Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

KIT PERICARDIOCENTESIS

Facility

$530.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$450.50
Max. Negotiated Rate	$514.10
Rate for Payer: Cash Price	$318.00
Rate for Payer: Health Management Network Commercial	$450.50
Rate for Payer: MDX Hawaii PPO	$514.10

KIT PERICARDIOCENTESIS

Facility

$530.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$270.30
Max. Negotiated Rate	$514.10
Rate for Payer: Cash Price	$318.00
Rate for Payer: Hawaii Western Management Group Commercial	$503.50
Rate for Payer: Health Management Network Commercial	$450.50
Rate for Payer: Kaiser Permanente Commercial	$333.90
Rate for Payer: Kaiser Permanente Medicaid	$270.30
Rate for Payer: MDX Hawaii PPO	$514.10
Rate for Payer: University Health Alliance Commercial	$386.32

KIT PREPARATION OF TC 99M-SESTAMIBI COMBO NO.1 IV SOLUTION [134046]

Facility

$463.00

Service Code	HCPCS A9500
Hospital Revenue Code	343
Min. Negotiated Rate	$393.55
Max. Negotiated Rate	$449.11
Rate for Payer: Cash Price	$277.80
Rate for Payer: Health Management Network Commercial	$393.55
Rate for Payer: MDX Hawaii PPO	$449.11

KIT PREPARATION OF TC 99M-SESTAMIBI COMBO NO.1 IV SOLUTION [134046]

Facility

$463.00

Service Code	HCPCS A9500
Hospital Revenue Code	343
Min. Negotiated Rate	$83.20
Max. Negotiated Rate	$449.11
Rate for Payer: Cash Price	$277.80
Rate for Payer: Cash Price	$277.80
Rate for Payer: Hawaii Western Management Group Commercial	$439.85
Rate for Payer: Health Management Network Commercial	$393.55
Rate for Payer: Kaiser Permanente Commercial	$291.69
Rate for Payer: Kaiser Permanente Medicaid	$236.13
Rate for Payer: MDX Hawaii PPO	$449.11
Rate for Payer: UnitedHealthcare Medicaid	$83.20
Rate for Payer: University Health Alliance Commercial	$337.48

KIT PREPARATION OF TC-99M-SODIUM PYROPHOSPHATE 12 MG IV SOLUTION [134584]

Facility

$72.00

Service Code	HCPCS A9558
Hospital Revenue Code	343
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$43.20
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: MDX Hawaii PPO	$69.84

KIT PREPARATION OF TC-99M-SODIUM PYROPHOSPHATE 12 MG IV SOLUTION [134584]

Facility

$72.00

Service Code	HCPCS A9558
Hospital Revenue Code	343
Min. Negotiated Rate	$36.72
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cash Price	$43.20
Rate for Payer: Hawaii Western Management Group Commercial	$68.40
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Kaiser Permanente Commercial	$45.36
Rate for Payer: Kaiser Permanente Medicaid	$36.72
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: UnitedHealthcare Medicaid	$40.00
Rate for Payer: University Health Alliance Commercial	$52.48

KIT RADIAL HEAD 03.405.000S

Facility

$1,509.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,282.65
Max. Negotiated Rate	$1,463.73
Rate for Payer: Cash Price	$905.40
Rate for Payer: Health Management Network Commercial	$1,282.65
Rate for Payer: MDX Hawaii PPO	$1,463.73

KIT RADIAL HEAD 03.405.000S

Facility

$1,509.00

Hospital Revenue Code	272
Min. Negotiated Rate	$769.59
Max. Negotiated Rate	$1,463.73
Rate for Payer: Cash Price	$905.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,433.55
Rate for Payer: Health Management Network Commercial	$1,282.65
Rate for Payer: Kaiser Permanente Commercial	$950.67
Rate for Payer: Kaiser Permanente Medicaid	$769.59
Rate for Payer: MDX Hawaii PPO	$1,463.73
Rate for Payer: University Health Alliance Commercial	$1,099.91

