Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

BASKET URINARY STONE NITINOL

Facility

$880.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$748.00
Max. Negotiated Rate	$853.60
Rate for Payer: Cash Price	$528.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: MDX Hawaii PPO	$853.60

BATTERY INTERSTIM II IPG 97800

Facility

$24,528.00

Service Code	HCPCS C1767
Hospital Revenue Code	278
Min. Negotiated Rate	$13,735.68
Max. Negotiated Rate	$23,792.16
Rate for Payer: Cash Price	$14,716.80
Rate for Payer: Hawaii Western Management Group Commercial	$17,169.60
Rate for Payer: Health Management Network Commercial	$20,848.80
Rate for Payer: MDX Hawaii PPO	$23,792.16
Rate for Payer: University Health Alliance Commercial	$13,735.68

BATTERY INTERSTIM II IPG 97800

Facility

$24,528.00

Service Code	HCPCS C1767
Hospital Revenue Code	278
Min. Negotiated Rate	$12,509.28
Max. Negotiated Rate	$23,792.16
Rate for Payer: Cash Price	$14,716.80
Rate for Payer: Hawaii Western Management Group Commercial	$17,169.60
Rate for Payer: Health Management Network Commercial	$20,848.80
Rate for Payer: Kaiser Permanente Commercial	$15,452.64
Rate for Payer: Kaiser Permanente Medicaid	$12,509.28
Rate for Payer: MDX Hawaii PPO	$23,792.16
Rate for Payer: University Health Alliance Commercial	$13,735.68

BAYONET FORCEP 6.25IN BIPOLAR

Facility

$229.00

Hospital Revenue Code	272
Min. Negotiated Rate	$116.79
Max. Negotiated Rate	$222.13
Rate for Payer: Cash Price	$137.40
Rate for Payer: Hawaii Western Management Group Commercial	$217.55
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: Kaiser Permanente Commercial	$144.27
Rate for Payer: Kaiser Permanente Medicaid	$116.79
Rate for Payer: MDX Hawaii PPO	$222.13
Rate for Payer: University Health Alliance Commercial	$166.92

BAYONET FORCEP 6.25IN BIPOLAR

Facility

$229.00

Hospital Revenue Code	272
Min. Negotiated Rate	$194.65
Max. Negotiated Rate	$222.13
Rate for Payer: Cash Price	$137.40
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: MDX Hawaii PPO	$222.13

BCG LIVE 50 MG INTRAVESICAL SUSPENSION [21570]

Facility

$328.00

Service Code	HCPCS J9030
Hospital Revenue Code	250
Min. Negotiated Rate	$278.80
Max. Negotiated Rate	$318.16
Rate for Payer: Cash Price	$196.80
Rate for Payer: Health Management Network Commercial	$278.80
Rate for Payer: MDX Hawaii PPO	$318.16

BCG LIVE 50 MG INTRAVESICAL SUSPENSION [21570]

Facility

$328.00

Service Code	HCPCS J9030
Hospital Revenue Code	636
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$318.16
Rate for Payer: AlohaCare Medicaid	$3.39
Rate for Payer: AlohaCare Medicare	$3.39
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cash Price	$196.80
Rate for Payer: Devoted Health Medicare	$3.73
Rate for Payer: Hawaii Medical Service Association ABD	$3.12
Rate for Payer: Hawaii Medical Service Association Commercial	$4.24
Rate for Payer: Hawaii Medical Service Association Medicare	$3.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.12
Rate for Payer: Hawaii Western Management Group Commercial	$311.60
Rate for Payer: Health Management Network Commercial	$278.80
Rate for Payer: Humana Medicare	$3.39
Rate for Payer: Kaiser Permanente Commercial	$206.64
Rate for Payer: Kaiser Permanente Medicaid	$167.28
Rate for Payer: Kaiser Permanente Medicare	$3.39
Rate for Payer: MDX Hawaii PPO	$318.16
Rate for Payer: Ohana Health Plan Medicaid	$3.73
Rate for Payer: Ohana Health Plan Medicare	$3.39
Rate for Payer: UnitedHealthcare Medicaid	$196.80
Rate for Payer: UnitedHealthcare Medicare	$3.39
Rate for Payer: University Health Alliance Commercial	$239.08

BCG LIVE 50 MG/ML (WET IS SUSR VIAL) [43021570]

