Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GRAFT LEG 23X12CM PLC231200

Facility

$10,156.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,179.56
Max. Negotiated Rate	$9,851.32
Rate for Payer: Cash Price	$6,093.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,109.20
Rate for Payer: Health Management Network Commercial	$8,632.60
Rate for Payer: Kaiser Permanente Commercial	$6,398.28
Rate for Payer: Kaiser Permanente Medicaid	$5,179.56
Rate for Payer: MDX Hawaii PPO	$9,851.32
Rate for Payer: University Health Alliance Commercial	$5,687.36

GRAFT LEG 23X14CM PLC231400

Facility

$9,714.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,439.84
Max. Negotiated Rate	$9,422.58
Rate for Payer: Cash Price	$5,828.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,799.80
Rate for Payer: Health Management Network Commercial	$8,256.90
Rate for Payer: MDX Hawaii PPO	$9,422.58
Rate for Payer: University Health Alliance Commercial	$5,439.84

GRAFT LEG 23X14CM PLC231400

Facility

$9,714.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$4,954.14
Max. Negotiated Rate	$9,422.58
Rate for Payer: Cash Price	$5,828.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,799.80
Rate for Payer: Health Management Network Commercial	$8,256.90
Rate for Payer: Kaiser Permanente Commercial	$6,119.82
Rate for Payer: Kaiser Permanente Medicaid	$4,954.14
Rate for Payer: MDX Hawaii PPO	$9,422.58
Rate for Payer: University Health Alliance Commercial	$5,439.84

GRAFT LEG 27X12CM PLC271200

Facility

$11,540.00

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 LEG 27X12CM PLC271200

Facility

$11,540.00

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 LEG 27X14CM PLC271400

Facility

$9,020.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,051.20
Max. Negotiated Rate	$8,749.40
Rate for Payer: Cash Price	$5,412.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,314.00
Rate for Payer: Health Management Network Commercial	$7,667.00
Rate for Payer: MDX Hawaii PPO	$8,749.40
Rate for Payer: University Health Alliance Commercial	$5,051.20

GRAFT LEG 27X14CM PLC271400

Facility

$9,020.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$4,600.20
Max. Negotiated Rate	$8,749.40
Rate for Payer: Cash Price	$5,412.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,314.00
Rate for Payer: Health Management Network Commercial	$7,667.00
Rate for Payer: Kaiser Permanente Commercial	$5,682.60
Rate for Payer: Kaiser Permanente Medicaid	$4,600.20
Rate for Payer: MDX Hawaii PPO	$8,749.40
Rate for Payer: University Health Alliance Commercial	$5,051.20

GRAFT LEG 4.5MMX10CM PXC141000

Facility

$4,510.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,525.60
Max. Negotiated Rate	$4,374.70
Rate for Payer: Cash Price	$2,706.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,157.00
Rate for Payer: Health Management Network Commercial	$3,833.50
Rate for Payer: MDX Hawaii PPO	$4,374.70
Rate for Payer: University Health Alliance Commercial	$2,525.60

GRAFT LEG 4.5MMX10CM PXC141000

Facility

$4,510.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$2,300.10
Max. Negotiated Rate	$4,374.70
Rate for Payer: Cash Price	$2,706.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,157.00
Rate for Payer: Health Management Network Commercial	$3,833.50
Rate for Payer: Kaiser Permanente Commercial	$2,841.30
Rate for Payer: Kaiser Permanente Medicaid	$2,300.10
Rate for Payer: MDX Hawaii PPO	$4,374.70
Rate for Payer: University Health Alliance Commercial	$2,525.60

GRAFT MESH PARIETENE 45X30CM

Facility

$860.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$438.60
Max. Negotiated Rate	$834.20
Rate for Payer: Cash Price	$516.00
Rate for Payer: Hawaii Western Management Group Commercial	$602.00
Rate for Payer: Health Management Network Commercial	$731.00
Rate for Payer: Kaiser Permanente Commercial	$541.80
Rate for Payer: Kaiser Permanente Medicaid	$438.60
Rate for Payer: MDX Hawaii PPO	$834.20
Rate for Payer: University Health Alliance Commercial	$481.60

GRAFT MESH PARIETENE 45X30CM

Facility

$860.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$481.60
Max. Negotiated Rate	$834.20
Rate for Payer: Cash Price	$516.00
Rate for Payer: Hawaii Western Management Group Commercial	$602.00
Rate for Payer: Health Management Network Commercial	$731.00
Rate for Payer: MDX Hawaii PPO	$834.20
Rate for Payer: University Health Alliance Commercial	$481.60

GRAFT PROPATEN 6X40 H060040A

Facility

$2,242.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,255.52
Max. Negotiated Rate	$2,174.74
Rate for Payer: Cash Price	$1,345.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,569.40
Rate for Payer: Health Management Network Commercial	$1,905.70
Rate for Payer: MDX Hawaii PPO	$2,174.74
Rate for Payer: University Health Alliance Commercial	$1,255.52

GRAFT PROPATEN 6X40 H060040A

Facility

$2,242.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,143.42
Max. Negotiated Rate	$2,174.74
Rate for Payer: Cash Price	$1,345.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,569.40
Rate for Payer: Health Management Network Commercial	$1,905.70
Rate for Payer: Kaiser Permanente Commercial	$1,412.46
Rate for Payer: Kaiser Permanente Medicaid	$1,143.42
Rate for Payer: MDX Hawaii PPO	$2,174.74
Rate for Payer: University Health Alliance Commercial	$1,255.52

