Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

INSERT TRIA X3 TI 5532-G-809-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 TRIA X3 TI 5532-G-809-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 TRIDENT X3 0 723-00-32D

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,378.53
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Kaiser Permanente Commercial	$1,702.89
Rate for Payer: Kaiser Permanente Medicaid	$1,378.53
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT TRIDENT X3 0 723-00-32D

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,513.68
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT TRIDENT X3 723-00-36D

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,378.53
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Kaiser Permanente Commercial	$1,702.89
Rate for Payer: Kaiser Permanente Medicaid	$1,378.53
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT TRIDENT X3 723-00-36D

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,513.68
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT TRIDENT X3 723-00-36G

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 TRIDENT X3 723-00-36G

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 TRIDENT X3 723-10-32D

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 TRIDENT X3 723-10-32D

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 TRIDENT X3 723-10-36E

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 TRIDENT X3 723-10-36E

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 TRIDENT X3 723-10-36F

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 TRIDENT X3 723-10-36F

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 X3 28/48 1236-2-848

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,816.64
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

INSERT X3 28/48 1236-2-848

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,654.44
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Kaiser Permanente Commercial	$2,043.72
Rate for Payer: Kaiser Permanente Medicaid	$1,654.44
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

INSERT X3 SZ7 10M 5532-G-710-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 X3 SZ7 10M 5532-G-710-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 X3 SZ 7 5532-G-713-E

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,513.68
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT X3 SZ 7 5532-G-713-E

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,378.53
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Kaiser Permanente Commercial	$1,702.89
Rate for Payer: Kaiser Permanente Medicaid	$1,378.53
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT X3 TB 5531-G-514-E

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,378.53
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Kaiser Permanente Commercial	$1,702.89
Rate for Payer: Kaiser Permanente Medicaid	$1,378.53
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT X3 TB 5531-G-514-E

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,513.68
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

INSERT X3 TB 5532-G-412-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 X3 TB 5532-G-412-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 X3 T.BEAR 5531-G-412-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

Know your out-of-pocket cost for care.

All Charges