Facility

$328.00

Service Code	HCPCS J9030
Hospital Revenue Code	636
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$318.16
Rate for Payer: AlohaCare Medicaid	$3.39
Rate for Payer: AlohaCare Medicare	$3.39
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cash Price	$196.80
Rate for Payer: Devoted Health Medicare	$3.73
Rate for Payer: Hawaii Medical Service Association ABD	$3.12
Rate for Payer: Hawaii Medical Service Association Commercial	$4.24
Rate for Payer: Hawaii Medical Service Association Medicare	$3.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.12
Rate for Payer: Hawaii Western Management Group Commercial	$311.60
Rate for Payer: Health Management Network Commercial	$278.80
Rate for Payer: Humana Medicare	$3.39
Rate for Payer: Kaiser Permanente Commercial	$206.64
Rate for Payer: Kaiser Permanente Medicaid	$167.28
Rate for Payer: Kaiser Permanente Medicare	$3.39
Rate for Payer: MDX Hawaii PPO	$318.16
Rate for Payer: Ohana Health Plan Medicaid	$3.73
Rate for Payer: Ohana Health Plan Medicare	$3.39
Rate for Payer: UnitedHealthcare Medicaid	$196.80
Rate for Payer: UnitedHealthcare Medicare	$3.39
Rate for Payer: University Health Alliance Commercial	$239.08

BCG LIVE 50 MG/ML (WET IS SUSR VIAL) [43021570]

Facility

$328.00

Service Code	HCPCS J9030
Hospital Revenue Code	250
Min. Negotiated Rate	$278.80
Max. Negotiated Rate	$318.16
Rate for Payer: Cash Price	$196.80
Rate for Payer: Health Management Network Commercial	$278.80
Rate for Payer: MDX Hawaii PPO	$318.16

BEARING INSERT PS 5532-G-609-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

BEARING INSERT PS 5532-G-609-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

BEARING INSERTR 42-5299-003-01

Facility

$328.00

Hospital Revenue Code	272
Min. Negotiated Rate	$167.28
Max. Negotiated Rate	$318.16
Rate for Payer: Cash Price	$196.80
Rate for Payer: Hawaii Western Management Group Commercial	$311.60
Rate for Payer: Health Management Network Commercial	$278.80
Rate for Payer: Kaiser Permanente Commercial	$206.64
Rate for Payer: Kaiser Permanente Medicaid	$167.28
Rate for Payer: MDX Hawaii PPO	$318.16
Rate for Payer: University Health Alliance Commercial	$239.08

BEARING INSERTR 42-5299-003-01

Facility

$328.00

Hospital Revenue Code	272
Min. Negotiated Rate	$278.80
Max. Negotiated Rate	$318.16
Rate for Payer: Cash Price	$196.80
Rate for Payer: Health Management Network Commercial	$278.80
Rate for Payer: MDX Hawaii PPO	$318.16

BEARING INSERT SZ.3 5532-G-309

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

BEARING INSERT SZ.3 5532-G-309

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

BEARING INSERT SZ.5 5531-G-511

Facility

$7,716.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,320.96
Max. Negotiated Rate	$7,484.52
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,401.20
Rate for Payer: Health Management Network Commercial	$6,558.60
Rate for Payer: MDX Hawaii PPO	$7,484.52
Rate for Payer: University Health Alliance Commercial	$4,320.96

BEARING INSERT SZ.5 5531-G-511

Facility

$7,716.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,935.16
Max. Negotiated Rate	$7,484.52
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,401.20
Rate for Payer: Health Management Network Commercial	$6,558.60
Rate for Payer: Kaiser Permanente Commercial	$4,861.08
Rate for Payer: Kaiser Permanente Medicaid	$3,935.16
Rate for Payer: MDX Hawaii PPO	$7,484.52
Rate for Payer: University Health Alliance Commercial	$4,320.96

BEARING INSERT X3 5530-G-711

Facility

$7,316.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,731.16
Max. Negotiated Rate	$7,096.52
Rate for Payer: Cash Price	$4,389.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,121.20
Rate for Payer: Health Management Network Commercial	$6,218.60
Rate for Payer: Kaiser Permanente Commercial	$4,609.08
Rate for Payer: Kaiser Permanente Medicaid	$3,731.16
Rate for Payer: MDX Hawaii PPO	$7,096.52
Rate for Payer: University Health Alliance Commercial	$4,096.96

BEARING INSERT X3 5530-G-711

Facility

$7,316.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,096.96
Max. Negotiated Rate	$7,096.52
Rate for Payer: Cash Price	$4,389.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,121.20
Rate for Payer: Health Management Network Commercial	$6,218.60
Rate for Payer: MDX Hawaii PPO	$7,096.52
Rate for Payer: University Health Alliance Commercial	$4,096.96

BEARING INSERT X3 5532-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

BEARING INSERT X3 5532-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

BEARING INSERT X3 5532-G-609

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

BEARING INSERT X3 5532-G-609

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

BEARING INS SZ3 9MM 5531-G-309

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

BEARING INS SZ3 9MM 5531-G-309

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

Know your out-of-pocket cost for care.

All Charges