Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

IMPLAN STENT/INTROD 6FRX22

Facility

$2,198.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.98
Max. Negotiated Rate	$2,132.06
Rate for Payer: Cash Price	$1,318.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,538.60
Rate for Payer: Health Management Network Commercial	$1,868.30
Rate for Payer: Kaiser Permanente Commercial	$1,384.74
Rate for Payer: Kaiser Permanente Medicaid	$1,120.98
Rate for Payer: MDX Hawaii PPO	$2,132.06
Rate for Payer: University Health Alliance Commercial	$1,230.88

IMPLAN STENT/INTROD 6FRX24

Facility

$2,286.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,280.16
Max. Negotiated Rate	$2,217.42
Rate for Payer: Cash Price	$1,371.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,600.20
Rate for Payer: Health Management Network Commercial	$1,943.10
Rate for Payer: MDX Hawaii PPO	$2,217.42
Rate for Payer: University Health Alliance Commercial	$1,280.16

IMPLAN STENT/INTROD 6FRX24

Facility

$2,286.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,165.86
Max. Negotiated Rate	$2,217.42
Rate for Payer: Cash Price	$1,371.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,600.20
Rate for Payer: Health Management Network Commercial	$1,943.10
Rate for Payer: Kaiser Permanente Commercial	$1,440.18
Rate for Payer: Kaiser Permanente Medicaid	$1,165.86
Rate for Payer: MDX Hawaii PPO	$2,217.42
Rate for Payer: University Health Alliance Commercial	$1,280.16

IMPLAN STENT/INTROD 6FRX26

Facility

$2,286.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,165.86
Max. Negotiated Rate	$2,217.42
Rate for Payer: Cash Price	$1,371.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,600.20
Rate for Payer: Health Management Network Commercial	$1,943.10
Rate for Payer: Kaiser Permanente Commercial	$1,440.18
Rate for Payer: Kaiser Permanente Medicaid	$1,165.86
Rate for Payer: MDX Hawaii PPO	$2,217.42
Rate for Payer: University Health Alliance Commercial	$1,280.16

IMPLAN STENT/INTROD 6FRX26

Facility

$2,286.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,280.16
Max. Negotiated Rate	$2,217.42
Rate for Payer: Cash Price	$1,371.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,600.20
Rate for Payer: Health Management Network Commercial	$1,943.10
Rate for Payer: MDX Hawaii PPO	$2,217.42
Rate for Payer: University Health Alliance Commercial	$1,280.16

IMPLAN STENT/INTROD 6FRX28

Facility

$2,199.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,231.44
Max. Negotiated Rate	$2,133.03
Rate for Payer: Cash Price	$1,319.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,539.30
Rate for Payer: Health Management Network Commercial	$1,869.15
Rate for Payer: MDX Hawaii PPO	$2,133.03
Rate for Payer: University Health Alliance Commercial	$1,231.44

IMPLAN STENT/INTROD 6FRX28

Facility

$2,199.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,121.49
Max. Negotiated Rate	$2,133.03
Rate for Payer: Cash Price	$1,319.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,539.30
Rate for Payer: Health Management Network Commercial	$1,869.15
Rate for Payer: Kaiser Permanente Commercial	$1,385.37
Rate for Payer: Kaiser Permanente Medicaid	$1,121.49
Rate for Payer: MDX Hawaii PPO	$2,133.03
Rate for Payer: University Health Alliance Commercial	$1,231.44

IMPLAN STENT/INTROD 6FRX30

Facility

$2,919.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,634.64
Max. Negotiated Rate	$2,831.43
Rate for Payer: Cash Price	$1,751.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,043.30
Rate for Payer: Health Management Network Commercial	$2,481.15
Rate for Payer: MDX Hawaii PPO	$2,831.43
Rate for Payer: University Health Alliance Commercial	$1,634.64

IMPLAN STENT/INTROD 6FRX30

Facility

$2,919.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,488.69
Max. Negotiated Rate	$2,831.43
Rate for Payer: Cash Price	$1,751.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,043.30
Rate for Payer: Health Management Network Commercial	$2,481.15
Rate for Payer: Kaiser Permanente Commercial	$1,838.97
Rate for Payer: Kaiser Permanente Medicaid	$1,488.69
Rate for Payer: MDX Hawaii PPO	$2,831.43
Rate for Payer: University Health Alliance Commercial	$1,634.64

IMPLAN STENT PANCREATIC 4FX3

Facility

$316.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$161.16
Max. Negotiated Rate	$306.52
Rate for Payer: Cash Price	$189.60
Rate for Payer: Hawaii Western Management Group Commercial	$221.20
Rate for Payer: Health Management Network Commercial	$268.60
Rate for Payer: Kaiser Permanente Commercial	$199.08
Rate for Payer: Kaiser Permanente Medicaid	$161.16
Rate for Payer: MDX Hawaii PPO	$306.52
Rate for Payer: University Health Alliance Commercial	$176.96

IMPLAN STENT PANCREATIC 4FX3

Facility

$316.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$176.96
Max. Negotiated Rate	$306.52
Rate for Payer: Cash Price	$189.60
Rate for Payer: Hawaii Western Management Group Commercial	$221.20
Rate for Payer: Health Management Network Commercial	$268.60
Rate for Payer: MDX Hawaii PPO	$306.52
Rate for Payer: University Health Alliance Commercial	$176.96

IMPLAN STENT PANCREATIC DUCT

Facility

$294.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$164.64
Max. Negotiated Rate	$285.18
Rate for Payer: Cash Price	$176.40
Rate for Payer: Hawaii Western Management Group Commercial	$205.80
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: MDX Hawaii PPO	$285.18
Rate for Payer: University Health Alliance Commercial	$164.64

