Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

WRAP EAR FLENTS EAVEY

Facility

$98.00

Hospital Revenue Code	272
Min. Negotiated Rate	$83.30
Max. Negotiated Rate	$95.06
Rate for Payer: Cash Price	$58.80
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: MDX Hawaii PPO	$95.06

WRAP EAR FLENTS EAVEY

Facility

$98.00

Hospital Revenue Code	272
Min. Negotiated Rate	$49.98
Max. Negotiated Rate	$95.06
Rate for Payer: Cash Price	$58.80
Rate for Payer: Hawaii Western Management Group Commercial	$93.10
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Kaiser Permanente Commercial	$61.74
Rate for Payer: Kaiser Permanente Medicaid	$49.98
Rate for Payer: MDX Hawaii PPO	$95.06
Rate for Payer: University Health Alliance Commercial	$71.43

WRENCH ALLEN 3MM 10.012

Facility

$88.00

Hospital Revenue Code	272
Min. Negotiated Rate	$44.88
Max. Negotiated Rate	$85.36
Rate for Payer: Cash Price	$52.80
Rate for Payer: Hawaii Western Management Group Commercial	$83.60
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Kaiser Permanente Commercial	$55.44
Rate for Payer: Kaiser Permanente Medicaid	$44.88
Rate for Payer: MDX Hawaii PPO	$85.36
Rate for Payer: University Health Alliance Commercial	$64.14

WRENCH ALLEN 3MM 10.012

Facility

$88.00

Hospital Revenue Code	272
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$85.36
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: MDX Hawaii PPO	$85.36

WRENCH TORQUE 108984

Facility

$200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: University Health Alliance Commercial	$145.78

WRENCH TORQUE 108984

Facility

$200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: MDX Hawaii PPO	$194.00

XEN AB 19CMx35CM 1151935

Facility

$40,520.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$20,665.20
Max. Negotiated Rate	$39,304.40
Rate for Payer: Cash Price	$24,312.00
Rate for Payer: Hawaii Western Management Group Commercial	$28,364.00
Rate for Payer: Health Management Network Commercial	$34,442.00
Rate for Payer: Kaiser Permanente Commercial	$25,527.60
Rate for Payer: Kaiser Permanente Medicaid	$20,665.20
Rate for Payer: MDX Hawaii PPO	$39,304.40
Rate for Payer: University Health Alliance Commercial	$22,691.20

XEN AB 19CMx35CM 1151935

Facility

$40,520.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$22,691.20
Max. Negotiated Rate	$39,304.40
Rate for Payer: Cash Price	$24,312.00
Rate for Payer: Hawaii Western Management Group Commercial	$28,364.00
Rate for Payer: Health Management Network Commercial	$34,442.00
Rate for Payer: MDX Hawaii PPO	$39,304.40
Rate for Payer: University Health Alliance Commercial	$22,691.20

XENMATRIX 10X15 BIOLOGY GRAFT

Facility

$8,620.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$4,396.20
Max. Negotiated Rate	$8,361.40
Rate for Payer: Cash Price	$5,172.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,034.00
Rate for Payer: Health Management Network Commercial	$7,327.00
Rate for Payer: Kaiser Permanente Commercial	$5,430.60
Rate for Payer: Kaiser Permanente Medicaid	$4,396.20
Rate for Payer: MDX Hawaii PPO	$8,361.40
Rate for Payer: University Health Alliance Commercial	$4,827.20

XENMATRIX 10X15 BIOLOGY GRAFT

Facility

$8,620.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$4,827.20
Max. Negotiated Rate	$8,361.40
Rate for Payer: Cash Price	$5,172.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,034.00
Rate for Payer: Health Management Network Commercial	$7,327.00
Rate for Payer: MDX Hawaii PPO	$8,361.40
Rate for Payer: University Health Alliance Commercial	$4,827.20

XENMATRIX 19X35 BIOLOGIC GRAFT

Facility

$38,529.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$21,576.24
Max. Negotiated Rate	$37,373.13
Rate for Payer: Cash Price	$23,117.40
Rate for Payer: Hawaii Western Management Group Commercial	$26,970.30
Rate for Payer: Health Management Network Commercial	$32,749.65
Rate for Payer: MDX Hawaii PPO	$37,373.13
Rate for Payer: University Health Alliance Commercial	$21,576.24

XENMATRIX 19X35 BIOLOGIC GRAFT

Facility

$38,529.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$19,649.79
Max. Negotiated Rate	$37,373.13
Rate for Payer: Cash Price	$23,117.40
Rate for Payer: Hawaii Western Management Group Commercial	$26,970.30
Rate for Payer: Health Management Network Commercial	$32,749.65
Rate for Payer: Kaiser Permanente Commercial	$24,273.27
Rate for Payer: Kaiser Permanente Medicaid	$19,649.79
Rate for Payer: MDX Hawaii PPO	$37,373.13
Rate for Payer: University Health Alliance Commercial	$21,576.24

XENMATRIX XEN AB 10X15 1151015

Facility

$9,480.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$4,834.80
Max. Negotiated Rate	$9,195.60
Rate for Payer: Cash Price	$5,688.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,636.00
Rate for Payer: Health Management Network Commercial	$8,058.00
Rate for Payer: Kaiser Permanente Commercial	$5,972.40
Rate for Payer: Kaiser Permanente Medicaid	$4,834.80
Rate for Payer: MDX Hawaii PPO	$9,195.60
Rate for Payer: University Health Alliance Commercial	$5,308.80

