Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

IMPLAN GEL PROLARYN 1.0CC

Facility

$2,205.00

Service Code	HCPCS L8607
Hospital Revenue Code	278
Min. Negotiated Rate	$1,234.80
Max. Negotiated Rate	$2,138.85
Rate for Payer: MDX Hawaii PPO	$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: University Health Alliance Commercial	$1,234.80

IMPLAN GEL PROLARYN PLUS 1CC

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

IMPLAN GEL PROLARYN PLUS 1CC

Facility

$2,205.00

Service Code	HCPCS L8607
Hospital Revenue Code	278
Min. Negotiated Rate	$1,234.80
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: MDX Hawaii PPO	$2,138.85
Rate for Payer: University Health Alliance Commercial	$1,234.80

IMPLAN INTRANASAL SPLINT

Facility

$445.00

Hospital Revenue Code	278
Min. Negotiated Rate	$226.95
Max. Negotiated Rate	$431.65
Rate for Payer: Cash Price	$267.00
Rate for Payer: Hawaii Western Management Group Commercial	$311.50
Rate for Payer: Health Management Network Commercial	$378.25
Rate for Payer: Kaiser Permanente Commercial	$280.35
Rate for Payer: Kaiser Permanente Medicaid	$226.95
Rate for Payer: MDX Hawaii PPO	$431.65
Rate for Payer: University Health Alliance Commercial	$249.20

IMPLAN INTRANASAL SPLINT

Facility

$445.00

Hospital Revenue Code	278
Min. Negotiated Rate	$249.20
Max. Negotiated Rate	$431.65
Rate for Payer: Cash Price	$267.00
Rate for Payer: Hawaii Western Management Group Commercial	$311.50
Rate for Payer: Health Management Network Commercial	$378.25
Rate for Payer: MDX Hawaii PPO	$431.65
Rate for Payer: University Health Alliance Commercial	$249.20

IMPLAN OSSICULAR CENTERED PART

Facility

$1,568.00

Hospital Revenue Code	278
Min. Negotiated Rate	$878.08
Max. Negotiated Rate	$1,520.96
Rate for Payer: Cash Price	$940.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,097.60
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: MDX Hawaii PPO	$1,520.96
Rate for Payer: University Health Alliance Commercial	$878.08

IMPLAN OSSICULAR CENTERED PART

Facility

$1,568.00

Hospital Revenue Code	278
Min. Negotiated Rate	$799.68
Max. Negotiated Rate	$1,520.96
Rate for Payer: Cash Price	$940.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,097.60
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: Kaiser Permanente Commercial	$987.84
Rate for Payer: Kaiser Permanente Medicaid	$799.68
Rate for Payer: MDX Hawaii PPO	$1,520.96
Rate for Payer: University Health Alliance Commercial	$878.08

IMPLAN OSSICULAR PARTIAL

Facility

$1,503.00

Hospital Revenue Code	278
Min. Negotiated Rate	$766.53
Max. Negotiated Rate	$1,457.91
Rate for Payer: Cash Price	$901.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,052.10
Rate for Payer: Health Management Network Commercial	$1,277.55
Rate for Payer: Kaiser Permanente Commercial	$946.89
Rate for Payer: Kaiser Permanente Medicaid	$766.53
Rate for Payer: MDX Hawaii PPO	$1,457.91
Rate for Payer: University Health Alliance Commercial	$841.68

IMPLAN OSSICULAR PARTIAL

Facility

$1,503.00

Hospital Revenue Code	278
Min. Negotiated Rate	$841.68
Max. Negotiated Rate	$1,457.91
Rate for Payer: Cash Price	$901.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,052.10
Rate for Payer: Health Management Network Commercial	$1,277.55
Rate for Payer: MDX Hawaii PPO	$1,457.91
Rate for Payer: University Health Alliance Commercial	$841.68

IMPLAN OSSICULAR PROST

Facility

$1,460.00

Hospital Revenue Code	278
Min. Negotiated Rate	$817.60
Max. Negotiated Rate	$1,416.20
Rate for Payer: Cash Price	$876.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,022.00
Rate for Payer: Health Management Network Commercial	$1,241.00
Rate for Payer: MDX Hawaii PPO	$1,416.20
Rate for Payer: University Health Alliance Commercial	$817.60

