Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GORE ERLY CANN GRFT ECH470045A

Facility

$2,960.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,657.60
Max. Negotiated Rate	$2,871.20
Rate for Payer: Cash Price	$1,776.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,072.00
Rate for Payer: Health Management Network Commercial	$2,516.00
Rate for Payer: MDX Hawaii PPO	$2,871.20
Rate for Payer: University Health Alliance Commercial	$1,657.60

GORE GRAFT 12X50CM SBT1202D

Facility

$2,892.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,474.92
Max. Negotiated Rate	$2,805.24
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,024.40
Rate for Payer: Health Management Network Commercial	$2,458.20
Rate for Payer: Kaiser Permanente Commercial	$1,821.96
Rate for Payer: Kaiser Permanente Medicaid	$1,474.92
Rate for Payer: MDX Hawaii PPO	$2,805.24
Rate for Payer: University Health Alliance Commercial	$1,619.52

GORE GRAFT 12X50CM SBT1202D

Facility

$2,892.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,619.52
Max. Negotiated Rate	$2,805.24
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,024.40
Rate for Payer: Health Management Network Commercial	$2,458.20
Rate for Payer: MDX Hawaii PPO	$2,805.24
Rate for Payer: University Health Alliance Commercial	$1,619.52

GORE INTERING 4-7X45 IRS47045L

Facility

$1,947.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,090.32
Max. Negotiated Rate	$1,888.59
Rate for Payer: Cash Price	$1,168.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,362.90
Rate for Payer: Health Management Network Commercial	$1,654.95
Rate for Payer: MDX Hawaii PPO	$1,888.59
Rate for Payer: University Health Alliance Commercial	$1,090.32

GORE INTERING 4-7X45 IRS47045L

Facility

$1,947.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$992.97
Max. Negotiated Rate	$1,888.59
Rate for Payer: Cash Price	$1,168.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,362.90
Rate for Payer: Health Management Network Commercial	$1,654.95
Rate for Payer: Kaiser Permanente Commercial	$1,226.61
Rate for Payer: Kaiser Permanente Medicaid	$992.97
Rate for Payer: MDX Hawaii PPO	$1,888.59
Rate for Payer: University Health Alliance Commercial	$1,090.32

GORE PROPATEN 4-7X45 H470045A

Facility

$2,744.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,536.64
Max. Negotiated Rate	$2,661.68
Rate for Payer: Cash Price	$1,646.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,920.80
Rate for Payer: Health Management Network Commercial	$2,332.40
Rate for Payer: MDX Hawaii PPO	$2,661.68
Rate for Payer: University Health Alliance Commercial	$1,536.64

GORE PROPATEN 4-7X45 H470045A

Facility

$2,744.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,399.44
Max. Negotiated Rate	$2,661.68
Rate for Payer: Cash Price	$1,646.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,920.80
Rate for Payer: Health Management Network Commercial	$2,332.40
Rate for Payer: Kaiser Permanente Commercial	$1,728.72
Rate for Payer: Kaiser Permanente Medicaid	$1,399.44
Rate for Payer: MDX Hawaii PPO	$2,661.68
Rate for Payer: University Health Alliance Commercial	$1,536.64

GORE STRETCH 7X10 S0701

Facility

$668.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$374.08
Max. Negotiated Rate	$647.96
Rate for Payer: Cash Price	$400.80
Rate for Payer: Hawaii Western Management Group Commercial	$467.60
Rate for Payer: Health Management Network Commercial	$567.80
Rate for Payer: MDX Hawaii PPO	$647.96
Rate for Payer: University Health Alliance Commercial	$374.08

GORE STRETCH 7X10 S0701

Facility

$668.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$340.68
Max. Negotiated Rate	$647.96
Rate for Payer: Cash Price	$400.80
Rate for Payer: Hawaii Western Management Group Commercial	$467.60
Rate for Payer: Health Management Network Commercial	$567.80
Rate for Payer: Kaiser Permanente Commercial	$420.84
Rate for Payer: Kaiser Permanente Medicaid	$340.68
Rate for Payer: MDX Hawaii PPO	$647.96
Rate for Payer: University Health Alliance Commercial	$374.08

GORE THIN 6MMX50CM HT064050A

Facility

$3,828.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,952.28
Max. Negotiated Rate	$3,713.16
Rate for Payer: Cash Price	$2,296.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,679.60
Rate for Payer: Health Management Network Commercial	$3,253.80
Rate for Payer: Kaiser Permanente Commercial	$2,411.64
Rate for Payer: Kaiser Permanente Medicaid	$1,952.28
Rate for Payer: MDX Hawaii PPO	$3,713.16
Rate for Payer: University Health Alliance Commercial	$2,143.68