XENMATRIX XEN AB 10X15 1151015

Facility

$9,480.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$5,308.80
Max. Negotiated Rate	$9,195.60
Rate for Payer: Cash Price	$5,688.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,636.00
Rate for Payer: Health Management Network Commercial	$8,058.00
Rate for Payer: MDX Hawaii PPO	$9,195.60
Rate for Payer: University Health Alliance Commercial	$5,308.80

XENOSURE BIOLOGIC PATCH 1.5X10

Facility

$1,047.00

Hospital Revenue Code	278
Min. Negotiated Rate	$533.97
Max. Negotiated Rate	$1,015.59
Rate for Payer: Cash Price	$628.20
Rate for Payer: Hawaii Western Management Group Commercial	$732.90
Rate for Payer: Health Management Network Commercial	$889.95
Rate for Payer: Kaiser Permanente Commercial	$659.61
Rate for Payer: Kaiser Permanente Medicaid	$533.97
Rate for Payer: MDX Hawaii PPO	$1,015.59
Rate for Payer: University Health Alliance Commercial	$586.32

XENOSURE BIOLOGIC PATCH 1.5X10

Facility

$1,047.00

Hospital Revenue Code	278
Min. Negotiated Rate	$586.32
Max. Negotiated Rate	$1,015.59
Rate for Payer: Cash Price	$628.20
Rate for Payer: Hawaii Western Management Group Commercial	$732.90
Rate for Payer: Health Management Network Commercial	$889.95
Rate for Payer: MDX Hawaii PPO	$1,015.59
Rate for Payer: University Health Alliance Commercial	$586.32

XENOSURE BIOLOGIC PATCH 1.5X14

Facility

$1,190.00

Hospital Revenue Code	278
Min. Negotiated Rate	$666.40
Max. Negotiated Rate	$1,154.30
Rate for Payer: Cash Price	$714.00
Rate for Payer: Hawaii Western Management Group Commercial	$833.00
Rate for Payer: Health Management Network Commercial	$1,011.50
Rate for Payer: MDX Hawaii PPO	$1,154.30
Rate for Payer: University Health Alliance Commercial	$666.40

XENOSURE BIOLOGIC PATCH 1.5X14

Facility

$1,190.00

Hospital Revenue Code	278
Min. Negotiated Rate	$606.90
Max. Negotiated Rate	$1,154.30
Rate for Payer: Cash Price	$714.00
Rate for Payer: Hawaii Western Management Group Commercial	$833.00
Rate for Payer: Health Management Network Commercial	$1,011.50
Rate for Payer: Kaiser Permanente Commercial	$749.70
Rate for Payer: Kaiser Permanente Medicaid	$606.90
Rate for Payer: MDX Hawaii PPO	$1,154.30
Rate for Payer: University Health Alliance Commercial	$666.40

XENOSURE BIOLOGIC VAS PATCH

Facility

$859.00

Hospital Revenue Code	278
Min. Negotiated Rate	$438.09
Max. Negotiated Rate	$833.23
Rate for Payer: Cash Price	$515.40
Rate for Payer: Hawaii Western Management Group Commercial	$601.30
Rate for Payer: Health Management Network Commercial	$730.15
Rate for Payer: Kaiser Permanente Commercial	$541.17
Rate for Payer: Kaiser Permanente Medicaid	$438.09
Rate for Payer: MDX Hawaii PPO	$833.23
Rate for Payer: University Health Alliance Commercial	$481.04

XENOSURE BIOLOGIC VAS PATCH

Facility

$859.00

Hospital Revenue Code	278
Min. Negotiated Rate	$481.04
Max. Negotiated Rate	$833.23
Rate for Payer: Cash Price	$515.40
Rate for Payer: Hawaii Western Management Group Commercial	$601.30
Rate for Payer: Health Management Network Commercial	$730.15
Rate for Payer: MDX Hawaii PPO	$833.23
Rate for Payer: University Health Alliance Commercial	$481.04

XXL ESOPHAGEAL 18X4X75

Facility

$851.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$723.35
Max. Negotiated Rate	$825.47
Rate for Payer: Cash Price	$510.60
Rate for Payer: Health Management Network Commercial	$723.35
Rate for Payer: MDX Hawaii PPO	$825.47

XXL ESOPHAGEAL 18X4X75

Facility

$851.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$434.01
Max. Negotiated Rate	$825.47
Rate for Payer: Cash Price	$510.60
Rate for Payer: Hawaii Western Management Group Commercial	$808.45
Rate for Payer: Health Management Network Commercial	$723.35
Rate for Payer: Kaiser Permanente Commercial	$536.13
Rate for Payer: Kaiser Permanente Medicaid	$434.01
Rate for Payer: MDX Hawaii PPO	$825.47
Rate for Payer: University Health Alliance Commercial	$620.29

Y-ADAPTER NS SGL 5920-000-304

Facility

$132.00

Hospital Revenue Code	272
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$79.20
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: MDX Hawaii PPO	$128.04

Y-ADAPTER NS SGL 5920-000-304

Facility

$132.00

Hospital Revenue Code	272
Min. Negotiated Rate	$67.32
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$79.20
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$83.16
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: University Health Alliance Commercial	$96.21

YOUNGSWICK 1MM ACCUCUT 19506

Facility

$469.00

Hospital Revenue Code	272
Min. Negotiated Rate	$239.19
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$281.40
Rate for Payer: Hawaii Western Management Group Commercial	$445.55
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Kaiser Permanente Commercial	$295.47
Rate for Payer: Kaiser Permanente Medicaid	$239.19
Rate for Payer: MDX Hawaii PPO	$454.93
Rate for Payer: University Health Alliance Commercial	$341.85

Know your out-of-pocket cost for care.

All Charges