Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

IMPLAN .15X50X40 NASAL PERF

Facility

$1,692.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$947.52
Max. Negotiated Rate	$1,641.24
Rate for Payer: Cash Price	$1,015.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,184.40
Rate for Payer: Health Management Network Commercial	$1,438.20
Rate for Payer: MDX Hawaii PPO	$1,641.24
Rate for Payer: University Health Alliance Commercial	$947.52

IMPLAN .15X50X40 NASAL PERF

Facility

$1,692.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$862.92
Max. Negotiated Rate	$1,641.24
Rate for Payer: Cash Price	$1,015.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,184.40
Rate for Payer: Health Management Network Commercial	$1,438.20
Rate for Payer: Kaiser Permanente Commercial	$1,065.96
Rate for Payer: Kaiser Permanente Medicaid	$862.92
Rate for Payer: MDX Hawaii PPO	$1,641.24
Rate for Payer: University Health Alliance Commercial	$947.52

IMPLAN .25X40X50 NASAL FLEX

Facility

$1,692.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$862.92
Max. Negotiated Rate	$1,641.24
Rate for Payer: Cash Price	$1,015.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,184.40
Rate for Payer: Health Management Network Commercial	$1,438.20
Rate for Payer: Kaiser Permanente Commercial	$1,065.96
Rate for Payer: Kaiser Permanente Medicaid	$862.92
Rate for Payer: MDX Hawaii PPO	$1,641.24
Rate for Payer: University Health Alliance Commercial	$947.52

IMPLAN .25X40X50 NASAL FLEX

Facility

$1,692.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$947.52
Max. Negotiated Rate	$1,641.24
Rate for Payer: Cash Price	$1,015.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,184.40
Rate for Payer: Health Management Network Commercial	$1,438.20
Rate for Payer: MDX Hawaii PPO	$1,641.24
Rate for Payer: University Health Alliance Commercial	$947.52

IMPLAN BUCKET HANDLE .4X4.25

Facility

$930.00

Hospital Revenue Code	278
Min. Negotiated Rate	$520.80
Max. Negotiated Rate	$902.10
Rate for Payer: Cash Price	$558.00
Rate for Payer: Hawaii Western Management Group Commercial	$651.00
Rate for Payer: Health Management Network Commercial	$790.50
Rate for Payer: MDX Hawaii PPO	$902.10
Rate for Payer: University Health Alliance Commercial	$520.80

IMPLAN BUCKET HANDLE .4X4.25

Facility

$930.00

Hospital Revenue Code	278
Min. Negotiated Rate	$474.30
Max. Negotiated Rate	$902.10
Rate for Payer: Cash Price	$558.00
Rate for Payer: Hawaii Western Management Group Commercial	$651.00
Rate for Payer: Health Management Network Commercial	$790.50
Rate for Payer: Kaiser Permanente Commercial	$585.90
Rate for Payer: Kaiser Permanente Medicaid	$474.30
Rate for Payer: MDX Hawaii PPO	$902.10
Rate for Payer: University Health Alliance Commercial	$520.80

IMPLAN BUCKET HANDLE .5X4.5

Facility

$930.00

Hospital Revenue Code	278
Min. Negotiated Rate	$520.80
Max. Negotiated Rate	$902.10
Rate for Payer: Cash Price	$558.00
Rate for Payer: Hawaii Western Management Group Commercial	$651.00
Rate for Payer: Health Management Network Commercial	$790.50
Rate for Payer: MDX Hawaii PPO	$902.10
Rate for Payer: University Health Alliance Commercial	$520.80

IMPLAN BUCKET HANDLE .5X4.5

Facility

$930.00

Hospital Revenue Code	278
Min. Negotiated Rate	$474.30
Max. Negotiated Rate	$902.10
Rate for Payer: Cash Price	$558.00
Rate for Payer: Hawaii Western Management Group Commercial	$651.00
Rate for Payer: Health Management Network Commercial	$790.50
Rate for Payer: Kaiser Permanente Commercial	$585.90
Rate for Payer: Kaiser Permanente Medicaid	$474.30
Rate for Payer: MDX Hawaii PPO	$902.10
Rate for Payer: University Health Alliance Commercial	$520.80

