Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

VERSYS CEMENTED LD/FX 14X135MM

Facility

$4,300.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,193.00
Max. Negotiated Rate	$4,171.00
Rate for Payer: Cash Price	$2,580.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,010.00
Rate for Payer: Health Management Network Commercial	$3,655.00
Rate for Payer: Kaiser Permanente Commercial	$2,709.00
Rate for Payer: Kaiser Permanente Medicaid	$2,193.00
Rate for Payer: MDX Hawaii PPO	$4,171.00
Rate for Payer: University Health Alliance Commercial	$2,408.00

VERSYS CEMENTED LD/FX 14X135MM

Facility

$4,300.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,408.00
Max. Negotiated Rate	$4,171.00
Rate for Payer: Cash Price	$2,580.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,010.00
Rate for Payer: Health Management Network Commercial	$3,655.00
Rate for Payer: MDX Hawaii PPO	$4,171.00
Rate for Payer: University Health Alliance Commercial	$2,408.00

VERTIGO & OTHER LABYRINTH DISORDERS

Facility

$4,084.56

Service Code	APR-DRG 1113
Min. Negotiated Rate	$4,084.56
Max. Negotiated Rate	$4,084.56
Rate for Payer: AlohaCare Medicaid	$4,084.56
Rate for Payer: Hawaii Medical Service Association ABD	$4,084.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,084.56
Rate for Payer: Kaiser Permanente Medicaid	$4,084.56
Rate for Payer: Ohana Health Plan Medicaid	$4,084.56
Rate for Payer: UnitedHealthcare Medicaid	$4,084.56

VERTIGO & OTHER LABYRINTH DISORDERS

Facility

$6,359.05

Service Code	APR-DRG 1114
Min. Negotiated Rate	$6,359.05
Max. Negotiated Rate	$6,359.05
Rate for Payer: AlohaCare Medicaid	$6,359.05
Rate for Payer: Hawaii Medical Service Association ABD	$6,359.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,359.05
Rate for Payer: Kaiser Permanente Medicaid	$6,359.05
Rate for Payer: Ohana Health Plan Medicaid	$6,359.05
Rate for Payer: UnitedHealthcare Medicaid	$6,359.05

VERTIGO & OTHER LABYRINTH DISORDERS

Facility

$3,294.65

Service Code	APR-DRG 1112
Min. Negotiated Rate	$3,294.65
Max. Negotiated Rate	$3,294.65
Rate for Payer: AlohaCare Medicaid	$3,294.65
Rate for Payer: Hawaii Medical Service Association ABD	$3,294.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,294.65
Rate for Payer: Kaiser Permanente Medicaid	$3,294.65
Rate for Payer: Ohana Health Plan Medicaid	$3,294.65
Rate for Payer: UnitedHealthcare Medicaid	$3,294.65

VERTIGO & OTHER LABYRINTH DISORDERS

Facility

$2,921.55

Service Code	APR-DRG 1111
Min. Negotiated Rate	$2,921.55
Max. Negotiated Rate	$2,921.55
Rate for Payer: AlohaCare Medicaid	$2,921.55
Rate for Payer: Hawaii Medical Service Association ABD	$2,921.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,921.55
Rate for Payer: Kaiser Permanente Medicaid	$2,921.55
Rate for Payer: Ohana Health Plan Medicaid	$2,921.55
Rate for Payer: UnitedHealthcare Medicaid	$2,921.55

VESSEL SEALER EXTENDED 480422

Facility

$1,969.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,004.19
Max. Negotiated Rate	$1,909.93
Rate for Payer: Cash Price	$1,181.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,870.55
Rate for Payer: Health Management Network Commercial	$1,673.65
Rate for Payer: Kaiser Permanente Commercial	$1,240.47
Rate for Payer: Kaiser Permanente Medicaid	$1,004.19
Rate for Payer: MDX Hawaii PPO	$1,909.93
Rate for Payer: University Health Alliance Commercial	$1,435.20