GORE THIN 6MMX50CM HT064050A

Facility

$3,828.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,143.68
Max. Negotiated Rate	$3,713.16
Rate for Payer: Cash Price	$2,296.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,679.60
Rate for Payer: Health Management Network Commercial	$3,253.80
Rate for Payer: MDX Hawaii PPO	$3,713.16
Rate for Payer: University Health Alliance Commercial	$2,143.68

GORE THIN 6MMX80CM HT066080A

Facility

$5,884.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,295.04
Max. Negotiated Rate	$5,707.48
Rate for Payer: Cash Price	$3,530.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,118.80
Rate for Payer: Health Management Network Commercial	$5,001.40
Rate for Payer: MDX Hawaii PPO	$5,707.48
Rate for Payer: University Health Alliance Commercial	$3,295.04

GORE THIN 6MMX80CM HT066080A

Facility

$5,884.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,000.84
Max. Negotiated Rate	$5,707.48
Rate for Payer: Cash Price	$3,530.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,118.80
Rate for Payer: Health Management Network Commercial	$5,001.40
Rate for Payer: Kaiser Permanente Commercial	$3,706.92
Rate for Payer: Kaiser Permanente Medicaid	$3,000.84
Rate for Payer: MDX Hawaii PPO	$5,707.48
Rate for Payer: University Health Alliance Commercial	$3,295.04

GORE THIN 8MMX40CM HT083040A

Facility

$3,066.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,563.66
Max. Negotiated Rate	$2,974.02
Rate for Payer: Cash Price	$1,839.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,146.20
Rate for Payer: Health Management Network Commercial	$2,606.10
Rate for Payer: Kaiser Permanente Commercial	$1,931.58
Rate for Payer: Kaiser Permanente Medicaid	$1,563.66
Rate for Payer: MDX Hawaii PPO	$2,974.02
Rate for Payer: University Health Alliance Commercial	$1,716.96

GORE THIN 8MMX40CM HT083040A

Facility

$3,066.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,716.96
Max. Negotiated Rate	$2,974.02
Rate for Payer: Cash Price	$1,839.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,146.20
Rate for Payer: Health Management Network Commercial	$2,606.10
Rate for Payer: MDX Hawaii PPO	$2,974.02
Rate for Payer: University Health Alliance Commercial	$1,716.96

GORE THIN 8MMX50CM HT084050A

Facility

$3,622.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,028.32
Max. Negotiated Rate	$3,513.34
Rate for Payer: Cash Price	$2,173.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,535.40
Rate for Payer: Health Management Network Commercial	$3,078.70
Rate for Payer: MDX Hawaii PPO	$3,513.34
Rate for Payer: University Health Alliance Commercial	$2,028.32

GORE THIN 8MMX50CM HT084050A

Facility

$3,622.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,847.22
Max. Negotiated Rate	$3,513.34
Rate for Payer: Cash Price	$2,173.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,535.40
Rate for Payer: Health Management Network Commercial	$3,078.70
Rate for Payer: Kaiser Permanente Commercial	$2,281.86
Rate for Payer: Kaiser Permanente Medicaid	$1,847.22
Rate for Payer: MDX Hawaii PPO	$3,513.34
Rate for Payer: University Health Alliance Commercial	$2,028.32

GORE THIN 8MMX80CM HT087080A

Facility

$6,062.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,394.72
Max. Negotiated Rate	$5,880.14
Rate for Payer: Cash Price	$3,637.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,243.40
Rate for Payer: Health Management Network Commercial	$5,152.70
Rate for Payer: MDX Hawaii PPO	$5,880.14
Rate for Payer: University Health Alliance Commercial	$3,394.72

GORE THIN 8MMX80CM HT087080A

Facility

$6,062.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,091.62
Max. Negotiated Rate	$5,880.14
Rate for Payer: Cash Price	$3,637.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,243.40
Rate for Payer: Health Management Network Commercial	$5,152.70
Rate for Payer: Kaiser Permanente Commercial	$3,819.06
Rate for Payer: Kaiser Permanente Medicaid	$3,091.62
Rate for Payer: MDX Hawaii PPO	$5,880.14
Rate for Payer: University Health Alliance Commercial	$3,394.72

GORE T-IPSI 12/12CM RLT231212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,220.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$13,860.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/12CM RLT231212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/12CM RLT261212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,220.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$13,860.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/12CM RLT261212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/12CM RLT281212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/12CM RLT281212

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,220.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$13,860.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

Know your out-of-pocket cost for care.

All Charges