Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

BIPOLAR HIP #98-0001-006-00

Facility

$7,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,570.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,900.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: Kaiser Permanente Commercial	$4,410.00
Rate for Payer: Kaiser Permanente Medicaid	$3,570.00
Rate for Payer: MDX Hawaii PPO	$6,790.00
Rate for Payer: University Health Alliance Commercial	$3,920.00

BIPOLAR LINER

Facility

$998.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$508.98
Max. Negotiated Rate	$968.06
Rate for Payer: Cash Price	$598.80
Rate for Payer: Hawaii Western Management Group Commercial	$698.60
Rate for Payer: Health Management Network Commercial	$848.30
Rate for Payer: Kaiser Permanente Commercial	$628.74
Rate for Payer: Kaiser Permanente Medicaid	$508.98
Rate for Payer: MDX Hawaii PPO	$968.06
Rate for Payer: University Health Alliance Commercial	$558.88

BIPOLAR LINER

Facility

$998.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$558.88
Max. Negotiated Rate	$968.06
Rate for Payer: Cash Price	$598.80
Rate for Payer: Hawaii Western Management Group Commercial	$698.60
Rate for Payer: Health Management Network Commercial	$848.30
Rate for Payer: MDX Hawaii PPO	$968.06
Rate for Payer: University Health Alliance Commercial	$558.88

BIPOLAR LINER #00-5001-047-28

Facility

$750.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$420.00

BIPOLAR LINER #00-5001-047-28

Facility

$750.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$420.00

BIPOLAR LINER 28X53/54/55

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$831.25
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$551.25
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$637.79

BIPOLAR LINER 28X53/54/55

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$743.75
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75

BIPOLAR LINER 40/41MM OD X22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$551.25
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 40/41MM OD X22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 40MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 40MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$551.25
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 42/43 OD X 22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$551.25
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 42/43 OD X 22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 42MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 42MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$551.25
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 44MM OD X 22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 44MM OD X 22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$551.25
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 44MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$551.25
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 44MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 47MM OD X 22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 47MM OD X 22MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$551.25
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 47MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$551.25
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 47MM OD X 26MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 47MM OD X 32MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$551.25
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

BIPOLAR LINER 47MM OD X 32MM

Facility

$875.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

Know your out-of-pocket cost for care.

All Charges