Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY

Facility

$10,421.61

Service Code	CPT 31257
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,421.61
Rate for Payer: AlohaCare Medicaid	$8,337.29
Rate for Payer: AlohaCare Medicare	$8,337.29
Rate for Payer: Devoted Health Medicare	$9,171.02
Rate for Payer: Hawaii Medical Service Association Commercial	$10,421.61
Rate for Payer: Hawaii Medical Service Association Medicare	$8,337.29
Rate for Payer: Humana Medicare	$8,337.29
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,337.29
Rate for Payer: Ohana Health Plan Medicaid	$9,171.02
Rate for Payer: Ohana Health Plan Medicare	$8,337.29
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$8,337.29

NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS

Facility

$24,500.00

Service Code	CPT 31259
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$8,337.29
Rate for Payer: AlohaCare Medicare	$8,337.29
Rate for Payer: Devoted Health Medicare	$9,171.02
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	$8,337.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$8,337.29
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,337.29
Rate for Payer: Ohana Health Plan Medicaid	$9,171.02
Rate for Payer: Ohana Health Plan Medicare	$8,337.29
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$8,337.29
Rate for Payer: University Health Alliance Commercial	$24,500.00

NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED

Facility

$13,778.00

Service Code	CPT 31276
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$8,337.29
Rate for Payer: AlohaCare Medicare	$8,337.29
Rate for Payer: Devoted Health Medicare	$9,171.02
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,337.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$8,337.29
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,337.29
Rate for Payer: Ohana Health Plan Medicaid	$9,171.02
Rate for Payer: Ohana Health Plan Medicare	$8,337.29
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$8,337.29
Rate for Payer: University Health Alliance Commercial	$6,743.44

NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;

Facility

$8,270.00

Service Code	CPT 31256
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	$6,743.44

NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS

Facility

$13,778.00

Service Code	CPT 31267
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$8,337.29
Rate for Payer: AlohaCare Medicare	$8,337.29
Rate for Payer: Devoted Health Medicare	$9,171.02
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,337.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$8,337.29
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,337.29
Rate for Payer: Ohana Health Plan Medicaid	$9,171.02
Rate for Payer: Ohana Health Plan Medicare	$8,337.29
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$8,337.29
Rate for Payer: University Health Alliance Commercial	$6,743.44

NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY;

Facility

$9,171.02

Service Code	CPT 31287
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,171.02
Rate for Payer: AlohaCare Medicaid	$8,337.29
Rate for Payer: AlohaCare Medicare	$8,337.29
Rate for Payer: Devoted Health Medicare	$9,171.02
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	$8,337.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$8,337.29
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,337.29
Rate for Payer: Ohana Health Plan Medicaid	$9,171.02
Rate for Payer: Ohana Health Plan Medicare	$8,337.29
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$8,337.29
Rate for Payer: University Health Alliance Commercial	$6,743.44

NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL

Facility

$7,692.70

Service Code	CPT 69706
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$7,692.70
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Devoted Health Medicare	$7,692.70
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,993.36
Rate for Payer: University Health Alliance Commercial	$6,743.44

NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL

Facility

$7,692.70

Service Code	CPT 69705
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$7,692.70
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Devoted Health Medicare	$7,692.70
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,993.36

NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION [40120]

Facility

$15,983.00

Service Code	HCPCS J2323
Hospital Revenue Code	250
Min. Negotiated Rate	$13,585.55
Max. Negotiated Rate	$15,503.51
Rate for Payer: Cash Price	$9,589.80
Rate for Payer: Health Management Network Commercial	$13,585.55
Rate for Payer: MDX Hawaii PPO	$15,503.51

NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION [40120]

