Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

FLEX SHOULDER SYS DWF500

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,020.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,260.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

FLEX SHOULDER SYS DWF500

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

FLEX SHOULDER SYS DWG043

Facility

$6,032.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,076.32
Max. Negotiated Rate	$5,851.04
Rate for Payer: Cash Price	$3,619.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,222.40
Rate for Payer: Health Management Network Commercial	$5,127.20
Rate for Payer: Kaiser Permanente Commercial	$3,800.16
Rate for Payer: Kaiser Permanente Medicaid	$3,076.32
Rate for Payer: MDX Hawaii PPO	$5,851.04
Rate for Payer: University Health Alliance Commercial	$3,377.92

FLEX SHOULDER SYS DWG043

Facility

$6,032.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,377.92
Max. Negotiated Rate	$5,851.04
Rate for Payer: Cash Price	$3,619.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,222.40
Rate for Payer: Health Management Network Commercial	$5,127.20
Rate for Payer: MDX Hawaii PPO	$5,851.04
Rate for Payer: University Health Alliance Commercial	$3,377.92

FLEX SHOULDER SYS DWG045

Facility

$8,306.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,236.06
Max. Negotiated Rate	$8,056.82
Rate for Payer: Cash Price	$4,983.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,814.20
Rate for Payer: Health Management Network Commercial	$7,060.10
Rate for Payer: Kaiser Permanente Commercial	$5,232.78
Rate for Payer: Kaiser Permanente Medicaid	$4,236.06
Rate for Payer: MDX Hawaii PPO	$8,056.82
Rate for Payer: University Health Alliance Commercial	$4,651.36

FLEX SHOULDER SYS DWG045

Facility

$8,306.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,651.36
Max. Negotiated Rate	$8,056.82
Rate for Payer: Cash Price	$4,983.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,814.20
Rate for Payer: Health Management Network Commercial	$7,060.10
Rate for Payer: MDX Hawaii PPO	$8,056.82
Rate for Payer: University Health Alliance Commercial	$4,651.36

FLEX SHOULDER SYS DWG049

Facility

$6,032.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,377.92
Max. Negotiated Rate	$5,851.04
Rate for Payer: Cash Price	$3,619.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,222.40
Rate for Payer: Health Management Network Commercial	$5,127.20
Rate for Payer: MDX Hawaii PPO	$5,851.04
Rate for Payer: University Health Alliance Commercial	$3,377.92

FLEX SHOULDER SYS DWG049

Facility

$6,032.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,076.32
Max. Negotiated Rate	$5,851.04
Rate for Payer: Cash Price	$3,619.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,222.40
Rate for Payer: Health Management Network Commercial	$5,127.20
Rate for Payer: Kaiser Permanente Commercial	$3,800.16
Rate for Payer: Kaiser Permanente Medicaid	$3,076.32
Rate for Payer: MDX Hawaii PPO	$5,851.04
Rate for Payer: University Health Alliance Commercial	$3,377.92

FLEX SHOULDER SYSTEM DWG050

Facility

$8,366.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,684.96
Max. Negotiated Rate	$8,115.02
Rate for Payer: Cash Price	$5,019.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,856.20
Rate for Payer: Health Management Network Commercial	$7,111.10
Rate for Payer: MDX Hawaii PPO	$8,115.02
Rate for Payer: University Health Alliance Commercial	$4,684.96

FLEX SHOULDER SYSTEM DWG050

Facility

$8,366.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,266.66
Max. Negotiated Rate	$8,115.02
Rate for Payer: Cash Price	$5,019.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,856.20
Rate for Payer: Health Management Network Commercial	$7,111.10
Rate for Payer: Kaiser Permanente Commercial	$5,270.58
Rate for Payer: Kaiser Permanente Medicaid	$4,266.66
Rate for Payer: MDX Hawaii PPO	$8,115.02
Rate for Payer: University Health Alliance Commercial	$4,684.96