VESSEL SEALER EXTENDED 480422

Facility

$1,969.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,673.65
Max. Negotiated Rate	$1,909.93
Rate for Payer: Cash Price	$1,181.40
Rate for Payer: Health Management Network Commercial	$1,673.65
Rate for Payer: MDX Hawaii PPO	$1,909.93

VIABAHN BALLOON BXB085902A

Facility

$8,106.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,134.06
Max. Negotiated Rate	$7,862.82
Rate for Payer: Cash Price	$4,863.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,674.20
Rate for Payer: Health Management Network Commercial	$6,890.10
Rate for Payer: Kaiser Permanente Commercial	$5,106.78
Rate for Payer: Kaiser Permanente Medicaid	$4,134.06
Rate for Payer: MDX Hawaii PPO	$7,862.82
Rate for Payer: University Health Alliance Commercial	$4,539.36

VIABAHN BALLOON BXB085902A

Facility

$8,106.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,539.36
Max. Negotiated Rate	$7,862.82
Rate for Payer: Cash Price	$4,863.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,674.20
Rate for Payer: Health Management Network Commercial	$6,890.10
Rate for Payer: MDX Hawaii PPO	$7,862.82
Rate for Payer: University Health Alliance Commercial	$4,539.36

VIABAHN BALLOON BXBL083902A

Facility

$8,106.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,539.36
Max. Negotiated Rate	$7,862.82
Rate for Payer: Cash Price	$4,863.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,674.20
Rate for Payer: Health Management Network Commercial	$6,890.10
Rate for Payer: MDX Hawaii PPO	$7,862.82
Rate for Payer: University Health Alliance Commercial	$4,539.36

VIABAHN BALLOON BXBL083902A

Facility

$8,106.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,134.06
Max. Negotiated Rate	$7,862.82
Rate for Payer: Cash Price	$4,863.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,674.20
Rate for Payer: Health Management Network Commercial	$6,890.10
Rate for Payer: Kaiser Permanente Commercial	$5,106.78
Rate for Payer: Kaiser Permanente Medicaid	$4,134.06
Rate for Payer: MDX Hawaii PPO	$7,862.82
Rate for Payer: University Health Alliance Commercial	$4,539.36

VIABAHN BALLOON BXBL085902A

Facility

$8,106.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,539.36
Max. Negotiated Rate	$7,862.82
Rate for Payer: Cash Price	$4,863.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,674.20
Rate for Payer: Health Management Network Commercial	$6,890.10
Rate for Payer: MDX Hawaii PPO	$7,862.82
Rate for Payer: University Health Alliance Commercial	$4,539.36

VIABAHN BALLOON BXBL085902A

Facility

$8,106.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,134.06
Max. Negotiated Rate	$7,862.82
Rate for Payer: Cash Price	$4,863.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,674.20
Rate for Payer: Health Management Network Commercial	$6,890.10
Rate for Payer: Kaiser Permanente Commercial	$5,106.78
Rate for Payer: Kaiser Permanente Medicaid	$4,134.06
Rate for Payer: MDX Hawaii PPO	$7,862.82
Rate for Payer: University Health Alliance Commercial	$4,539.36

VIABAHN BX BALLOON BXA085901A

Facility

$8,106.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,539.36
Max. Negotiated Rate	$7,862.82
Rate for Payer: Cash Price	$4,863.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,674.20
Rate for Payer: Health Management Network Commercial	$6,890.10
Rate for Payer: MDX Hawaii PPO	$7,862.82
Rate for Payer: University Health Alliance Commercial	$4,539.36

VIABAHN BX BALLOON BXA085901A

Facility

$8,106.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,134.06
Max. Negotiated Rate	$7,862.82
Rate for Payer: Cash Price	$4,863.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,674.20
Rate for Payer: Health Management Network Commercial	$6,890.10
Rate for Payer: Kaiser Permanente Commercial	$5,106.78
Rate for Payer: Kaiser Permanente Medicaid	$4,134.06
Rate for Payer: MDX Hawaii PPO	$7,862.82
Rate for Payer: University Health Alliance Commercial	$4,539.36

