Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

BASEPLATE TT SZ 5 5536-B-500

Facility

$3,244.00

Service Code	HCPCS C1713
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

BASEPLATE TT SZ 5 5536-B-500

Facility

$3,244.00

Service Code	HCPCS C1713
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

BASEPLTE TIBIAL SZ8 5521-B-800

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

BASEPLTE TIBIAL SZ8 5521-B-800

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

BASKET AIRWAY RETRIEVAL

Facility

$952.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$485.52
Max. Negotiated Rate	$923.44
Rate for Payer: Cash Price	$571.20
Rate for Payer: Hawaii Western Management Group Commercial	$904.40
Rate for Payer: Health Management Network Commercial	$809.20
Rate for Payer: Kaiser Permanente Commercial	$599.76
Rate for Payer: Kaiser Permanente Medicaid	$485.52
Rate for Payer: MDX Hawaii PPO	$923.44
Rate for Payer: University Health Alliance Commercial	$693.91

BASKET AIRWAY RETRIEVAL

Facility

$952.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$809.20
Max. Negotiated Rate	$923.44
Rate for Payer: Cash Price	$571.20
Rate for Payer: Health Management Network Commercial	$809.20
Rate for Payer: MDX Hawaii PPO	$923.44

BASKET ESCAPE URINARY STONE

Facility

$913.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$776.05
Max. Negotiated Rate	$885.61
Rate for Payer: Cash Price	$547.80
Rate for Payer: Health Management Network Commercial	$776.05
Rate for Payer: MDX Hawaii PPO	$885.61

BASKET ESCAPE URINARY STONE

Facility

$913.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$465.63
Max. Negotiated Rate	$885.61
Rate for Payer: Cash Price	$547.80
Rate for Payer: Hawaii Western Management Group Commercial	$867.35
Rate for Payer: Health Management Network Commercial	$776.05
Rate for Payer: Kaiser Permanente Commercial	$575.19
Rate for Payer: Kaiser Permanente Medicaid	$465.63
Rate for Payer: MDX Hawaii PPO	$885.61
Rate for Payer: University Health Alliance Commercial	$665.49

BASKET FORCEP MINI 3PRONG

Facility

$898.00

Hospital Revenue Code	272
Min. Negotiated Rate	$763.30
Max. Negotiated Rate	$871.06
Rate for Payer: Cash Price	$538.80
Rate for Payer: Health Management Network Commercial	$763.30
Rate for Payer: MDX Hawaii PPO	$871.06

BASKET FORCEP MINI 3PRONG

Facility

$898.00

Hospital Revenue Code	272
Min. Negotiated Rate	$457.98
Max. Negotiated Rate	$871.06
Rate for Payer: Cash Price	$538.80
Rate for Payer: Hawaii Western Management Group Commercial	$853.10
Rate for Payer: Health Management Network Commercial	$763.30
Rate for Payer: Kaiser Permanente Commercial	$565.74
Rate for Payer: Kaiser Permanente Medicaid	$457.98
Rate for Payer: MDX Hawaii PPO	$871.06
Rate for Payer: University Health Alliance Commercial	$654.55

BASKET MINI GRASPING

Facility

$817.00

Hospital Revenue Code	272
Min. Negotiated Rate	$416.67
Max. Negotiated Rate	$792.49
Rate for Payer: Cash Price	$490.20
Rate for Payer: Hawaii Western Management Group Commercial	$776.15
Rate for Payer: Health Management Network Commercial	$694.45
Rate for Payer: Kaiser Permanente Commercial	$514.71
Rate for Payer: Kaiser Permanente Medicaid	$416.67
Rate for Payer: MDX Hawaii PPO	$792.49
Rate for Payer: University Health Alliance Commercial	$595.51

BASKET MINI GRASPING

Facility

$817.00

Hospital Revenue Code	272
Min. Negotiated Rate	$694.45
Max. Negotiated Rate	$792.49
Rate for Payer: Cash Price	$490.20
Rate for Payer: Health Management Network Commercial	$694.45
Rate for Payer: MDX Hawaii PPO	$792.49

BASKET NITINOL 1.9 ZERO TIP

Facility

$746.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$634.10
Max. Negotiated Rate	$723.62
Rate for Payer: Cash Price	$447.60
Rate for Payer: Health Management Network Commercial	$634.10
Rate for Payer: MDX Hawaii PPO	$723.62

BASKET NITINOL 1.9 ZERO TIP

Facility

$746.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$380.46
Max. Negotiated Rate	$723.62
Rate for Payer: Cash Price	$447.60
Rate for Payer: Hawaii Western Management Group Commercial	$708.70
Rate for Payer: Health Management Network Commercial	$634.10
Rate for Payer: Kaiser Permanente Commercial	$469.98
Rate for Payer: Kaiser Permanente Medicaid	$380.46
Rate for Payer: MDX Hawaii PPO	$723.62
Rate for Payer: University Health Alliance Commercial	$543.76

