Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

BLADE 115MM HELICL 04.038.415S

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,358.64
Max. Negotiated Rate	$2,584.08
Rate for Payer: Cash Price	$1,598.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,864.80
Rate for Payer: Health Management Network Commercial	$2,264.40
Rate for Payer: Kaiser Permanente Commercial	$1,678.32
Rate for Payer: Kaiser Permanente Medicaid	$1,358.64
Rate for Payer: MDX Hawaii PPO	$2,584.08
Rate for Payer: University Health Alliance Commercial	$1,491.84

BLADE 115MM HELICL 04.038.415S

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,491.84
Max. Negotiated Rate	$2,584.08
Rate for Payer: Cash Price	$1,598.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,864.80
Rate for Payer: Health Management Network Commercial	$2,264.40
Rate for Payer: MDX Hawaii PPO	$2,584.08
Rate for Payer: University Health Alliance Commercial	$1,491.84

BLADE 120MM HELICL 04.038.420S

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,491.84
Max. Negotiated Rate	$2,584.08
Rate for Payer: Cash Price	$1,598.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,864.80
Rate for Payer: Health Management Network Commercial	$2,264.40
Rate for Payer: MDX Hawaii PPO	$2,584.08
Rate for Payer: University Health Alliance Commercial	$1,491.84

BLADE 120MM HELICL 04.038.420S

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,358.64
Max. Negotiated Rate	$2,584.08
Rate for Payer: Cash Price	$1,598.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,864.80
Rate for Payer: Health Management Network Commercial	$2,264.40
Rate for Payer: Kaiser Permanente Commercial	$1,678.32
Rate for Payer: Kaiser Permanente Medicaid	$1,358.64
Rate for Payer: MDX Hawaii PPO	$2,584.08
Rate for Payer: University Health Alliance Commercial	$1,491.84

BLADE 125MM HELICL 04.038.425S

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,358.64
Max. Negotiated Rate	$2,584.08
Rate for Payer: Cash Price	$1,598.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,864.80
Rate for Payer: Health Management Network Commercial	$2,264.40
Rate for Payer: Kaiser Permanente Commercial	$1,678.32
Rate for Payer: Kaiser Permanente Medicaid	$1,358.64
Rate for Payer: MDX Hawaii PPO	$2,584.08
Rate for Payer: University Health Alliance Commercial	$1,491.84

BLADE 125MM HELICL 04.038.425S

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,491.84
Max. Negotiated Rate	$2,584.08
Rate for Payer: Cash Price	$1,598.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,864.80
Rate for Payer: Health Management Network Commercial	$2,264.40
Rate for Payer: MDX Hawaii PPO	$2,584.08
Rate for Payer: University Health Alliance Commercial	$1,491.84

BLADE 3.0MM PWRD AGGRSV

Facility

$724.00

Hospital Revenue Code	272
Min. Negotiated Rate	$615.40
Max. Negotiated Rate	$702.28
Rate for Payer: Cash Price	$434.40
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: MDX Hawaii PPO	$702.28

BLADE 3.0MM PWRD AGGRSV

Facility

$724.00

Hospital Revenue Code	272
Min. Negotiated Rate	$369.24
Max. Negotiated Rate	$702.28
Rate for Payer: Cash Price	$434.40
Rate for Payer: Hawaii Western Management Group Commercial	$687.80
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: Kaiser Permanente Commercial	$456.12
Rate for Payer: Kaiser Permanente Medicaid	$369.24
Rate for Payer: MDX Hawaii PPO	$702.28
Rate for Payer: University Health Alliance Commercial	$527.72

BLADE 3MM NEEDLE

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

BLADE 3MM NEEDLE

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

BLADE 4.2MM SERRATED BIPOLAR

Facility

$707.00

Hospital Revenue Code	272
Min. Negotiated Rate	$360.57
Max. Negotiated Rate	$685.79
Rate for Payer: Cash Price	$424.20
Rate for Payer: Hawaii Western Management Group Commercial	$671.65
Rate for Payer: Health Management Network Commercial	$600.95
Rate for Payer: Kaiser Permanente Commercial	$445.41
Rate for Payer: Kaiser Permanente Medicaid	$360.57
Rate for Payer: MDX Hawaii PPO	$685.79
Rate for Payer: University Health Alliance Commercial	$515.33

BLADE 4.2MM SERRATED BIPOLAR

Facility

$707.00

Hospital Revenue Code	272
Min. Negotiated Rate	$600.95
Max. Negotiated Rate	$685.79
Rate for Payer: Cash Price	$424.20
Rate for Payer: Health Management Network Commercial	$600.95
Rate for Payer: MDX Hawaii PPO	$685.79

BLADE 45 DEGREE SPEAR TIP

Facility

$99.00

Hospital Revenue Code	272
Min. Negotiated Rate	$84.15
Max. Negotiated Rate	$96.03
Rate for Payer: Cash Price	$59.40
Rate for Payer: Health Management Network Commercial	$84.15
Rate for Payer: MDX Hawaii PPO	$96.03