FLEX SHOULDER SYSTEM DWG053

Facility

$8,834.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,505.34
Max. Negotiated Rate	$8,568.98
Rate for Payer: Cash Price	$5,300.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,183.80
Rate for Payer: Health Management Network Commercial	$7,508.90
Rate for Payer: Kaiser Permanente Commercial	$5,565.42
Rate for Payer: Kaiser Permanente Medicaid	$4,505.34
Rate for Payer: MDX Hawaii PPO	$8,568.98
Rate for Payer: University Health Alliance Commercial	$4,947.04

FLEX SHOULDER SYSTEM DWG053

Facility

$8,834.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,947.04
Max. Negotiated Rate	$8,568.98
Rate for Payer: Cash Price	$5,300.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,183.80
Rate for Payer: Health Management Network Commercial	$7,508.90
Rate for Payer: MDX Hawaii PPO	$8,568.98
Rate for Payer: University Health Alliance Commercial	$4,947.04

FLEX SHOULDER SYSTEM DWG150

Facility

$8,834.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,947.04
Max. Negotiated Rate	$8,568.98
Rate for Payer: Cash Price	$5,300.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,183.80
Rate for Payer: Health Management Network Commercial	$7,508.90
Rate for Payer: MDX Hawaii PPO	$8,568.98
Rate for Payer: University Health Alliance Commercial	$4,947.04

FLEX SHOULDER SYSTEM DWG150

Facility

$8,834.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,505.34
Max. Negotiated Rate	$8,568.98
Rate for Payer: Cash Price	$5,300.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,183.80
Rate for Payer: Health Management Network Commercial	$7,508.90
Rate for Payer: Kaiser Permanente Commercial	$5,565.42
Rate for Payer: Kaiser Permanente Medicaid	$4,505.34
Rate for Payer: MDX Hawaii PPO	$8,568.98
Rate for Payer: University Health Alliance Commercial	$4,947.04

FLIPCUTTER 3 DRILL AR-1204FF

Facility

$1,453.00

Hospital Revenue Code	272
Min. Negotiated Rate	$741.03
Max. Negotiated Rate	$1,409.41
Rate for Payer: Cash Price	$871.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,380.35
Rate for Payer: Health Management Network Commercial	$1,235.05
Rate for Payer: Kaiser Permanente Commercial	$915.39
Rate for Payer: Kaiser Permanente Medicaid	$741.03
Rate for Payer: MDX Hawaii PPO	$1,409.41
Rate for Payer: University Health Alliance Commercial	$1,059.09

FLIPCUTTER 3 DRILL AR-1204FF

Facility

$1,453.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,235.05
Max. Negotiated Rate	$1,409.41
Rate for Payer: Cash Price	$871.80
Rate for Payer: Health Management Network Commercial	$1,235.05
Rate for Payer: MDX Hawaii PPO	$1,409.41

FLOPPY STR TIP GUIDEWIRE 9X330

Facility

$1,120.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$571.20
Max. Negotiated Rate	$1,086.40
Rate for Payer: Cash Price	$672.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,064.00
Rate for Payer: Health Management Network Commercial	$952.00
Rate for Payer: Kaiser Permanente Commercial	$705.60
Rate for Payer: Kaiser Permanente Medicaid	$571.20
Rate for Payer: MDX Hawaii PPO	$1,086.40
Rate for Payer: University Health Alliance Commercial	$816.37

FLOPPY STR TIP GUIDEWIRE 9X330

Facility

$1,120.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$952.00
Max. Negotiated Rate	$1,086.40
Rate for Payer: Cash Price	$672.00
Rate for Payer: Health Management Network Commercial	$952.00
Rate for Payer: MDX Hawaii PPO	$1,086.40

FLO-RESTER, DISP VESSEL OCLDR

Facility

$295.00

Hospital Revenue Code	272
Min. Negotiated Rate	$150.45
Max. Negotiated Rate	$286.15
Rate for Payer: Cash Price	$177.00
Rate for Payer: Hawaii Western Management Group Commercial	$280.25
Rate for Payer: Health Management Network Commercial	$250.75
Rate for Payer: Kaiser Permanente Commercial	$185.85
Rate for Payer: Kaiser Permanente Medicaid	$150.45
Rate for Payer: MDX Hawaii PPO	$286.15
Rate for Payer: University Health Alliance Commercial	$215.03

