Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

INSERT X3 T.BEAR 5531-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 5532-G-610-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 T.BEAR 5532-G-610-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 TIBIAL 5531-G-211-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 TIBIAL 5531-G-211-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 TIBIAL 5531-G-610-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 TIBIAL 5531-G-610-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 TIBIAL 5531-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: 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 TIBIAL 5531-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 X3 TIBIAL 5537-G-509-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 X3 TIBIAL 5537-G-509-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 X3 TIBIA SZ6 5531-G-611

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 TIBIA SZ6 5531-G-611

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

INSPACE US MEDIUM 0131

Facility

$11,000.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$5,610.00
Max. Negotiated Rate	$10,670.00
Rate for Payer: Cash Price	$6,600.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,700.00
Rate for Payer: Health Management Network Commercial	$9,350.00
Rate for Payer: Kaiser Permanente Commercial	$6,930.00
Rate for Payer: Kaiser Permanente Medicaid	$5,610.00
Rate for Payer: MDX Hawaii PPO	$10,670.00
Rate for Payer: University Health Alliance Commercial	$6,160.00

INSPACE US MEDIUM 0131

Facility

$11,000.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$6,160.00
Max. Negotiated Rate	$10,670.00
Rate for Payer: Cash Price	$6,600.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,700.00
Rate for Payer: Health Management Network Commercial	$9,350.00
Rate for Payer: MDX Hawaii PPO	$10,670.00
Rate for Payer: University Health Alliance Commercial	$6,160.00

INSTILLATION OF ANTI-NEOPLASTIC PHARMACOLOGIC/BIOLOGIC AGENT INTO RENAL PELVIS, ANY METHOD, INCLUDING ALL IMAGING GUIDANCE, INCLUDING VOLUMETRIC MEASUREMENT IF PERFORMED

Facility

$2,837.00

Service Code	CPT C9789
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$1,445.95
Rate for Payer: AlohaCare Medicare	$1,445.95
Rate for Payer: Devoted Health Medicare	$1,590.55
Rate for Payer: Hawaii Medical Service Association Commercial	$1,807.44
Rate for Payer: Hawaii Medical Service Association Medicare	$1,445.95
Rate for Payer: Humana Medicare	$1,445.95
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,445.95
Rate for Payer: Ohana Health Plan Medicaid	$1,590.55
Rate for Payer: Ohana Health Plan Medicare	$1,445.95
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,445.95

INSTR 10MM ENDO RETRACT II

Facility

$395.00

Hospital Revenue Code	272
Min. Negotiated Rate	$201.45
Max. Negotiated Rate	$383.15
Rate for Payer: Cash Price	$237.00
Rate for Payer: Hawaii Western Management Group Commercial	$375.25
Rate for Payer: Health Management Network Commercial	$335.75
Rate for Payer: Kaiser Permanente Commercial	$248.85
Rate for Payer: Kaiser Permanente Medicaid	$201.45
Rate for Payer: MDX Hawaii PPO	$383.15
Rate for Payer: University Health Alliance Commercial	$287.92

INSTR 10MM ENDO RETRACT II

Facility

$395.00

Hospital Revenue Code	272
Min. Negotiated Rate	$335.75
Max. Negotiated Rate	$383.15
Rate for Payer: Cash Price	$237.00
Rate for Payer: Health Management Network Commercial	$335.75
Rate for Payer: MDX Hawaii PPO	$383.15

INSTR 5MM ENDO GRASPER

Facility

$234.00

Hospital Revenue Code	272
Min. Negotiated Rate	$198.90
Max. Negotiated Rate	$226.98
Rate for Payer: Cash Price	$140.40
Rate for Payer: Health Management Network Commercial	$198.90
Rate for Payer: MDX Hawaii PPO	$226.98

INSTR 5MM ENDO GRASPER

Facility

$234.00

Hospital Revenue Code	272
Min. Negotiated Rate	$119.34
Max. Negotiated Rate	$226.98
Rate for Payer: Cash Price	$140.40
Rate for Payer: Hawaii Western Management Group Commercial	$222.30
Rate for Payer: Health Management Network Commercial	$198.90
Rate for Payer: Kaiser Permanente Commercial	$147.42
Rate for Payer: Kaiser Permanente Medicaid	$119.34
Rate for Payer: MDX Hawaii PPO	$226.98
Rate for Payer: University Health Alliance Commercial	$170.56

INSTR 5MM MINI SHEARS

Facility

$149.00

Hospital Revenue Code	272
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$89.40
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: MDX Hawaii PPO	$144.53

INSTR 5MM MINI SHEARS

Facility

$149.00

Hospital Revenue Code	272
Min. Negotiated Rate	$75.99
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$89.40
Rate for Payer: Hawaii Western Management Group Commercial	$141.55
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$93.87
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: University Health Alliance Commercial	$108.61

INSTR BIOPSY NEEDLE MONOPTY

Facility

$162.00

Hospital Revenue Code	272
Min. Negotiated Rate	$82.62
Max. Negotiated Rate	$157.14
Rate for Payer: Cash Price	$97.20
Rate for Payer: Hawaii Western Management Group Commercial	$153.90
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$102.06
Rate for Payer: Kaiser Permanente Medicaid	$82.62
Rate for Payer: MDX Hawaii PPO	$157.14
Rate for Payer: University Health Alliance Commercial	$118.08

INSTR BIOPSY NEEDLE MONOPTY

Facility

$162.00

Hospital Revenue Code	272
Min. Negotiated Rate	$137.70
Max. Negotiated Rate	$157.14
Rate for Payer: Cash Price	$97.20
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: MDX Hawaii PPO	$157.14

INSTR DUODENOSCOPE

Facility

$7,650.00

Service Code	HCPCS C1748
Hospital Revenue Code	272
Min. Negotiated Rate	$3,901.50
Max. Negotiated Rate	$7,420.50
Rate for Payer: Cash Price	$4,590.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,267.50
Rate for Payer: Health Management Network Commercial	$6,502.50
Rate for Payer: Kaiser Permanente Commercial	$4,819.50
Rate for Payer: Kaiser Permanente Medicaid	$3,901.50
Rate for Payer: MDX Hawaii PPO	$7,420.50
Rate for Payer: University Health Alliance Commercial	$5,576.09

Know your out-of-pocket cost for care.

All Charges