KIT REPAIR ACUTE AC AR-2271

Facility

$3,750.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$1,912.50
Max. Negotiated Rate	$3,637.50
Rate for Payer: Cash Price	$2,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,562.50
Rate for Payer: Health Management Network Commercial	$3,187.50
Rate for Payer: Kaiser Permanente Commercial	$2,362.50
Rate for Payer: Kaiser Permanente Medicaid	$1,912.50
Rate for Payer: MDX Hawaii PPO	$3,637.50
Rate for Payer: University Health Alliance Commercial	$2,733.38

KIT REPAIR ACUTE AC AR-2271

Facility

$3,750.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$3,187.50
Max. Negotiated Rate	$3,637.50
Rate for Payer: Cash Price	$2,250.00
Rate for Payer: Health Management Network Commercial	$3,187.50
Rate for Payer: MDX Hawaii PPO	$3,637.50

KIT SMALL PARTS PHACO

Facility

$179.00

Hospital Revenue Code	272
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$107.40
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: MDX Hawaii PPO	$173.63

KIT SMALL PARTS PHACO

Facility

$179.00

Hospital Revenue Code	272
Min. Negotiated Rate	$91.29
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$107.40
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$112.77
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: University Health Alliance Commercial	$130.47

KIT TRANS-TIBIAL #AR-1898S

Facility

$780.00

Hospital Revenue Code	272
Min. Negotiated Rate	$397.80
Max. Negotiated Rate	$756.60
Rate for Payer: Cash Price	$468.00
Rate for Payer: Hawaii Western Management Group Commercial	$741.00
Rate for Payer: Health Management Network Commercial	$663.00
Rate for Payer: Kaiser Permanente Commercial	$491.40
Rate for Payer: Kaiser Permanente Medicaid	$397.80
Rate for Payer: MDX Hawaii PPO	$756.60
Rate for Payer: University Health Alliance Commercial	$568.54

KIT TRANS-TIBIAL #AR-1898S

Facility

$780.00

Hospital Revenue Code	272
Min. Negotiated Rate	$663.00
Max. Negotiated Rate	$756.60
Rate for Payer: Cash Price	$468.00
Rate for Payer: Health Management Network Commercial	$663.00
Rate for Payer: MDX Hawaii PPO	$756.60

KIT URETERAL 6FX70 FIBEROPTIC

Facility

$997.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$558.32
Max. Negotiated Rate	$967.09
Rate for Payer: Cash Price	$598.20
Rate for Payer: Hawaii Western Management Group Commercial	$697.90
Rate for Payer: Health Management Network Commercial	$847.45
Rate for Payer: MDX Hawaii PPO	$967.09
Rate for Payer: University Health Alliance Commercial	$558.32

KIT URETERAL 6FX70 FIBEROPTIC

Facility

$997.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$508.47
Max. Negotiated Rate	$967.09
Rate for Payer: Cash Price	$598.20
Rate for Payer: Hawaii Western Management Group Commercial	$697.90
Rate for Payer: Health Management Network Commercial	$847.45
Rate for Payer: Kaiser Permanente Commercial	$628.11
Rate for Payer: Kaiser Permanente Medicaid	$508.47
Rate for Payer: MDX Hawaii PPO	$967.09
Rate for Payer: University Health Alliance Commercial	$558.32

KL 1.8 FIBERTAK SHOULD AR-3636

Facility

$1,617.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$824.67
Max. Negotiated Rate	$1,568.49
Rate for Payer: Cash Price	$970.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,131.90
Rate for Payer: Health Management Network Commercial	$1,374.45
Rate for Payer: Kaiser Permanente Commercial	$1,018.71
Rate for Payer: Kaiser Permanente Medicaid	$824.67
Rate for Payer: MDX Hawaii PPO	$1,568.49
Rate for Payer: University Health Alliance Commercial	$905.52

