Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

INSERT REVERSE THCK +6 DWF391B

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,411.68
Max. Negotiated Rate	$2,684.96
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: Kaiser Permanente Commercial	$1,743.84
Rate for Payer: Kaiser Permanente Medicaid	$1,411.68
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: University Health Alliance Commercial	$1,550.08

INSERT REV THICK +3MM DWP1363

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,411.68
Max. Negotiated Rate	$2,684.96
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: Kaiser Permanente Commercial	$1,743.84
Rate for Payer: Kaiser Permanente Medicaid	$1,411.68
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: University Health Alliance Commercial	$1,550.08

INSERT REV THICK +3MM DWP1363

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,550.08
Max. Negotiated Rate	$2,684.96
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: University Health Alliance Commercial	$1,550.08

INSERT STABILIZER 5537-G-316-E

Facility

$4,903.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,745.68
Max. Negotiated Rate	$4,755.91
Rate for Payer: Cash Price	$2,941.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,432.10
Rate for Payer: Health Management Network Commercial	$4,167.55
Rate for Payer: MDX Hawaii PPO	$4,755.91
Rate for Payer: University Health Alliance Commercial	$2,745.68

INSERT STABILIZER 5537-G-316-E

Facility

$4,903.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,500.53
Max. Negotiated Rate	$4,755.91
Rate for Payer: Cash Price	$2,941.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,432.10
Rate for Payer: Health Management Network Commercial	$4,167.55
Rate for Payer: Kaiser Permanente Commercial	$3,088.89
Rate for Payer: Kaiser Permanente Medicaid	$2,500.53
Rate for Payer: MDX Hawaii PPO	$4,755.91
Rate for Payer: University Health Alliance Commercial	$2,745.68

INSERT TB 5531-G-613-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.76
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$1,685.88
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB 5531-G-613-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB 5532-G-612-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB 5532-G-612-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.76
Max. Negotiated Rate	$2,595.72
Rate for Payer: Kaiser Permanente Commercial	$1,685.88
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB CS 5531-G-110-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.76
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$1,685.88
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB CS 5531-G-110-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB SIZE 5 5532-G-510-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.76
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$1,685.88
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB SIZE 5 5532-G-510-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB SZ2 9MM 5531-G-209-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.76
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$1,685.88
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB SZ2 9MM 5531-G-209-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB X3 5531-G-316-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB X3 5531-G-316-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.76
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$1,685.88
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB X3 5531-G-414-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.76
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$1,685.88
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TB X3 5531-G-414-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TIB BEARIN 5532-G-313-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TIB BEARIN 5532-G-313-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.76
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$1,685.88
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TI BEAR CS 5531-G-810-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TI BEAR CS 5531-G-810-E

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.76
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$1,685.88
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

INSERT TIBIAL

Facility

$5,148.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,625.48
Max. Negotiated Rate	$4,993.56
Rate for Payer: Cash Price	$3,088.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,603.60
Rate for Payer: Health Management Network Commercial	$4,375.80
Rate for Payer: Kaiser Permanente Commercial	$3,243.24
Rate for Payer: Kaiser Permanente Medicaid	$2,625.48
Rate for Payer: MDX Hawaii PPO	$4,993.56
Rate for Payer: University Health Alliance Commercial	$2,882.88

INSERT TIBIAL

Facility

$5,148.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,882.88
Max. Negotiated Rate	$4,993.56
Rate for Payer: Cash Price	$3,088.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,603.60
Rate for Payer: Health Management Network Commercial	$4,375.80
Rate for Payer: MDX Hawaii PPO	$4,993.56
Rate for Payer: University Health Alliance Commercial	$2,882.88

Know your out-of-pocket cost for care.

All Charges