IMPLAN OSSICULAR PROST

Facility

$1,460.00

Hospital Revenue Code	278
Min. Negotiated Rate	$744.60
Max. Negotiated Rate	$1,416.20
Rate for Payer: Cash Price	$876.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,022.00
Rate for Payer: Health Management Network Commercial	$1,241.00
Rate for Payer: Kaiser Permanente Commercial	$919.80
Rate for Payer: Kaiser Permanente Medicaid	$744.60
Rate for Payer: MDX Hawaii PPO	$1,416.20
Rate for Payer: University Health Alliance Commercial	$817.60

IMPLAN OSS NIT PISTON .6X4.25

Facility

$1,265.00

Hospital Revenue Code	278
Min. Negotiated Rate	$708.40
Max. Negotiated Rate	$1,227.05
Rate for Payer: Cash Price	$759.00
Rate for Payer: Hawaii Western Management Group Commercial	$885.50
Rate for Payer: Health Management Network Commercial	$1,075.25
Rate for Payer: MDX Hawaii PPO	$1,227.05
Rate for Payer: University Health Alliance Commercial	$708.40

IMPLAN OSS NIT PISTON .6X4.25

Facility

$1,265.00

Hospital Revenue Code	278
Min. Negotiated Rate	$645.15
Max. Negotiated Rate	$1,227.05
Rate for Payer: Cash Price	$759.00
Rate for Payer: Hawaii Western Management Group Commercial	$885.50
Rate for Payer: Health Management Network Commercial	$1,075.25
Rate for Payer: Kaiser Permanente Commercial	$796.95
Rate for Payer: Kaiser Permanente Medicaid	$645.15
Rate for Payer: MDX Hawaii PPO	$1,227.05
Rate for Payer: University Health Alliance Commercial	$708.40

IMPLAN OSS NIT PISTON .6X4.5

Facility

$1,253.00

Hospital Revenue Code	278
Min. Negotiated Rate	$701.68
Max. Negotiated Rate	$1,215.41
Rate for Payer: Cash Price	$751.80
Rate for Payer: Hawaii Western Management Group Commercial	$877.10
Rate for Payer: Health Management Network Commercial	$1,065.05
Rate for Payer: MDX Hawaii PPO	$1,215.41
Rate for Payer: University Health Alliance Commercial	$701.68

IMPLAN OSS NIT PISTON .6X4.5

Facility

$1,253.00

Hospital Revenue Code	278
Min. Negotiated Rate	$639.03
Max. Negotiated Rate	$1,215.41
Rate for Payer: Cash Price	$751.80
Rate for Payer: Hawaii Western Management Group Commercial	$877.10
Rate for Payer: Health Management Network Commercial	$1,065.05
Rate for Payer: Kaiser Permanente Commercial	$789.39
Rate for Payer: Kaiser Permanente Medicaid	$639.03
Rate for Payer: MDX Hawaii PPO	$1,215.41
Rate for Payer: University Health Alliance Commercial	$701.68

IMPLAN PENILE PRO RES 100ML

Facility

$6,530.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$3,330.30
Max. Negotiated Rate	$6,334.10
Rate for Payer: Cash Price	$3,918.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,571.00
Rate for Payer: Health Management Network Commercial	$5,550.50
Rate for Payer: Kaiser Permanente Commercial	$4,113.90
Rate for Payer: Kaiser Permanente Medicaid	$3,330.30
Rate for Payer: MDX Hawaii PPO	$6,334.10
Rate for Payer: University Health Alliance Commercial	$3,656.80

IMPLAN PENILE PRO RES 100ML

Facility

$6,530.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$3,656.80
Max. Negotiated Rate	$6,334.10
Rate for Payer: Cash Price	$3,918.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,571.00
Rate for Payer: Health Management Network Commercial	$5,550.50
Rate for Payer: MDX Hawaii PPO	$6,334.10
Rate for Payer: University Health Alliance Commercial	$3,656.80

IMPLAN PENILE PUMP 15X12

Facility

$27,550.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$14,050.50
Max. Negotiated Rate	$26,723.50
Rate for Payer: Cash Price	$16,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$19,285.00
Rate for Payer: Health Management Network Commercial	$23,417.50
Rate for Payer: Kaiser Permanente Commercial	$17,356.50
Rate for Payer: Kaiser Permanente Medicaid	$14,050.50
Rate for Payer: MDX Hawaii PPO	$26,723.50
Rate for Payer: University Health Alliance Commercial	$15,428.00