IMPLAN CATHETER PASSER 38CM

Facility

$776.00

Hospital Revenue Code	278
Min. Negotiated Rate	$434.56
Max. Negotiated Rate	$752.72
Rate for Payer: Cash Price	$465.60
Rate for Payer: Hawaii Western Management Group Commercial	$543.20
Rate for Payer: Health Management Network Commercial	$659.60
Rate for Payer: MDX Hawaii PPO	$752.72
Rate for Payer: University Health Alliance Commercial	$434.56

IMPLAN CATHETER PASSER 38CM

Facility

$776.00

Hospital Revenue Code	278
Min. Negotiated Rate	$395.76
Max. Negotiated Rate	$752.72
Rate for Payer: Cash Price	$465.60
Rate for Payer: Hawaii Western Management Group Commercial	$543.20
Rate for Payer: Health Management Network Commercial	$659.60
Rate for Payer: Kaiser Permanente Commercial	$488.88
Rate for Payer: Kaiser Permanente Medicaid	$395.76
Rate for Payer: MDX Hawaii PPO	$752.72
Rate for Payer: University Health Alliance Commercial	$434.56

IMPLAN CUFF OCCLUSIVE

Facility

$15,800.00

Service Code	HCPCS C1815
Hospital Revenue Code	278
Min. Negotiated Rate	$8,058.00
Max. Negotiated Rate	$15,326.00
Rate for Payer: Cash Price	$9,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,060.00
Rate for Payer: Health Management Network Commercial	$13,430.00
Rate for Payer: Kaiser Permanente Commercial	$9,954.00
Rate for Payer: Kaiser Permanente Medicaid	$8,058.00
Rate for Payer: MDX Hawaii PPO	$15,326.00
Rate for Payer: University Health Alliance Commercial	$8,848.00

IMPLAN CUFF OCCLUSIVE

Facility

$15,800.00

Service Code	HCPCS C1815
Hospital Revenue Code	278
Min. Negotiated Rate	$8,848.00
Max. Negotiated Rate	$15,326.00
Rate for Payer: Cash Price	$9,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,060.00
Rate for Payer: Health Management Network Commercial	$13,430.00
Rate for Payer: MDX Hawaii PPO	$15,326.00
Rate for Payer: University Health Alliance Commercial	$8,848.00

IMPLAN DEACTIV PENILE PROT

Facility

$827.00

Hospital Revenue Code	278
Min. Negotiated Rate	$463.12
Max. Negotiated Rate	$802.19
Rate for Payer: Cash Price	$496.20
Rate for Payer: Hawaii Western Management Group Commercial	$578.90
Rate for Payer: Health Management Network Commercial	$702.95
Rate for Payer: MDX Hawaii PPO	$802.19
Rate for Payer: University Health Alliance Commercial	$463.12

IMPLAN DEACTIV PENILE PROT

Facility

$827.00

Hospital Revenue Code	278
Min. Negotiated Rate	$421.77
Max. Negotiated Rate	$802.19
Rate for Payer: Cash Price	$496.20
Rate for Payer: Hawaii Western Management Group Commercial	$578.90
Rate for Payer: Health Management Network Commercial	$702.95
Rate for Payer: Kaiser Permanente Commercial	$521.01
Rate for Payer: Kaiser Permanente Medicaid	$421.77
Rate for Payer: MDX Hawaii PPO	$802.19
Rate for Payer: University Health Alliance Commercial	$463.12

IMPLAN ESOPH 23X101 STENT

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,958.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: Kaiser Permanente Commercial	$3,654.00
Rate for Payer: Kaiser Permanente Medicaid	$2,958.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

IMPLAN ESOPH 23X101 STENT

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,248.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

IMPLAN EXCLUDER AAA 16X12X7

Facility

$7,288.00

Hospital Revenue Code	278
Min. Negotiated Rate	$3,716.88
Max. Negotiated Rate	$7,069.36
Rate for Payer: Cash Price	$4,372.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,101.60
Rate for Payer: Health Management Network Commercial	$6,194.80
Rate for Payer: Kaiser Permanente Commercial	$4,591.44
Rate for Payer: Kaiser Permanente Medicaid	$3,716.88
Rate for Payer: MDX Hawaii PPO	$7,069.36
Rate for Payer: University Health Alliance Commercial	$4,081.28