IMPLAN STENT PANCREATIC DUCT

Facility

$294.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$149.94
Max. Negotiated Rate	$285.18
Rate for Payer: Cash Price	$176.40
Rate for Payer: Hawaii Western Management Group Commercial	$205.80
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: Kaiser Permanente Commercial	$185.22
Rate for Payer: Kaiser Permanente Medicaid	$149.94
Rate for Payer: MDX Hawaii PPO	$285.18
Rate for Payer: University Health Alliance Commercial	$164.64

IMPLAN STIMULATION LEAD

Facility

$3,900.00

Service Code	HCPCS C1778
Hospital Revenue Code	278
Min. Negotiated Rate	$1,989.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,730.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Kaiser Permanente Commercial	$2,457.00
Rate for Payer: Kaiser Permanente Medicaid	$1,989.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: University Health Alliance Commercial	$2,184.00

IMPLAN STIMULATION LEAD

Facility

$3,900.00

Service Code	HCPCS C1778
Hospital Revenue Code	278
Min. Negotiated Rate	$2,184.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,730.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: University Health Alliance Commercial	$2,184.00

IMPLANTABLE HEART ASSIST SYSTEMS

Facility

$117,314.63

Service Code	APR-DRG 1614
Min. Negotiated Rate	$117,314.63
Max. Negotiated Rate	$117,314.63
Rate for Payer: AlohaCare Medicaid	$117,314.63
Rate for Payer: Hawaii Medical Service Association ABD	$117,314.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$117,314.63
Rate for Payer: Kaiser Permanente Medicaid	$117,314.63
Rate for Payer: Ohana Health Plan Medicaid	$117,314.63
Rate for Payer: UnitedHealthcare Medicaid	$117,314.63

IMPLANTABLE HEART ASSIST SYSTEMS

Facility

$93,715.25

Service Code	APR-DRG 1613
Min. Negotiated Rate	$93,715.25
Max. Negotiated Rate	$93,715.25
Rate for Payer: AlohaCare Medicaid	$93,715.25
Rate for Payer: Hawaii Medical Service Association ABD	$93,715.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$93,715.25
Rate for Payer: Kaiser Permanente Medicaid	$93,715.25
Rate for Payer: Ohana Health Plan Medicaid	$93,715.25
Rate for Payer: UnitedHealthcare Medicaid	$93,715.25

IMPLANTABLE HEART ASSIST SYSTEMS

Facility

$66,864.26

Service Code	APR-DRG 1612
Min. Negotiated Rate	$66,864.26
Max. Negotiated Rate	$66,864.26
Rate for Payer: AlohaCare Medicaid	$66,864.26
Rate for Payer: Hawaii Medical Service Association ABD	$66,864.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$66,864.26
Rate for Payer: Kaiser Permanente Medicaid	$66,864.26
Rate for Payer: Ohana Health Plan Medicaid	$66,864.26
Rate for Payer: UnitedHealthcare Medicaid	$66,864.26

IMPLANTABLE HEART ASSIST SYSTEMS

Facility

$53,302.12

Service Code	APR-DRG 1611
Min. Negotiated Rate	$53,302.12
Max. Negotiated Rate	$53,302.12
Rate for Payer: AlohaCare Medicaid	$53,302.12
Rate for Payer: Hawaii Medical Service Association ABD	$53,302.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$53,302.12
Rate for Payer: Kaiser Permanente Medicaid	$53,302.12
Rate for Payer: Ohana Health Plan Medicaid	$53,302.12
Rate for Payer: UnitedHealthcare Medicaid	$53,302.12

IMPLANT ALLODERM 2X4CM

Facility

$1,650.00

Service Code	HCPCS Q4116
Hospital Revenue Code	278
Min. Negotiated Rate	$147.01
Max. Negotiated Rate	$1,600.50
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$990.00
Rate for Payer: Cash Price	$990.00
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: Kaiser Permanente Medicaid	$841.50
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$924.00

IMPLANT ALLODERM 2X4CM

Facility

$1,650.00

Service Code	HCPCS Q4116
Hospital Revenue Code	278
Min. Negotiated Rate	$924.00
Max. Negotiated Rate	$1,600.50
Rate for Payer: Cash Price	$990.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: University Health Alliance Commercial	$924.00

IMPLANTATION OF BIOLOGIC IMPLANT (EG, ACELLULAR DERMAL MATRIX) FOR SOFT TISSUE REINFORCEMENT (IE, BREAST, TRUNK) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 15777
Hospital Revenue Code	360
Min. Negotiated Rate	$129.62
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$129.62

IMPLANT BIOINDUCTIVE LG 4566

Facility

$4,000.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

IMPLANT BIOINDUCTIVE LG 4566

Facility

$4,000.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$2,040.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$2,520.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

IMPLANT PENILE PROSTHSEIS

Facility

$25,110.00

Service Code	HCPCS C2622
Hospital Revenue Code	278
Min. Negotiated Rate	$12,806.10
Max. Negotiated Rate	$24,356.70
Rate for Payer: Cash Price	$15,066.00
Rate for Payer: Hawaii Western Management Group Commercial	$17,577.00
Rate for Payer: Health Management Network Commercial	$21,343.50
Rate for Payer: Kaiser Permanente Commercial	$15,819.30
Rate for Payer: Kaiser Permanente Medicaid	$12,806.10
Rate for Payer: MDX Hawaii PPO	$24,356.70
Rate for Payer: University Health Alliance Commercial	$14,061.60

Know your out-of-pocket cost for care.

All Charges