GRAFT RTI BIOLOGICS 3MM 453014

Facility

$2,910.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,484.10
Max. Negotiated Rate	$2,822.70
Rate for Payer: Cash Price	$1,746.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,037.00
Rate for Payer: Health Management Network Commercial	$2,473.50
Rate for Payer: Kaiser Permanente Commercial	$1,833.30
Rate for Payer: Kaiser Permanente Medicaid	$1,484.10
Rate for Payer: MDX Hawaii PPO	$2,822.70
Rate for Payer: University Health Alliance Commercial	$1,629.60

GRAFT RTI BIOLOGICS 3MM 453014

Facility

$2,910.00

Service Code	HCPCS C1762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,629.60
Max. Negotiated Rate	$2,822.70
Rate for Payer: Cash Price	$1,746.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,037.00
Rate for Payer: Health Management Network Commercial	$2,473.50
Rate for Payer: MDX Hawaii PPO	$2,822.70
Rate for Payer: University Health Alliance Commercial	$1,629.60

GRAFT STENT40X40X20 TGMR404020

Facility

$40,290.00

Hospital Revenue Code	278
Min. Negotiated Rate	$20,547.90
Max. Negotiated Rate	$39,081.30
Rate for Payer: Cash Price	$24,174.00
Rate for Payer: Hawaii Western Management Group Commercial	$28,203.00
Rate for Payer: Health Management Network Commercial	$34,246.50
Rate for Payer: Kaiser Permanente Commercial	$25,382.70
Rate for Payer: Kaiser Permanente Medicaid	$20,547.90
Rate for Payer: MDX Hawaii PPO	$39,081.30
Rate for Payer: University Health Alliance Commercial	$22,562.40

GRAFT STENT40X40X20 TGMR404020

Facility

$40,290.00

Hospital Revenue Code	278
Min. Negotiated Rate	$22,562.40
Max. Negotiated Rate	$39,081.30
Rate for Payer: Cash Price	$24,174.00
Rate for Payer: Hawaii Western Management Group Commercial	$28,203.00
Rate for Payer: Health Management Network Commercial	$34,246.50
Rate for Payer: MDX Hawaii PPO	$39,081.30
Rate for Payer: University Health Alliance Commercial	$22,562.40

GRAFT TAPER 16-18X40 SBT1601D

Facility

$2,802.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,429.02
Max. Negotiated Rate	$2,717.94
Rate for Payer: Cash Price	$1,681.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,961.40
Rate for Payer: Health Management Network Commercial	$2,381.70
Rate for Payer: Kaiser Permanente Commercial	$1,765.26
Rate for Payer: Kaiser Permanente Medicaid	$1,429.02
Rate for Payer: MDX Hawaii PPO	$2,717.94
Rate for Payer: University Health Alliance Commercial	$1,569.12

GRAFT TAPER 16-18X40 SBT1601D

Facility

$2,802.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,569.12
Max. Negotiated Rate	$2,717.94
Rate for Payer: Cash Price	$1,681.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,961.40
Rate for Payer: Health Management Network Commercial	$2,381.70
Rate for Payer: MDX Hawaii PPO	$2,717.94
Rate for Payer: University Health Alliance Commercial	$1,569.12

GRAFT TAPERED EPTE V47050L

Facility

$1,785.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$999.60
Max. Negotiated Rate	$1,731.45
Rate for Payer: Cash Price	$1,071.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: University Health Alliance Commercial	$999.60

GRAFT TAPERED EPTE V47050L

Facility

$1,785.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$910.35
Max. Negotiated Rate	$1,731.45
Rate for Payer: Cash Price	$1,071.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,249.50
Rate for Payer: Health Management Network Commercial	$1,517.25
Rate for Payer: Kaiser Permanente Commercial	$1,124.55
Rate for Payer: Kaiser Permanente Medicaid	$910.35
Rate for Payer: MDX Hawaii PPO	$1,731.45
Rate for Payer: University Health Alliance Commercial	$999.60

GRAFT VASCULAR ECH060050A

Facility

$3,080.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,724.80
Max. Negotiated Rate	$2,987.60
Rate for Payer: Cash Price	$1,848.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,156.00
Rate for Payer: Health Management Network Commercial	$2,618.00
Rate for Payer: MDX Hawaii PPO	$2,987.60
Rate for Payer: University Health Alliance Commercial	$1,724.80

GRAFT VASCULAR ECH060050A

Facility

$3,080.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,570.80
Max. Negotiated Rate	$2,987.60
Rate for Payer: Cash Price	$1,848.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,156.00
Rate for Payer: Health Management Network Commercial	$2,618.00
Rate for Payer: Kaiser Permanente Commercial	$1,940.40
Rate for Payer: Kaiser Permanente Medicaid	$1,570.80
Rate for Payer: MDX Hawaii PPO	$2,987.60
Rate for Payer: University Health Alliance Commercial	$1,724.80

GRASPER MINIGRIP CLTCH PGCC300

Facility

$945.00

Hospital Revenue Code	272
Min. Negotiated Rate	$803.25
Max. Negotiated Rate	$916.65
Rate for Payer: Cash Price	$567.00
Rate for Payer: Health Management Network Commercial	$803.25
Rate for Payer: MDX Hawaii PPO	$916.65

GRASPER MINIGRIP CLTCH PGCC300

Facility

$945.00

Hospital Revenue Code	272
Min. Negotiated Rate	$481.95
Max. Negotiated Rate	$916.65
Rate for Payer: Cash Price	$567.00
Rate for Payer: Hawaii Western Management Group Commercial	$897.75
Rate for Payer: Health Management Network Commercial	$803.25
Rate for Payer: Kaiser Permanente Commercial	$595.35
Rate for Payer: Kaiser Permanente Medicaid	$481.95
Rate for Payer: MDX Hawaii PPO	$916.65
Rate for Payer: University Health Alliance Commercial	$688.81

Know your out-of-pocket cost for care.

All Charges