KL 1.8 FIBERTAK SHOULD AR-3636

Facility

$1,617.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$905.52
Max. Negotiated Rate	$1,568.49
Rate for Payer: Cash Price	$970.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,131.90
Rate for Payer: Health Management Network Commercial	$1,374.45
Rate for Payer: MDX Hawaii PPO	$1,568.49
Rate for Payer: University Health Alliance Commercial	$905.52

KNEE-CONSTRAINE 00-5994-040-10

Facility

$4,257.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,171.07
Max. Negotiated Rate	$4,129.29
Rate for Payer: Cash Price	$2,554.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,979.90
Rate for Payer: Health Management Network Commercial	$3,618.45
Rate for Payer: Kaiser Permanente Commercial	$2,681.91
Rate for Payer: Kaiser Permanente Medicaid	$2,171.07
Rate for Payer: MDX Hawaii PPO	$4,129.29
Rate for Payer: University Health Alliance Commercial	$2,383.92

KNEE-CONSTRAINE 00-5994-040-10

Facility

$4,257.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,383.92
Max. Negotiated Rate	$4,129.29
Rate for Payer: Cash Price	$2,554.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,979.90
Rate for Payer: Health Management Network Commercial	$3,618.45
Rate for Payer: MDX Hawaii PPO	$4,129.29
Rate for Payer: University Health Alliance Commercial	$2,383.92

KNEE CRYO CUFF ONLY MED 11A01

Facility

$181.00

Hospital Revenue Code	272
Min. Negotiated Rate	$92.31
Max. Negotiated Rate	$175.57
Rate for Payer: Cash Price	$108.60
Rate for Payer: Hawaii Western Management Group Commercial	$171.95
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: Kaiser Permanente Commercial	$114.03
Rate for Payer: Kaiser Permanente Medicaid	$92.31
Rate for Payer: MDX Hawaii PPO	$175.57
Rate for Payer: University Health Alliance Commercial	$131.93

KNEE CRYO CUFF ONLY MED 11A01

Facility

$181.00

Hospital Revenue Code	272
Min. Negotiated Rate	$153.85
Max. Negotiated Rate	$175.57
Rate for Payer: Cash Price	$108.60
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: MDX Hawaii PPO	$175.57

KNEE IMMOBILIZER, TROM COOL

Facility

$356.00

Service Code	HCPCS L1830
Hospital Revenue Code	274
Min. Negotiated Rate	$199.36
Max. Negotiated Rate	$345.32
Rate for Payer: Cash Price	$213.60
Rate for Payer: Hawaii Western Management Group Commercial	$249.20
Rate for Payer: Health Management Network Commercial	$302.60
Rate for Payer: MDX Hawaii PPO	$345.32
Rate for Payer: University Health Alliance Commercial	$199.36

KNEE IMMOBILIZER, TROM COOL

Facility

$384.00

Service Code	HCPCS L1833
Hospital Revenue Code	274
Min. Negotiated Rate	$215.04
Max. Negotiated Rate	$372.48
Rate for Payer: Cash Price	$230.40
Rate for Payer: Hawaii Western Management Group Commercial	$268.80
Rate for Payer: Health Management Network Commercial	$326.40
Rate for Payer: MDX Hawaii PPO	$372.48
Rate for Payer: University Health Alliance Commercial	$215.04

KNEE IMMOBILIZER, TROM COOL

Facility

$384.00

Service Code	HCPCS L1833
Hospital Revenue Code	274
Min. Negotiated Rate	$195.84
Max. Negotiated Rate	$668.79
Rate for Payer: Cash Price	$230.40
Rate for Payer: Cash Price	$230.40
Rate for Payer: Hawaii Western Management Group Commercial	$268.80
Rate for Payer: Health Management Network Commercial	$326.40
Rate for Payer: Kaiser Permanente Commercial	$241.92
Rate for Payer: Kaiser Permanente Medicaid	$195.84
Rate for Payer: MDX Hawaii PPO	$372.48
Rate for Payer: UnitedHealthcare Medicaid	$668.79
Rate for Payer: University Health Alliance Commercial	$215.04

Know your out-of-pocket cost for care.

All Charges