Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

ENDOPATH BLUNT DISSECTOR

Facility

$257.00

Hospital Revenue Code	272
Min. Negotiated Rate	$131.07
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$154.20
Rate for Payer: Hawaii Western Management Group Commercial	$244.15
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$161.91
Rate for Payer: Kaiser Permanente Medicaid	$131.07
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: University Health Alliance Commercial	$187.33

ENDOPROSTHESIS 7FR VBJR081502A

Facility

$8,980.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,579.80
Max. Negotiated Rate	$8,710.60
Rate for Payer: Cash Price	$5,388.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,286.00
Rate for Payer: Health Management Network Commercial	$7,633.00
Rate for Payer: Kaiser Permanente Commercial	$5,657.40
Rate for Payer: Kaiser Permanente Medicaid	$4,579.80
Rate for Payer: MDX Hawaii PPO	$8,710.60
Rate for Payer: University Health Alliance Commercial	$5,028.80

ENDOPROSTHESIS 7FR VBJR081502A

Facility

$8,980.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$5,028.80
Max. Negotiated Rate	$8,710.60
Rate for Payer: Cash Price	$5,388.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,286.00
Rate for Payer: Health Management Network Commercial	$7,633.00
Rate for Payer: MDX Hawaii PPO	$8,710.60
Rate for Payer: University Health Alliance Commercial	$5,028.80

ENDOPROSTHESIS VBHR091002A

Facility

$7,138.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,997.28
Max. Negotiated Rate	$6,923.86
Rate for Payer: Cash Price	$4,282.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,996.60
Rate for Payer: Health Management Network Commercial	$6,067.30
Rate for Payer: MDX Hawaii PPO	$6,923.86
Rate for Payer: University Health Alliance Commercial	$3,997.28

ENDOPROSTHESIS VBHR091002A

Facility

$7,138.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,640.38
Max. Negotiated Rate	$6,923.86
Rate for Payer: Cash Price	$4,282.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,996.60
Rate for Payer: Health Management Network Commercial	$6,067.30
Rate for Payer: Kaiser Permanente Commercial	$4,496.94
Rate for Payer: Kaiser Permanente Medicaid	$3,640.38
Rate for Payer: MDX Hawaii PPO	$6,923.86
Rate for Payer: University Health Alliance Commercial	$3,997.28

ENDOPROSTHESIS VBHR131002A

Facility

$7,138.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,997.28
Max. Negotiated Rate	$6,923.86
Rate for Payer: Cash Price	$4,282.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,996.60
Rate for Payer: Health Management Network Commercial	$6,067.30
Rate for Payer: MDX Hawaii PPO	$6,923.86
Rate for Payer: University Health Alliance Commercial	$3,997.28

ENDOPROSTHESIS VBHR131002A

Facility

$7,138.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,640.38
Max. Negotiated Rate	$6,923.86
Rate for Payer: Cash Price	$4,282.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,996.60
Rate for Payer: Health Management Network Commercial	$6,067.30
Rate for Payer: Kaiser Permanente Commercial	$4,496.94
Rate for Payer: Kaiser Permanente Medicaid	$3,640.38
Rate for Payer: MDX Hawaii PPO	$6,923.86
Rate for Payer: University Health Alliance Commercial	$3,997.28

ENDOPROSTHE VIABHN VBHR111002A

Facility

$8,242.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,203.42
Max. Negotiated Rate	$7,994.74
Rate for Payer: Cash Price	$4,945.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,769.40
Rate for Payer: Health Management Network Commercial	$7,005.70
Rate for Payer: Kaiser Permanente Commercial	$5,192.46
Rate for Payer: Kaiser Permanente Medicaid	$4,203.42
Rate for Payer: MDX Hawaii PPO	$7,994.74
Rate for Payer: University Health Alliance Commercial	$4,615.52

ENDOPROSTHE VIABHN VBHR111002A

Facility

$8,242.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,615.52
Max. Negotiated Rate	$7,994.74
Rate for Payer: Cash Price	$4,945.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,769.40
Rate for Payer: Health Management Network Commercial	$7,005.70
Rate for Payer: MDX Hawaii PPO	$7,994.74
Rate for Payer: University Health Alliance Commercial	$4,615.52

ENDORA 8 SR-T 407157

Facility

$9,600.00

Service Code	HCPCS C1786
Hospital Revenue Code	275
Min. Negotiated Rate	$5,376.00
Max. Negotiated Rate	$9,312.00
Rate for Payer: Cash Price	$5,760.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,720.00
Rate for Payer: Health Management Network Commercial	$8,160.00
Rate for Payer: MDX Hawaii PPO	$9,312.00
Rate for Payer: University Health Alliance Commercial	$5,376.00

ENDORA 8 SR-T 407157

Facility

$9,600.00

Service Code	HCPCS C1786
Hospital Revenue Code	275
Min. Negotiated Rate	$4,896.00
Max. Negotiated Rate	$9,312.00
Rate for Payer: Cash Price	$5,760.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,720.00
Rate for Payer: Health Management Network Commercial	$8,160.00
Rate for Payer: Kaiser Permanente Commercial	$6,048.00
Rate for Payer: Kaiser Permanente Medicaid	$4,896.00
Rate for Payer: MDX Hawaii PPO	$9,312.00
Rate for Payer: University Health Alliance Commercial	$5,376.00

ENDOSCOPIC CANNULATION OF PAPILLA WITH DIRECT VISUALIZATION OF PANCREATIC/COMMON BILE DUCT(S) (LIST SEPARATELY IN ADDITION TO CODE(S) FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 43273
Hospital Revenue Code	360
Min. Negotiated Rate	$77.91
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$77.91