IMPLAN PENILE PUMP 15X12

Facility

$27,550.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$15,428.00
Max. Negotiated Rate	$26,723.50
Rate for Payer: Cash Price	$16,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$19,285.00
Rate for Payer: Health Management Network Commercial	$23,417.50
Rate for Payer: MDX Hawaii PPO	$26,723.50
Rate for Payer: University Health Alliance Commercial	$15,428.00

IMPLAN PORT CHRONOFLEX 8FR

Facility

$889.00

Service Code	HCPCS C1788
Hospital Revenue Code	278
Min. Negotiated Rate	$497.84
Max. Negotiated Rate	$862.33
Rate for Payer: Cash Price	$533.40
Rate for Payer: Hawaii Western Management Group Commercial	$622.30
Rate for Payer: Health Management Network Commercial	$755.65
Rate for Payer: MDX Hawaii PPO	$862.33
Rate for Payer: University Health Alliance Commercial	$497.84

IMPLAN PORT CHRONOFLEX 8FR

Facility

$889.00

Service Code	HCPCS C1788
Hospital Revenue Code	278
Min. Negotiated Rate	$453.39
Max. Negotiated Rate	$862.33
Rate for Payer: Cash Price	$533.40
Rate for Payer: Hawaii Western Management Group Commercial	$622.30
Rate for Payer: Health Management Network Commercial	$755.65
Rate for Payer: Kaiser Permanente Commercial	$560.07
Rate for Payer: Kaiser Permanente Medicaid	$453.39
Rate for Payer: MDX Hawaii PPO	$862.33
Rate for Payer: University Health Alliance Commercial	$497.84

IMPLAN PULSE GENERATOR IV

Facility

$36,450.00

Service Code	HCPCS C1767
Hospital Revenue Code	278
Min. Negotiated Rate	$20,412.00
Max. Negotiated Rate	$35,356.50
Rate for Payer: Cash Price	$21,870.00
Rate for Payer: Hawaii Western Management Group Commercial	$25,515.00
Rate for Payer: Health Management Network Commercial	$30,982.50
Rate for Payer: MDX Hawaii PPO	$35,356.50
Rate for Payer: University Health Alliance Commercial	$20,412.00

IMPLAN PULSE GENERATOR IV

Facility

$36,450.00

Service Code	HCPCS C1767
Hospital Revenue Code	278
Min. Negotiated Rate	$18,589.50
Max. Negotiated Rate	$35,356.50
Rate for Payer: Cash Price	$21,870.00
Rate for Payer: Hawaii Western Management Group Commercial	$25,515.00
Rate for Payer: Health Management Network Commercial	$30,982.50
Rate for Payer: Kaiser Permanente Commercial	$22,963.50
Rate for Payer: Kaiser Permanente Medicaid	$18,589.50
Rate for Payer: MDX Hawaii PPO	$35,356.50
Rate for Payer: University Health Alliance Commercial	$20,412.00

IMPLAN PUMP PENILE PRO 24X12

Facility

$24,754.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$12,624.54
Max. Negotiated Rate	$24,011.38
Rate for Payer: Cash Price	$14,852.40
Rate for Payer: Hawaii Western Management Group Commercial	$17,327.80
Rate for Payer: Health Management Network Commercial	$21,040.90
Rate for Payer: Kaiser Permanente Commercial	$15,595.02
Rate for Payer: Kaiser Permanente Medicaid	$12,624.54
Rate for Payer: MDX Hawaii PPO	$24,011.38
Rate for Payer: University Health Alliance Commercial	$13,862.24

IMPLAN PUMP PENILE PRO 24X12

Facility

$24,754.00

Service Code	HCPCS C1813
Hospital Revenue Code	278
Min. Negotiated Rate	$13,862.24
Max. Negotiated Rate	$24,011.38
Rate for Payer: Cash Price	$14,852.40
Rate for Payer: Hawaii Western Management Group Commercial	$17,327.80
Rate for Payer: Health Management Network Commercial	$21,040.90
Rate for Payer: MDX Hawaii PPO	$24,011.38
Rate for Payer: University Health Alliance Commercial	$13,862.24

Know your out-of-pocket cost for care.

All Charges