Facility

$15,983.00

Service Code	HCPCS J2323
Hospital Revenue Code	636
Min. Negotiated Rate	$24.13
Max. Negotiated Rate	$15,503.51
Rate for Payer: AlohaCare Medicaid	$24.32
Rate for Payer: AlohaCare Medicare	$24.32
Rate for Payer: Cash Price	$9,589.80
Rate for Payer: Cash Price	$9,589.80
Rate for Payer: Devoted Health Medicare	$26.75
Rate for Payer: Hawaii Medical Service Association ABD	$24.13
Rate for Payer: Hawaii Medical Service Association Commercial	$30.40
Rate for Payer: Hawaii Medical Service Association Medicare	$24.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.13
Rate for Payer: Hawaii Western Management Group Commercial	$15,183.85
Rate for Payer: Health Management Network Commercial	$13,585.55
Rate for Payer: Humana Medicare	$24.32
Rate for Payer: Kaiser Permanente Commercial	$10,069.29
Rate for Payer: Kaiser Permanente Medicaid	$8,151.33
Rate for Payer: Kaiser Permanente Medicare	$24.32
Rate for Payer: MDX Hawaii PPO	$15,503.51
Rate for Payer: Ohana Health Plan Medicaid	$26.75
Rate for Payer: Ohana Health Plan Medicare	$24.32
Rate for Payer: UnitedHealthcare Medicaid	$9,589.80
Rate for Payer: UnitedHealthcare Medicare	$24.32
Rate for Payer: University Health Alliance Commercial	$11,650.01

NATRELLE BREAST IMPLAN SCX-800

Facility

$2,190.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,226.40
Max. Negotiated Rate	$2,124.30
Rate for Payer: Cash Price	$1,314.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,533.00
Rate for Payer: Health Management Network Commercial	$1,861.50
Rate for Payer: MDX Hawaii PPO	$2,124.30
Rate for Payer: University Health Alliance Commercial	$1,226.40

NATRELLE BREAST IMPLAN SCX-800

Facility

$2,190.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,116.90
Max. Negotiated Rate	$2,124.30
Rate for Payer: Cash Price	$1,314.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,533.00
Rate for Payer: Health Management Network Commercial	$1,861.50
Rate for Payer: Kaiser Permanente Commercial	$1,379.70
Rate for Payer: Kaiser Permanente Medicaid	$1,116.90
Rate for Payer: MDX Hawaii PPO	$2,124.30
Rate for Payer: University Health Alliance Commercial	$1,226.40

NATRELLE INSPIRA 110 SCL-110

Facility

$2,190.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,116.90
Max. Negotiated Rate	$2,124.30
Rate for Payer: Cash Price	$1,314.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,533.00
Rate for Payer: Health Management Network Commercial	$1,861.50
Rate for Payer: Kaiser Permanente Commercial	$1,379.70
Rate for Payer: Kaiser Permanente Medicaid	$1,116.90
Rate for Payer: MDX Hawaii PPO	$2,124.30
Rate for Payer: University Health Alliance Commercial	$1,226.40

NATRELLE INSPIRA 110 SCL-110

Facility

$2,190.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,226.40
Max. Negotiated Rate	$2,124.30
Rate for Payer: Cash Price	$1,314.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,533.00
Rate for Payer: Health Management Network Commercial	$1,861.50
Rate for Payer: MDX Hawaii PPO	$2,124.30
Rate for Payer: University Health Alliance Commercial	$1,226.40

NATRELLE SALINE-FILLED 420MM

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

NATRELLE SALINE-FILLED 420MM

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

NATRELLE SALINE-FILLED 800CC

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

NATRELLE SALINE-FILLED 800CC

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

NATRELLE SIZER 550CC

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

NATRELLE SIZER 550CC

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$110.25
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

NATRELLE STY SALINE 68HP-700

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

NATRELLE STY SALINE 68HP-700

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

NATRELLE STY SALINE 68HP-800

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

NATRELLE STY SALINE 68HP-800

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

NATURELLE STY SALINE 684HP-500

Facility

$1,050.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

Know your out-of-pocket cost for care.

All Charges