ENDOSCOPIC HELIX M00505500

Facility

$2,612.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,332.12
Max. Negotiated Rate	$2,533.64
Rate for Payer: Cash Price	$1,567.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,481.40
Rate for Payer: Health Management Network Commercial	$2,220.20
Rate for Payer: Kaiser Permanente Commercial	$1,645.56
Rate for Payer: Kaiser Permanente Medicaid	$1,332.12
Rate for Payer: MDX Hawaii PPO	$2,533.64
Rate for Payer: University Health Alliance Commercial	$1,903.89

ENDOSCOPIC HELIX M00505500

Facility

$2,612.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,220.20
Max. Negotiated Rate	$2,533.64
Rate for Payer: Cash Price	$1,567.20
Rate for Payer: Health Management Network Commercial	$2,220.20
Rate for Payer: MDX Hawaii PPO	$2,533.64

ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK

Facility

$8,270.00

Service Code	CPT 51715
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22
Rate for Payer: University Health Alliance Commercial	$6,743.44

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)

Facility

$5,509.00

Service Code	CPT 43260
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$4,554.64
Rate for Payer: AlohaCare Medicare	$4,554.64
Rate for Payer: Devoted Health Medicare	$5,010.10
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	$4,554.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$4,554.64
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,554.64
Rate for Payer: Ohana Health Plan Medicaid	$5,010.10
Rate for Payer: Ohana Health Plan Medicare	$4,554.64
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,554.64
Rate for Payer: University Health Alliance Commercial	$5,160.40

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE

Facility

$8,270.00

Service Code	CPT 43261
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$4,554.64
Rate for Payer: AlohaCare Medicare	$4,554.64
Rate for Payer: Devoted Health Medicare	$5,010.10
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,554.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$4,554.64
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,554.64
Rate for Payer: Ohana Health Plan Medicaid	$5,010.10
Rate for Payer: Ohana Health Plan Medicare	$4,554.64
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,554.64
Rate for Payer: University Health Alliance Commercial	$5,160.40

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT

Facility

$13,778.00

Service Code	CPT 43274
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$7,171.82
Rate for Payer: AlohaCare Medicare	$7,171.82
Rate for Payer: Devoted Health Medicare	$7,889.00
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	$7,171.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$7,171.82
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,171.82
Rate for Payer: Ohana Health Plan Medicaid	$7,889.00
Rate for Payer: Ohana Health Plan Medicare	$7,171.82
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$7,171.82
Rate for Payer: University Health Alliance Commercial	$10,679.55

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED

Facility

$13,778.00

Service Code	CPT 43276
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$7,171.82
Rate for Payer: AlohaCare Medicare	$7,171.82
Rate for Payer: Devoted Health Medicare	$7,889.00
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	$7,171.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$7,171.82
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,171.82
Rate for Payer: Ohana Health Plan Medicaid	$7,889.00
Rate for Payer: Ohana Health Plan Medicare	$7,171.82
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$7,171.82
Rate for Payer: University Health Alliance Commercial	$10,679.55

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S)

Facility

$13,778.00

Service Code	CPT 43264
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$4,554.64
Rate for Payer: AlohaCare Medicare	$4,554.64
Rate for Payer: Devoted Health Medicare	$5,010.10
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	$4,554.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$4,554.64
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,554.64
Rate for Payer: Ohana Health Plan Medicaid	$5,010.10
Rate for Payer: Ohana Health Plan Medicare	$4,554.64
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,554.64
Rate for Payer: University Health Alliance Commercial	$5,160.40

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S)

Facility

$10,679.55

Service Code	CPT 43275
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$2,266.89
Rate for Payer: AlohaCare Medicare	$2,266.89
Rate for Payer: Devoted Health Medicare	$2,493.58
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,266.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$2,266.89
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,266.89
Rate for Payer: Ohana Health Plan Medicaid	$2,493.58
Rate for Payer: Ohana Health Plan Medicare	$2,266.89
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,266.89
Rate for Payer: University Health Alliance Commercial	$10,679.55

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY

Facility

$5,509.00

Service Code	CPT 43262
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$4,554.64
Rate for Payer: AlohaCare Medicare	$4,554.64
Rate for Payer: Devoted Health Medicare	$5,010.10
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	$4,554.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$4,554.64
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,554.64
Rate for Payer: Ohana Health Plan Medicaid	$5,010.10
Rate for Payer: Ohana Health Plan Medicare	$4,554.64
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,554.64
Rate for Payer: University Health Alliance Commercial	$5,160.40

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT

Facility

$8,270.00

Service Code	CPT 43277
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$4,554.64
Rate for Payer: AlohaCare Medicare	$4,554.64
Rate for Payer: Devoted Health Medicare	$5,010.10
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,554.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$4,554.64
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,554.64
Rate for Payer: Ohana Health Plan Medicaid	$5,010.10
Rate for Payer: Ohana Health Plan Medicare	$4,554.64
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,554.64

ENDO STITCH 10MM

Facility

$408.00

Hospital Revenue Code	272
Min. Negotiated Rate	$208.08
Max. Negotiated Rate	$395.76
Rate for Payer: Cash Price	$244.80
Rate for Payer: Hawaii Western Management Group Commercial	$387.60
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Kaiser Permanente Commercial	$257.04
Rate for Payer: Kaiser Permanente Medicaid	$208.08
Rate for Payer: MDX Hawaii PPO	$395.76
Rate for Payer: University Health Alliance Commercial	$297.39

ENDO STITCH 10MM

Facility

$408.00

Hospital Revenue Code	272
Min. Negotiated Rate	$346.80
Max. Negotiated Rate	$395.76
Rate for Payer: Cash Price	$244.80
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: MDX Hawaii PPO	$395.76

Know your out-of-pocket cost for care.

All Charges