Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]

Facility

$21.00

Service Code	NDC 32909075003
Hospital Revenue Code	637
Min. Negotiated Rate	$10.71
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$13.23
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: University Health Alliance Commercial	$15.31

BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION [19436]

Facility

$24.00

Service Code	NDC 32909076401
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40

BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION [19436]

Facility

$24.00

Service Code	NDC 32909076401
Hospital Revenue Code	637
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$15.12
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: University Health Alliance Commercial	$17.49

BARTHOLIN GLAND CATH 5640-00

Facility

$132.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$67.32
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$79.20
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$83.16
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: University Health Alliance Commercial	$96.21

BARTHOLIN GLAND CATH 5640-00

Facility

$132.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$79.20
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: MDX Hawaii PPO	$128.04

BASE PLATE 15MM 00-4349-015-00

Facility

$4,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,193.00
Max. Negotiated Rate	$4,171.00
Rate for Payer: Cash Price	$2,580.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,010.00
Rate for Payer: Health Management Network Commercial	$3,655.00
Rate for Payer: Kaiser Permanente Commercial	$2,709.00
Rate for Payer: Kaiser Permanente Medicaid	$2,193.00
Rate for Payer: MDX Hawaii PPO	$4,171.00
Rate for Payer: University Health Alliance Commercial	$2,408.00

BASE PLATE 15MM 00-4349-015-00

Facility

$4,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,408.00
Max. Negotiated Rate	$4,171.00
Rate for Payer: Cash Price	$2,580.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,010.00
Rate for Payer: Health Management Network Commercial	$3,655.00
Rate for Payer: MDX Hawaii PPO	$4,171.00
Rate for Payer: University Health Alliance Commercial	$2,408.00

BASEPLATE GLENOID LATER DWJ502

Facility

$7,944.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,448.64
Max. Negotiated Rate	$7,705.68
Rate for Payer: Cash Price	$4,766.40
Rate for Payer: Hawaii Western Management Group Commercial	$5,560.80
Rate for Payer: Health Management Network Commercial	$6,752.40
Rate for Payer: MDX Hawaii PPO	$7,705.68
Rate for Payer: University Health Alliance Commercial	$4,448.64

BASEPLATE GLENOID LATER DWJ502

Facility

$7,944.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,051.44
Max. Negotiated Rate	$7,705.68
Rate for Payer: Cash Price	$4,766.40
Rate for Payer: Hawaii Western Management Group Commercial	$5,560.80
Rate for Payer: Health Management Network Commercial	$6,752.40
Rate for Payer: Kaiser Permanente Commercial	$5,004.72
Rate for Payer: Kaiser Permanente Medicaid	$4,051.44
Rate for Payer: MDX Hawaii PPO	$7,705.68
Rate for Payer: University Health Alliance Commercial	$4,448.64

BASEPLATE MINI TAPR ADPTR

Facility

$2,864.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,460.64
Max. Negotiated Rate	$2,778.08
Rate for Payer: Cash Price	$1,718.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,004.80
Rate for Payer: Health Management Network Commercial	$2,434.40
Rate for Payer: Kaiser Permanente Commercial	$1,804.32
Rate for Payer: Kaiser Permanente Medicaid	$1,460.64
Rate for Payer: MDX Hawaii PPO	$2,778.08
Rate for Payer: University Health Alliance Commercial	$1,603.84

BASEPLATE MINI TAPR ADPTR

Facility

$2,864.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,603.84
Max. Negotiated Rate	$2,778.08
Rate for Payer: Cash Price	$1,718.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,004.80
Rate for Payer: Health Management Network Commercial	$2,434.40
Rate for Payer: MDX Hawaii PPO	$2,778.08
Rate for Payer: University Health Alliance Commercial	$1,603.84

BASEPLATE REV TIBIA 5612-B-500

Facility

$10,353.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,797.68
Max. Negotiated Rate	$10,042.41
Rate for Payer: Cash Price	$6,211.80
Rate for Payer: Hawaii Western Management Group Commercial	$7,247.10
Rate for Payer: Health Management Network Commercial	$8,800.05
Rate for Payer: MDX Hawaii PPO	$10,042.41
Rate for Payer: University Health Alliance Commercial	$5,797.68