IMPLAN EXCLUDER AAA 16X12X7

Facility

$7,288.00

Hospital Revenue Code	278
Min. Negotiated Rate	$4,081.28
Max. Negotiated Rate	$7,069.36
Rate for Payer: Cash Price	$4,372.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,101.60
Rate for Payer: Health Management Network Commercial	$6,194.80
Rate for Payer: MDX Hawaii PPO	$7,069.36
Rate for Payer: University Health Alliance Commercial	$4,081.28

IMPLAN GASTRO CLIP 16MM

Facility

$360.00

Hospital Revenue Code	278
Min. Negotiated Rate	$201.60
Max. Negotiated Rate	$349.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Hawaii Western Management Group Commercial	$252.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: MDX Hawaii PPO	$349.20
Rate for Payer: University Health Alliance Commercial	$201.60

IMPLAN GASTRO CLIP 16MM

Facility

$360.00

Hospital Revenue Code	278
Min. Negotiated Rate	$183.60
Max. Negotiated Rate	$349.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Hawaii Western Management Group Commercial	$252.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: Kaiser Permanente Commercial	$226.80
Rate for Payer: Kaiser Permanente Medicaid	$183.60
Rate for Payer: MDX Hawaii PPO	$349.20
Rate for Payer: University Health Alliance Commercial	$201.60

IMPLAN GASTRO PADLOCK CLIP

Facility

$1,977.00

Hospital Revenue Code	278
Min. Negotiated Rate	$1,008.27
Max. Negotiated Rate	$1,917.69
Rate for Payer: Cash Price	$1,186.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,383.90
Rate for Payer: Health Management Network Commercial	$1,680.45
Rate for Payer: Kaiser Permanente Commercial	$1,245.51
Rate for Payer: Kaiser Permanente Medicaid	$1,008.27
Rate for Payer: MDX Hawaii PPO	$1,917.69
Rate for Payer: University Health Alliance Commercial	$1,107.12

IMPLAN GASTRO PADLOCK CLIP

Facility

$1,977.00

Hospital Revenue Code	278
Min. Negotiated Rate	$1,107.12
Max. Negotiated Rate	$1,917.69
Rate for Payer: Cash Price	$1,186.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,383.90
Rate for Payer: Health Management Network Commercial	$1,680.45
Rate for Payer: MDX Hawaii PPO	$1,917.69
Rate for Payer: University Health Alliance Commercial	$1,107.12

IMPLAN GASTRO PADLOCK CLIP PRO

Facility

$2,157.00

Hospital Revenue Code	278
Min. Negotiated Rate	$1,207.92
Max. Negotiated Rate	$2,092.29
Rate for Payer: Cash Price	$1,294.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,509.90
Rate for Payer: Health Management Network Commercial	$1,833.45
Rate for Payer: MDX Hawaii PPO	$2,092.29
Rate for Payer: University Health Alliance Commercial	$1,207.92

IMPLAN GASTRO PADLOCK CLIP PRO

Facility

$2,157.00

Hospital Revenue Code	278
Min. Negotiated Rate	$1,100.07
Max. Negotiated Rate	$2,092.29
Rate for Payer: Cash Price	$1,294.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,509.90
Rate for Payer: Health Management Network Commercial	$1,833.45
Rate for Payer: Kaiser Permanente Commercial	$1,358.91
Rate for Payer: Kaiser Permanente Medicaid	$1,100.07
Rate for Payer: MDX Hawaii PPO	$2,092.29
Rate for Payer: University Health Alliance Commercial	$1,207.92

IMPLAN GEL PROLARYN 1.0CC

Facility

$2,205.00

Service Code	HCPCS L8607
Hospital Revenue Code	278
Min. Negotiated Rate	$1,124.55
Max. Negotiated Rate	$2,138.85
Rate for Payer: Cash Price	$1,323.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,543.50
Rate for Payer: Health Management Network Commercial	$1,874.25
Rate for Payer: Kaiser Permanente Commercial	$1,389.15
Rate for Payer: Kaiser Permanente Medicaid	$1,124.55
Rate for Payer: MDX Hawaii PPO	$2,138.85
Rate for Payer: University Health Alliance Commercial	$1,234.80

Know your out-of-pocket cost for care.

All Charges