Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GORE T-IPSI 14.5/18 RLT351418

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 14.5/18 RLT351418

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

GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]

Facility

$4,211.00

Service Code	HCPCS J9202
Hospital Revenue Code	250
Min. Negotiated Rate	$3,579.35
Max. Negotiated Rate	$4,084.67
Rate for Payer: Cash Price	$2,526.60
Rate for Payer: Health Management Network Commercial	$3,579.35
Rate for Payer: MDX Hawaii PPO	$4,084.67

GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]

Facility

$4,211.00

Service Code	HCPCS J9202
Hospital Revenue Code	637
Min. Negotiated Rate	$550.61
Max. Negotiated Rate	$4,084.67
Rate for Payer: Cash Price	$2,526.60
Rate for Payer: Cash Price	$2,526.60
Rate for Payer: Hawaii Medical Service Association ABD	$734.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$734.15
Rate for Payer: Hawaii Western Management Group Commercial	$4,000.45
Rate for Payer: Health Management Network Commercial	$3,579.35
Rate for Payer: Kaiser Permanente Commercial	$2,652.93
Rate for Payer: Kaiser Permanente Medicaid	$2,147.61
Rate for Payer: MDX Hawaii PPO	$4,084.67
Rate for Payer: UnitedHealthcare Medicaid	$550.61
Rate for Payer: University Health Alliance Commercial	$3,069.40

GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]

Facility

$1,849.00

Service Code	HCPCS J9202
Hospital Revenue Code	637
Min. Negotiated Rate	$550.61
Max. Negotiated Rate	$1,793.53
Rate for Payer: Cash Price	$1,109.40
Rate for Payer: Cash Price	$1,109.40
Rate for Payer: Hawaii Medical Service Association ABD	$734.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$734.15
Rate for Payer: Hawaii Western Management Group Commercial	$1,756.55
Rate for Payer: Health Management Network Commercial	$1,571.65
Rate for Payer: Kaiser Permanente Commercial	$1,164.87
Rate for Payer: Kaiser Permanente Medicaid	$942.99
Rate for Payer: MDX Hawaii PPO	$1,793.53
Rate for Payer: UnitedHealthcare Medicaid	$550.61
Rate for Payer: University Health Alliance Commercial	$1,347.74

GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]

Facility

$1,849.00

Service Code	HCPCS J9202
Hospital Revenue Code	250
Min. Negotiated Rate	$1,571.65
Max. Negotiated Rate	$1,793.53
Rate for Payer: Cash Price	$1,109.40
Rate for Payer: Health Management Network Commercial	$1,571.65
Rate for Payer: MDX Hawaii PPO	$1,793.53

GRAFT AMNIC MEMBRANE 1.5X2

Facility

$1,725.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$966.00
Max. Negotiated Rate	$1,673.25
Rate for Payer: Cash Price	$1,035.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,207.50
Rate for Payer: Health Management Network Commercial	$1,466.25
Rate for Payer: MDX Hawaii PPO	$1,673.25
Rate for Payer: University Health Alliance Commercial	$966.00

GRAFT AMNIC MEMBRANE 1.5X2

Facility

$1,725.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$879.75
Max. Negotiated Rate	$1,673.25
Rate for Payer: Cash Price	$1,035.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,207.50
Rate for Payer: Health Management Network Commercial	$1,466.25
Rate for Payer: Kaiser Permanente Commercial	$1,086.75
Rate for Payer: Kaiser Permanente Medicaid	$879.75
Rate for Payer: MDX Hawaii PPO	$1,673.25
Rate for Payer: University Health Alliance Commercial	$966.00

GRAFT COLLAGEN 6MMX39CM AG735

Facility

$3,638.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,855.38
Max. Negotiated Rate	$3,528.86
Rate for Payer: Cash Price	$2,182.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,546.60
Rate for Payer: Health Management Network Commercial	$3,092.30
Rate for Payer: Kaiser Permanente Commercial	$2,291.94
Rate for Payer: Kaiser Permanente Medicaid	$1,855.38
Rate for Payer: MDX Hawaii PPO	$3,528.86
Rate for Payer: University Health Alliance Commercial	$2,037.28

GRAFT COLLAGEN 6MMX39CM AG735

Facility

$3,638.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,037.28
Max. Negotiated Rate	$3,528.86
Rate for Payer: Cash Price	$2,182.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,546.60
Rate for Payer: Health Management Network Commercial	$3,092.30
Rate for Payer: MDX Hawaii PPO	$3,528.86
Rate for Payer: University Health Alliance Commercial	$2,037.28

GRAFT COLLAGEN 6MMX40CM AG740

Facility

$4,718.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,406.18
Max. Negotiated Rate	$4,576.46
Rate for Payer: Cash Price	$2,830.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,302.60
Rate for Payer: Health Management Network Commercial	$4,010.30
Rate for Payer: Kaiser Permanente Commercial	$2,972.34
Rate for Payer: Kaiser Permanente Medicaid	$2,406.18
Rate for Payer: MDX Hawaii PPO	$4,576.46
Rate for Payer: University Health Alliance Commercial	$2,642.08

GRAFT COLLAGEN 6MMX40CM AG740

Facility

$4,718.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,642.08
Max. Negotiated Rate	$4,576.46
Rate for Payer: Cash Price	$2,830.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,302.60
Rate for Payer: Health Management Network Commercial	$4,010.30
Rate for Payer: MDX Hawaii PPO	$4,576.46
Rate for Payer: University Health Alliance Commercial	$2,642.08