BASEPLATE REV TIBIA 5612-B-500

Facility

$10,353.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,280.03
Max. Negotiated Rate	$10,042.41
Rate for Payer: Cash Price	$6,211.80
Rate for Payer: Hawaii Western Management Group Commercial	$7,247.10
Rate for Payer: Health Management Network Commercial	$8,800.05
Rate for Payer: Kaiser Permanente Commercial	$6,522.39
Rate for Payer: Kaiser Permanente Medicaid	$5,280.03
Rate for Payer: MDX Hawaii PPO	$10,042.41
Rate for Payer: University Health Alliance Commercial	$5,797.68

BASEPLATE RSA 28MM 5572-2800

Facility

$4,400.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

BASEPLATE RSA 28MM 5572-2800

Facility

$4,400.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,244.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$2,772.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

BASEPLATE S GLENOID AR-9120-01

Facility

$3,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,749.30
Max. Negotiated Rate	$3,327.10
Rate for Payer: Cash Price	$2,058.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,401.00
Rate for Payer: Health Management Network Commercial	$2,915.50
Rate for Payer: Kaiser Permanente Commercial	$2,160.90
Rate for Payer: Kaiser Permanente Medicaid	$1,749.30
Rate for Payer: MDX Hawaii PPO	$3,327.10
Rate for Payer: University Health Alliance Commercial	$1,920.80

BASEPLATE S GLENOID AR-9120-01

Facility

$3,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,920.80
Max. Negotiated Rate	$3,327.10
Rate for Payer: Cash Price	$2,058.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,401.00
Rate for Payer: Health Management Network Commercial	$2,915.50
Rate for Payer: MDX Hawaii PPO	$3,327.10
Rate for Payer: University Health Alliance Commercial	$1,920.80

BASEPLATE TIB 42-5420-075-01

Facility

$4,980.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,539.80
Max. Negotiated Rate	$4,830.60
Rate for Payer: Cash Price	$2,988.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,486.00
Rate for Payer: Health Management Network Commercial	$4,233.00
Rate for Payer: Kaiser Permanente Commercial	$3,137.40
Rate for Payer: Kaiser Permanente Medicaid	$2,539.80
Rate for Payer: MDX Hawaii PPO	$4,830.60
Rate for Payer: University Health Alliance Commercial	$2,788.80

BASEPLATE TIB 42-5420-075-01

Facility

$4,980.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,788.80
Max. Negotiated Rate	$4,830.60
Rate for Payer: Cash Price	$2,988.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,486.00
Rate for Payer: Health Management Network Commercial	$4,233.00
Rate for Payer: MDX Hawaii PPO	$4,830.60
Rate for Payer: University Health Alliance Commercial	$2,788.80

BASEPLATE TIB SZ3 5521-B-300

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,688.61
Max. Negotiated Rate	$3,211.67
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: Kaiser Permanente Commercial	$2,085.93
Rate for Payer: Kaiser Permanente Medicaid	$1,688.61
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: University Health Alliance Commercial	$1,854.16

BASEPLATE TIB SZ3 5521-B-300

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,854.16
Max. Negotiated Rate	$3,211.67
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: University Health Alliance Commercial	$1,854.16

BASEPLATE TIB UNIV 5521-B-700

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,854.16
Max. Negotiated Rate	$3,211.67
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: University Health Alliance Commercial	$1,854.16

BASEPLATE TIB UNIV 5521-B-700

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,688.61
Max. Negotiated Rate	$3,211.67
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: Kaiser Permanente Commercial	$2,085.93
Rate for Payer: Kaiser Permanente Medicaid	$1,688.61
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: University Health Alliance Commercial	$1,854.16

BASEPLATE TOT KNEE 5521-B-100

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,854.16
Max. Negotiated Rate	$3,211.67
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: University Health Alliance Commercial	$1,854.16

BASEPLATE TOT KNEE 5521-B-100

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,688.61
Max. Negotiated Rate	$3,211.67
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: Kaiser Permanente Commercial	$2,085.93
Rate for Payer: Kaiser Permanente Medicaid	$1,688.61
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: University Health Alliance Commercial	$1,854.16

Know your out-of-pocket cost for care.

All Charges