0445-2

Facility

$239.00

Service Code	HCPCS L3670
Hospital Revenue Code	274
Min. Negotiated Rate	$133.84
Max. Negotiated Rate	$231.83
Rate for Payer: Cash Price	$143.40
Rate for Payer: Hawaii Western Management Group Commercial	$167.30
Rate for Payer: Health Management Network Commercial	$203.15
Rate for Payer: MDX Hawaii PPO	$231.83
Rate for Payer: University Health Alliance Commercial	$133.84

ULTRASLING UNISX LRG 11-0445-4

Facility

$239.00

Service Code	HCPCS L3670
Hospital Revenue Code	274
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$231.83
Rate for Payer: Cash Price	$143.40
Rate for Payer: Cash Price	$143.40
Rate for Payer: Hawaii Western Management Group Commercial	$167.30
Rate for Payer: Health Management Network Commercial	$203.15
Rate for Payer: Kaiser Permanente Commercial	$150.57
Rate for Payer: Kaiser Permanente Medicaid	$121.89
Rate for Payer: MDX Hawaii PPO	$231.83
Rate for Payer: UnitedHealthcare Medicaid	$84.70
Rate for Payer: University Health Alliance Commercial	$133.84

ULTRASLING UNISX LRG 11-0445-4

Facility

$239.00

Service Code	HCPCS L3670
Hospital Revenue Code	274
Min. Negotiated Rate	$133.84
Max. Negotiated Rate	$231.83
Rate for Payer: Cash Price	$143.40
Rate for Payer: Hawaii Western Management Group Commercial	$167.30
Rate for Payer: Health Management Network Commercial	$203.15
Rate for Payer: MDX Hawaii PPO	$231.83
Rate for Payer: University Health Alliance Commercial	$133.84

ULTRASLING UNISX MED 11-0445-3

Facility

$239.00

Service Code	HCPCS L3670
Hospital Revenue Code	274
Min. Negotiated Rate	$133.84
Max. Negotiated Rate	$231.83
Rate for Payer: Cash Price	$143.40
Rate for Payer: Hawaii Western Management Group Commercial	$167.30
Rate for Payer: Health Management Network Commercial	$203.15
Rate for Payer: MDX Hawaii PPO	$231.83
Rate for Payer: University Health Alliance Commercial	$133.84

ULTRASLING UNISX MED 11-0445-3

Facility

$239.00

Service Code	HCPCS L3670
Hospital Revenue Code	274
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$231.83
Rate for Payer: Cash Price	$143.40
Rate for Payer: Cash Price	$143.40
Rate for Payer: Hawaii Western Management Group Commercial	$167.30
Rate for Payer: Health Management Network Commercial	$203.15
Rate for Payer: Kaiser Permanente Commercial	$150.57
Rate for Payer: Kaiser Permanente Medicaid	$121.89
Rate for Payer: MDX Hawaii PPO	$231.83
Rate for Payer: UnitedHealthcare Medicaid	$84.70
Rate for Payer: University Health Alliance Commercial	$133.84

Know your out-of-pocket cost for care.

All Charges