FLO-RESTER, DISP VESSEL OCLDR

Facility

$295.00

Hospital Revenue Code	272
Min. Negotiated Rate	$250.75
Max. Negotiated Rate	$286.15
Rate for Payer: Cash Price	$177.00
Rate for Payer: Health Management Network Commercial	$250.75
Rate for Payer: MDX Hawaii PPO	$286.15

FLOSEAL HEMOSTATC 10ML 1505291

Facility

$1,356.00

Hospital Revenue Code	250
Min. Negotiated Rate	$691.56
Max. Negotiated Rate	$1,315.32
Rate for Payer: Cash Price	$813.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,288.20
Rate for Payer: Health Management Network Commercial	$1,152.60
Rate for Payer: Kaiser Permanente Commercial	$854.28
Rate for Payer: Kaiser Permanente Medicaid	$691.56
Rate for Payer: MDX Hawaii PPO	$1,315.32
Rate for Payer: UnitedHealthcare Medicaid	$813.60
Rate for Payer: University Health Alliance Commercial	$988.39

FLOSEAL HEMOSTATC 10ML 1505291

Facility

$1,356.00

Hospital Revenue Code	250
Min. Negotiated Rate	$1,152.60
Max. Negotiated Rate	$1,315.32
Rate for Payer: Cash Price	$813.60
Rate for Payer: Health Management Network Commercial	$1,152.60
Rate for Payer: MDX Hawaii PPO	$1,315.32

FLOSEAL HEMOSTATIC ADS202105

Facility

$911.00

Hospital Revenue Code	250
Min. Negotiated Rate	$464.61
Max. Negotiated Rate	$883.67
Rate for Payer: Cash Price	$546.60
Rate for Payer: Hawaii Western Management Group Commercial	$865.45
Rate for Payer: Health Management Network Commercial	$774.35
Rate for Payer: Kaiser Permanente Commercial	$573.93
Rate for Payer: Kaiser Permanente Medicaid	$464.61
Rate for Payer: MDX Hawaii PPO	$883.67
Rate for Payer: UnitedHealthcare Medicaid	$546.60
Rate for Payer: University Health Alliance Commercial	$664.03

FLOSEAL HEMOSTATIC ADS202105

Facility

$911.00

Hospital Revenue Code	250
Min. Negotiated Rate	$774.35
Max. Negotiated Rate	$883.67
Rate for Payer: Cash Price	$546.60
Rate for Payer: Health Management Network Commercial	$774.35
Rate for Payer: MDX Hawaii PPO	$883.67

FLT3 GENE ANLYS TYROSINE KINASE DOMAIN VARIANTS

Facility

$696.00

Service Code	HCPCS 81246
Hospital Charge Code	3108124601
Hospital Revenue Code	310
Min. Negotiated Rate	$62.25
Max. Negotiated Rate	$675.12
Rate for Payer: AlohaCare Medicaid	$83.00
Rate for Payer: AlohaCare Medicare	$83.00
Rate for Payer: Cash Price	$417.60
Rate for Payer: Cash Price	$417.60
Rate for Payer: Devoted Health Medicare	$91.30
Rate for Payer: Hawaii Medical Service Association ABD	$83.04
Rate for Payer: Hawaii Medical Service Association Commercial	$103.75
Rate for Payer: Hawaii Medical Service Association Medicare	$83.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$83.04
Rate for Payer: Hawaii Western Management Group Commercial	$83.00
Rate for Payer: Health Management Network Commercial	$591.60
Rate for Payer: Humana Medicare	$83.00
Rate for Payer: Kaiser Permanente Commercial	$438.48
Rate for Payer: Kaiser Permanente Medicaid	$354.96
Rate for Payer: Kaiser Permanente Medicare	$83.00
Rate for Payer: MDX Hawaii PPO	$675.12
Rate for Payer: Ohana Health Plan Medicaid	$91.30
Rate for Payer: Ohana Health Plan Medicare	$83.00
Rate for Payer: UnitedHealthcare Medicaid	$62.25
Rate for Payer: UnitedHealthcare Medicare	$83.00
Rate for Payer: University Health Alliance Commercial	$507.31

Know your out-of-pocket cost for care.

All Charges