GRAFT CONTRLT LEG 16MMX11.5CM

Facility

$11,540.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$6,462.40
Max. Negotiated Rate	$11,193.80
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: University Health Alliance Commercial	$6,462.40

GRAFT CONTRLT LEG 16MMX11.5CM

Facility

$11,540.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,885.40
Max. Negotiated Rate	$11,193.80
Rate for Payer: Cash Price	$6,924.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,078.00
Rate for Payer: Health Management Network Commercial	$9,809.00
Rate for Payer: Kaiser Permanente Commercial	$7,270.20
Rate for Payer: Kaiser Permanente Medicaid	$5,885.40
Rate for Payer: MDX Hawaii PPO	$11,193.80
Rate for Payer: University Health Alliance Commercial	$6,462.40

GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)

Facility

$16,700.00

Service Code	CPT 21235
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$16,700.00
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Devoted Health Medicare	$7,692.70
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	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$6,993.36
Rate for Payer: University Health Alliance Commercial	$16,700.00

GRAFT GRACILIS FGRACILIS

Facility

$2,315.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,180.65
Max. Negotiated Rate	$2,245.55
Rate for Payer: Cash Price	$1,389.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,620.50
Rate for Payer: Health Management Network Commercial	$1,967.75
Rate for Payer: Kaiser Permanente Commercial	$1,458.45
Rate for Payer: Kaiser Permanente Medicaid	$1,180.65
Rate for Payer: MDX Hawaii PPO	$2,245.55
Rate for Payer: University Health Alliance Commercial	$1,296.40

GRAFT GRACILIS FGRACILIS

Facility

$2,315.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,296.40
Max. Negotiated Rate	$2,245.55
Rate for Payer: Cash Price	$1,389.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,620.50
Rate for Payer: Health Management Network Commercial	$1,967.75
Rate for Payer: MDX Hawaii PPO	$2,245.55
Rate for Payer: University Health Alliance Commercial	$1,296.40

GRAFT HEPARIN 6X40 ECH060040A

Facility

$2,712.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,518.72
Max. Negotiated Rate	$2,630.64
Rate for Payer: Cash Price	$1,627.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,898.40
Rate for Payer: Health Management Network Commercial	$2,305.20
Rate for Payer: MDX Hawaii PPO	$2,630.64
Rate for Payer: University Health Alliance Commercial	$1,518.72

GRAFT HEPARIN 6X40 ECH060040A

Facility

$2,712.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,383.12
Max. Negotiated Rate	$2,630.64
Rate for Payer: Cash Price	$1,627.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,898.40
Rate for Payer: Health Management Network Commercial	$2,305.20
Rate for Payer: Kaiser Permanente Commercial	$1,708.56
Rate for Payer: Kaiser Permanente Medicaid	$1,383.12
Rate for Payer: MDX Hawaii PPO	$2,630.64
Rate for Payer: University Health Alliance Commercial	$1,518.72

GRAFT HERO 1000 SUPERHERO

Facility

$8,800.00

Service Code	HCPCS C1750
Hospital Revenue Code	278
Min. Negotiated Rate	$4,928.00
Max. Negotiated Rate	$8,536.00
Rate for Payer: Cash Price	$5,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,160.00
Rate for Payer: Health Management Network Commercial	$7,480.00
Rate for Payer: MDX Hawaii PPO	$8,536.00
Rate for Payer: University Health Alliance Commercial	$4,928.00

GRAFT HERO 1000 SUPERHERO

Facility

$8,800.00

Service Code	HCPCS C1750
Hospital Revenue Code	278
Min. Negotiated Rate	$4,488.00
Max. Negotiated Rate	$8,536.00
Rate for Payer: Cash Price	$5,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,160.00
Rate for Payer: Health Management Network Commercial	$7,480.00
Rate for Payer: Kaiser Permanente Commercial	$5,544.00
Rate for Payer: Kaiser Permanente Medicaid	$4,488.00
Rate for Payer: MDX Hawaii PPO	$8,536.00
Rate for Payer: University Health Alliance Commercial	$4,928.00

GRAFT ILIAC CREST WEDGE BONE

Facility

$2,070.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,159.20
Max. Negotiated Rate	$2,007.90
Rate for Payer: Cash Price	$1,242.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,449.00
Rate for Payer: Health Management Network Commercial	$1,759.50
Rate for Payer: MDX Hawaii PPO	$2,007.90
Rate for Payer: University Health Alliance Commercial	$1,159.20

GRAFT ILIAC CREST WEDGE BONE

Facility

$2,070.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,055.70
Max. Negotiated Rate	$2,007.90
Rate for Payer: Cash Price	$1,242.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,449.00
Rate for Payer: Health Management Network Commercial	$1,759.50
Rate for Payer: Kaiser Permanente Commercial	$1,304.10
Rate for Payer: Kaiser Permanente Medicaid	$1,055.70
Rate for Payer: MDX Hawaii PPO	$2,007.90
Rate for Payer: University Health Alliance Commercial	$1,159.20

GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE

Facility

$5,509.00

Service Code	CPT 15773
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
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	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45

GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE

Facility

$5,509.00

Service Code	CPT 15771
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$4,186.36
Rate for Payer: AlohaCare Medicare	$4,186.36
Rate for Payer: Devoted Health Medicare	$4,605.00
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	$4,186.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$4,186.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,186.36
Rate for Payer: Ohana Health Plan Medicaid	$4,605.00
Rate for Payer: Ohana Health Plan Medicare	$4,186.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,186.36
Rate for Payer: University Health Alliance Commercial	$4,035.20

Know your out-of-pocket cost for care.

All Charges