BLADE 45 DEGREE SPEAR TIP

Facility

$99.00

Hospital Revenue Code	272
Min. Negotiated Rate	$50.49
Max. Negotiated Rate	$96.03
Rate for Payer: Cash Price	$59.40
Rate for Payer: Hawaii Western Management Group Commercial	$94.05
Rate for Payer: Health Management Network Commercial	$84.15
Rate for Payer: Kaiser Permanente Commercial	$62.37
Rate for Payer: Kaiser Permanente Medicaid	$50.49
Rate for Payer: MDX Hawaii PPO	$96.03
Rate for Payer: University Health Alliance Commercial	$72.16

BLADE 5" 10MM OSTEOTOME S1008

Facility

$394.00

Hospital Revenue Code	272
Min. Negotiated Rate	$200.94
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Hawaii Western Management Group Commercial	$374.30
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Kaiser Permanente Commercial	$248.22
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: University Health Alliance Commercial	$287.19

BLADE 5" 10MM OSTEOTOME S1008

Facility

$394.00

Hospital Revenue Code	272
Min. Negotiated Rate	$334.90
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: MDX Hawaii PPO	$382.18

BLADE 5" 8MM OSTEOTOME S1009

Facility

$394.00

Hospital Revenue Code	272
Min. Negotiated Rate	$334.90
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: MDX Hawaii PPO	$382.18

BLADE 5" 8MM OSTEOTOME S1009

Facility

$394.00

Hospital Revenue Code	272
Min. Negotiated Rate	$200.94
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Hawaii Western Management Group Commercial	$374.30
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Kaiser Permanente Commercial	$248.22
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: University Health Alliance Commercial	$287.19

BLADE 75MM HELICAL 04.038.375S

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,358.64
Max. Negotiated Rate	$2,584.08
Rate for Payer: Cash Price	$1,598.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,864.80
Rate for Payer: Health Management Network Commercial	$2,264.40
Rate for Payer: Kaiser Permanente Commercial	$1,678.32
Rate for Payer: Kaiser Permanente Medicaid	$1,358.64
Rate for Payer: MDX Hawaii PPO	$2,584.08
Rate for Payer: University Health Alliance Commercial	$1,491.84

BLADE 75MM HELICAL 04.038.375S

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,491.84
Max. Negotiated Rate	$2,584.08
Rate for Payer: Cash Price	$1,598.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,864.80
Rate for Payer: Health Management Network Commercial	$2,264.40
Rate for Payer: MDX Hawaii PPO	$2,584.08
Rate for Payer: University Health Alliance Commercial	$1,491.84

BLADE 80MM HELICAL 04.038.380S

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,491.84
Max. Negotiated Rate	$2,584.08
Rate for Payer: Cash Price	$1,598.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,864.80
Rate for Payer: Health Management Network Commercial	$2,264.40
Rate for Payer: MDX Hawaii PPO	$2,584.08
Rate for Payer: University Health Alliance Commercial	$1,491.84

BLADE 80MM HELICAL 04.038.380S

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,358.64
Max. Negotiated Rate	$2,584.08
Rate for Payer: Cash Price	$1,598.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,864.80
Rate for Payer: Health Management Network Commercial	$2,264.40
Rate for Payer: Kaiser Permanente Commercial	$1,678.32
Rate for Payer: Kaiser Permanente Medicaid	$1,358.64
Rate for Payer: MDX Hawaii PPO	$2,584.08
Rate for Payer: University Health Alliance Commercial	$1,491.84

BLADE 85MM HELICAL 04.038.385S

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,358.64
Max. Negotiated Rate	$2,584.08
Rate for Payer: Cash Price	$1,598.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,864.80
Rate for Payer: Health Management Network Commercial	$2,264.40
Rate for Payer: Kaiser Permanente Commercial	$1,678.32
Rate for Payer: Kaiser Permanente Medicaid	$1,358.64
Rate for Payer: MDX Hawaii PPO	$2,584.08
Rate for Payer: University Health Alliance Commercial	$1,491.84

BLADE 85MM HELICAL 04.038.385S

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,491.84
Max. Negotiated Rate	$2,584.08
Rate for Payer: Cash Price	$1,598.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,864.80
Rate for Payer: Health Management Network Commercial	$2,264.40
Rate for Payer: MDX Hawaii PPO	$2,584.08
Rate for Payer: University Health Alliance Commercial	$1,491.84

BLADE 90MM HELICAL 04.038.390S

Facility

$2,664.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,491.84
Max. Negotiated Rate	$2,584.08
Rate for Payer: Cash Price	$1,598.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,864.80
Rate for Payer: Health Management Network Commercial	$2,264.40
Rate for Payer: MDX Hawaii PPO	$2,584.08
Rate for Payer: University Health Alliance Commercial	$1,491.84

Know your out-of-pocket cost for care.

All Charges