BASKET RETRIEVAL 15MM

Facility

$1,568.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,332.80
Max. Negotiated Rate	$1,520.96
Rate for Payer: Cash Price	$940.80
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: MDX Hawaii PPO	$1,520.96

BASKET RETRIEVAL 15MM

Facility

$1,568.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$799.68
Max. Negotiated Rate	$1,520.96
Rate for Payer: Cash Price	$940.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,489.60
Rate for Payer: Health Management Network Commercial	$1,332.80
Rate for Payer: Kaiser Permanente Commercial	$987.84
Rate for Payer: Kaiser Permanente Medicaid	$799.68
Rate for Payer: MDX Hawaii PPO	$1,520.96
Rate for Payer: University Health Alliance Commercial	$1,142.92

BASKET STONE EXTRACTOR

Facility

$926.00

Service Code	HCPCS A4649
Hospital Revenue Code	272
Min. Negotiated Rate	$472.26
Max. Negotiated Rate	$898.22
Rate for Payer: Cash Price	$555.60
Rate for Payer: Hawaii Western Management Group Commercial	$879.70
Rate for Payer: Health Management Network Commercial	$787.10
Rate for Payer: Kaiser Permanente Commercial	$583.38
Rate for Payer: Kaiser Permanente Medicaid	$472.26
Rate for Payer: MDX Hawaii PPO	$898.22
Rate for Payer: University Health Alliance Commercial	$674.96

BASKET STONE EXTRACTOR

Facility

$926.00

Service Code	HCPCS A4649
Hospital Revenue Code	272
Min. Negotiated Rate	$787.10
Max. Negotiated Rate	$898.22
Rate for Payer: Cash Price	$555.60
Rate for Payer: Health Management Network Commercial	$787.10
Rate for Payer: MDX Hawaii PPO	$898.22

BASKET STONE RETRIEV ENDO 2

Facility

$923.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$784.55
Max. Negotiated Rate	$895.31
Rate for Payer: Cash Price	$553.80
Rate for Payer: Health Management Network Commercial	$784.55
Rate for Payer: MDX Hawaii PPO	$895.31

BASKET STONE RETRIEV ENDO 2

Facility

$923.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$470.73
Max. Negotiated Rate	$895.31
Rate for Payer: Cash Price	$553.80
Rate for Payer: Hawaii Western Management Group Commercial	$876.85
Rate for Payer: Health Management Network Commercial	$784.55
Rate for Payer: Kaiser Permanente Commercial	$581.49
Rate for Payer: Kaiser Permanente Medicaid	$470.73
Rate for Payer: MDX Hawaii PPO	$895.31
Rate for Payer: University Health Alliance Commercial	$672.77

BASKET STONE RETRIEV ENDO 2.5

Facility

$923.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$470.73
Max. Negotiated Rate	$895.31
Rate for Payer: Cash Price	$553.80
Rate for Payer: Hawaii Western Management Group Commercial	$876.85
Rate for Payer: Health Management Network Commercial	$784.55
Rate for Payer: Kaiser Permanente Commercial	$581.49
Rate for Payer: Kaiser Permanente Medicaid	$470.73
Rate for Payer: MDX Hawaii PPO	$895.31
Rate for Payer: University Health Alliance Commercial	$672.77

BASKET STONE RETRIEV ENDO 2.5

Facility

$923.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$784.55
Max. Negotiated Rate	$895.31
Rate for Payer: Cash Price	$553.80
Rate for Payer: Health Management Network Commercial	$784.55
Rate for Payer: MDX Hawaii PPO	$895.31

BASKET STONE RETRIEV ENDO 3

Facility

$923.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$784.55
Max. Negotiated Rate	$895.31
Rate for Payer: Cash Price	$553.80
Rate for Payer: Health Management Network Commercial	$784.55
Rate for Payer: MDX Hawaii PPO	$895.31

BASKET STONE RETRIEV ENDO 3

Facility

$923.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$470.73
Max. Negotiated Rate	$895.31
Rate for Payer: Cash Price	$553.80
Rate for Payer: Hawaii Western Management Group Commercial	$876.85
Rate for Payer: Health Management Network Commercial	$784.55
Rate for Payer: Kaiser Permanente Commercial	$581.49
Rate for Payer: Kaiser Permanente Medicaid	$470.73
Rate for Payer: MDX Hawaii PPO	$895.31
Rate for Payer: University Health Alliance Commercial	$672.77

BASKET URINARY STONE NITINOL

Facility

$880.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$448.80
Max. Negotiated Rate	$853.60
Rate for Payer: Cash Price	$528.00
Rate for Payer: Hawaii Western Management Group Commercial	$836.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Kaiser Permanente Commercial	$554.40
Rate for Payer: Kaiser Permanente Medicaid	$448.80
Rate for Payer: MDX Hawaii PPO	$853.60
Rate for Payer: University Health Alliance Commercial	$641.43

Know your out-of-pocket cost for care.

All Charges