VIABAHN BX BALLOON BXAL087901A

Facility

$8,894.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,535.94
Max. Negotiated Rate	$8,627.18
Rate for Payer: Cash Price	$5,336.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,225.80
Rate for Payer: Health Management Network Commercial	$7,559.90
Rate for Payer: Kaiser Permanente Commercial	$5,603.22
Rate for Payer: Kaiser Permanente Medicaid	$4,535.94
Rate for Payer: MDX Hawaii PPO	$8,627.18
Rate for Payer: University Health Alliance Commercial	$4,980.64

VIABAHN BX BALLOON BXAL087901A

Facility

$8,894.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,980.64
Max. Negotiated Rate	$8,627.18
Rate for Payer: Cash Price	$5,336.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,225.80
Rate for Payer: Health Management Network Commercial	$7,559.90
Rate for Payer: MDX Hawaii PPO	$8,627.18
Rate for Payer: University Health Alliance Commercial	$4,980.64

VIABAHN ENDOPROSTH VBHR060501A

Facility

$7,918.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,434.08
Max. Negotiated Rate	$7,680.46
Rate for Payer: Cash Price	$4,750.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,542.60
Rate for Payer: Health Management Network Commercial	$6,730.30
Rate for Payer: MDX Hawaii PPO	$7,680.46
Rate for Payer: University Health Alliance Commercial	$4,434.08

VIABAHN ENDOPROSTH VBHR060501A

Facility

$7,918.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,038.18
Max. Negotiated Rate	$7,680.46
Rate for Payer: Cash Price	$4,750.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,542.60
Rate for Payer: Health Management Network Commercial	$6,730.30
Rate for Payer: Kaiser Permanente Commercial	$4,988.34
Rate for Payer: Kaiser Permanente Medicaid	$4,038.18
Rate for Payer: MDX Hawaii PPO	$7,680.46
Rate for Payer: University Health Alliance Commercial	$4,434.08

VIABAHN GORE VBHR081001A

Facility

$8,002.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,481.12
Max. Negotiated Rate	$7,761.94
Rate for Payer: Cash Price	$4,801.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,601.40
Rate for Payer: Health Management Network Commercial	$6,801.70
Rate for Payer: MDX Hawaii PPO	$7,761.94
Rate for Payer: University Health Alliance Commercial	$4,481.12

VIABAHN GORE VBHR081001A

Facility

$8,002.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,081.02
Max. Negotiated Rate	$7,761.94
Rate for Payer: Cash Price	$4,801.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,601.40
Rate for Payer: Health Management Network Commercial	$6,801.70
Rate for Payer: Kaiser Permanente Commercial	$5,041.26
Rate for Payer: Kaiser Permanente Medicaid	$4,081.02
Rate for Payer: MDX Hawaii PPO	$7,761.94
Rate for Payer: University Health Alliance Commercial	$4,481.12

VIABAHN SX ENDO VBHR061001A

Facility

$8,684.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,428.84
Max. Negotiated Rate	$8,423.48
Rate for Payer: Cash Price	$5,210.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,078.80
Rate for Payer: Health Management Network Commercial	$7,381.40
Rate for Payer: Kaiser Permanente Commercial	$5,470.92
Rate for Payer: Kaiser Permanente Medicaid	$4,428.84
Rate for Payer: MDX Hawaii PPO	$8,423.48
Rate for Payer: University Health Alliance Commercial	$4,863.04

VIABAHN SX ENDO VBHR061001A

Facility

$8,684.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,863.04
Max. Negotiated Rate	$8,423.48
Rate for Payer: Cash Price	$5,210.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,078.80
Rate for Payer: Health Management Network Commercial	$7,381.40
Rate for Payer: MDX Hawaii PPO	$8,423.48
Rate for Payer: University Health Alliance Commercial	$4,863.04

VIABAHN VBX EX BAL BXA073901A

Facility

$6,510.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,645.60
Max. Negotiated Rate	$6,314.70
Rate for Payer: Cash Price	$3,906.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,557.00
Rate for Payer: Health Management Network Commercial	$5,533.50
Rate for Payer: MDX Hawaii PPO	$6,314.70
Rate for Payer: University Health Alliance Commercial	$3,645.60

Know your out-of-pocket cost for care.

All Charges