Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE

Facility

$10,679.55

Service Code	CPT 31541
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$4,404.46
Rate for Payer: AlohaCare Medicare	$4,404.46
Rate for Payer: Devoted Health Medicare	$4,844.91
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,404.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$4,404.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,404.46
Rate for Payer: Ohana Health Plan Medicaid	$4,844.91
Rate for Payer: Ohana Health Plan Medicare	$4,404.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,404.46
Rate for Payer: University Health Alliance Commercial	$10,679.55

LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE

Facility

$8,270.00

Service Code	CPT 31571
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$4,404.46
Rate for Payer: AlohaCare Medicare	$4,404.46
Rate for Payer: Devoted Health Medicare	$4,844.91
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,404.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$4,404.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,404.46
Rate for Payer: Ohana Health Plan Medicaid	$4,844.91
Rate for Payer: Ohana Health Plan Medicare	$4,404.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,404.46
Rate for Payer: University Health Alliance Commercial	$5,160.40

LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; DIAGNOSTIC, WITH OPERATING MICROSCOPE OR TELESCOPE

Facility

$5,160.40

Service Code	CPT 31526
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$2,102.67
Rate for Payer: AlohaCare Medicare	$2,102.67
Rate for Payer: Devoted Health Medicare	$2,312.94
Rate for Payer: Hawaii Medical Service Association Commercial	$2,628.34
Rate for Payer: Hawaii Medical Service Association Medicare	$2,102.67
Rate for Payer: Humana Medicare	$2,102.67
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,102.67
Rate for Payer: Ohana Health Plan Medicaid	$2,312.94
Rate for Payer: Ohana Health Plan Medicare	$2,102.67
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,102.67
Rate for Payer: University Health Alliance Commercial	$5,160.40

LATANOPROST 0.005 % EYE DROPS [18621]

Facility

$238.00

Service Code	NDC 70069042101
Hospital Revenue Code	250
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$230.86
Rate for Payer: Cash Price	$142.80
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: MDX Hawaii PPO	$230.86

LATANOPROST 0.005 % EYE DROPS [18621]

Facility

$32.00

Service Code	NDC 70069042103
Hospital Revenue Code	250
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: MDX Hawaii PPO	$31.04

LATANOPROST 0.005 % EYE DROPS [18621]

Facility

$32.00

Service Code	NDC 70069042103
Hospital Revenue Code	637
Min. Negotiated Rate	$16.32
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Hawaii Western Management Group Commercial	$30.40
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Kaiser Permanente Commercial	$20.16
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: University Health Alliance Commercial	$23.32

LATANOPROST 0.005 % EYE DROPS [18621]

Facility

$238.00

Service Code	NDC 70069042101
Hospital Revenue Code	637
Min. Negotiated Rate	$121.38
Max. Negotiated Rate	$230.86
Rate for Payer: Cash Price	$142.80
Rate for Payer: Hawaii Western Management Group Commercial	$226.10
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Kaiser Permanente Commercial	$149.94
Rate for Payer: Kaiser Permanente Medicaid	$121.38
Rate for Payer: MDX Hawaii PPO	$230.86
Rate for Payer: University Health Alliance Commercial	$173.48

LAUNCHER BACK UP LEFT 4.5

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$141.75
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: University Health Alliance Commercial	$164.00

LAUNCHER BACK UP LEFT 4.5

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: MDX Hawaii PPO	$218.25

LAUNCHER CORONARY 7FR EBU 3.5

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$141.75
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: University Health Alliance Commercial	$164.00

LAUNCHER CORONARY 7FR EBU 3.5

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: MDX Hawaii PPO	$218.25

LAUNCHER GUIDE JR5 6FR

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$141.75
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: University Health Alliance Commercial	$164.00

LAUNCHER GUIDE JR5 6FR

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: MDX Hawaii PPO	$218.25

LAUNCHER JR 6F

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$141.75
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: University Health Alliance Commercial	$164.00

LAUNCHER JR 6F

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: MDX Hawaii PPO	$218.25

LAUNCHER JR 6FX35

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: MDX Hawaii PPO	$218.25

LAUNCHER JR 6FX35

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$141.75
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: University Health Alliance Commercial	$164.00

LAUNCHR BU LT 5FR EBU 3.0

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: MDX Hawaii PPO	$218.25

LAUNCHR BU LT 5FR EBU 3.0

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$141.75
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: University Health Alliance Commercial	$164.00

LAUNCHR BU LT 5FR EBU 3.5

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: MDX Hawaii PPO	$218.25

LAUNCHR BU LT 5FR EBU 3.5

Facility

$225.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$141.75
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: University Health Alliance Commercial	$164.00

LCD 2.7/3.5 2H/RT 02.117.402

Facility

$2,749.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,539.44
Max. Negotiated Rate	$2,666.53
Rate for Payer: Cash Price	$1,649.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,924.30
Rate for Payer: Health Management Network Commercial	$2,336.65
Rate for Payer: MDX Hawaii PPO	$2,666.53
Rate for Payer: University Health Alliance Commercial	$1,539.44

LCD 2.7/3.5 2H/RT 02.117.402

Facility

$2,749.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,401.99
Max. Negotiated Rate	$2,666.53
Rate for Payer: Cash Price	$1,649.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,924.30
Rate for Payer: Health Management Network Commercial	$2,336.65
Rate for Payer: Kaiser Permanente Commercial	$1,731.87
Rate for Payer: Kaiser Permanente Medicaid	$1,401.99
Rate for Payer: MDX Hawaii PPO	$2,666.53
Rate for Payer: University Health Alliance Commercial	$1,539.44

LCD 2.7/3.5 2H/RT 02.117.602

Facility

$2,837.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,446.87
Max. Negotiated Rate	$2,751.89
Rate for Payer: Cash Price	$1,702.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,985.90
Rate for Payer: Health Management Network Commercial	$2,411.45
Rate for Payer: Kaiser Permanente Commercial	$1,787.31
Rate for Payer: Kaiser Permanente Medicaid	$1,446.87
Rate for Payer: MDX Hawaii PPO	$2,751.89
Rate for Payer: University Health Alliance Commercial	$1,588.72

LCD 2.7/3.5 2H/RT 02.117.602

Facility

$2,837.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,588.72
Max. Negotiated Rate	$2,751.89
Rate for Payer: Cash Price	$1,702.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,985.90
Rate for Payer: Health Management Network Commercial	$2,411.45
Rate for Payer: MDX Hawaii PPO	$2,751.89
Rate for Payer: University Health Alliance Commercial	$1,588.72

Know your out-of-pocket cost for care.

All Charges