Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

BLADE 90MM HELICAL 04.038.390S

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 95MM HELICAL 04.038.395S

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 95MM HELICAL 04.038.395S

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 BIPOLAR 4MM CLOSED

Facility

$599.00

Hospital Revenue Code	272
Min. Negotiated Rate	$305.49
Max. Negotiated Rate	$581.03
Rate for Payer: Cash Price	$359.40
Rate for Payer: Hawaii Western Management Group Commercial	$569.05
Rate for Payer: Health Management Network Commercial	$509.15
Rate for Payer: Kaiser Permanente Commercial	$377.37
Rate for Payer: Kaiser Permanente Medicaid	$305.49
Rate for Payer: MDX Hawaii PPO	$581.03
Rate for Payer: University Health Alliance Commercial	$436.61

BLADE BIPOLAR 4MM CLOSED

Facility

$599.00

Hospital Revenue Code	272
Min. Negotiated Rate	$509.15
Max. Negotiated Rate	$581.03
Rate for Payer: Cash Price	$359.40
Rate for Payer: Health Management Network Commercial	$509.15
Rate for Payer: MDX Hawaii PPO	$581.03

BLADE FLX OSTEOTOME 6210-0-740

Facility

$1,083.00

Hospital Revenue Code	272
Min. Negotiated Rate	$552.33
Max. Negotiated Rate	$1,050.51
Rate for Payer: Cash Price	$649.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,028.85
Rate for Payer: Health Management Network Commercial	$920.55
Rate for Payer: Kaiser Permanente Commercial	$682.29
Rate for Payer: Kaiser Permanente Medicaid	$552.33
Rate for Payer: MDX Hawaii PPO	$1,050.51
Rate for Payer: University Health Alliance Commercial	$789.40

BLADE FLX OSTEOTOME 6210-0-740

Facility

$1,083.00

Hospital Revenue Code	272
Min. Negotiated Rate	$920.55
Max. Negotiated Rate	$1,050.51
Rate for Payer: Cash Price	$649.80
Rate for Payer: Health Management Network Commercial	$920.55
Rate for Payer: MDX Hawaii PPO	$1,050.51

BLADE HEL 11.0X120MM 456.309

Facility

$2,823.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,439.73
Max. Negotiated Rate	$2,738.31
Rate for Payer: Cash Price	$1,693.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,976.10
Rate for Payer: Health Management Network Commercial	$2,399.55
Rate for Payer: Kaiser Permanente Commercial	$1,778.49
Rate for Payer: Kaiser Permanente Medicaid	$1,439.73
Rate for Payer: MDX Hawaii PPO	$2,738.31
Rate for Payer: University Health Alliance Commercial	$1,580.88

BLADE HEL 11.0X120MM 456.309

Facility

$2,823.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,580.88
Max. Negotiated Rate	$2,738.31
Rate for Payer: Cash Price	$1,693.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,976.10
Rate for Payer: Health Management Network Commercial	$2,399.55
Rate for Payer: MDX Hawaii PPO	$2,738.31
Rate for Payer: University Health Alliance Commercial	$1,580.88

BLADE HELI TI 11X105MM 456.306

Facility

$2,586.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,318.86
Max. Negotiated Rate	$2,508.42
Rate for Payer: Cash Price	$1,551.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,810.20
Rate for Payer: Health Management Network Commercial	$2,198.10
Rate for Payer: Kaiser Permanente Commercial	$1,629.18
Rate for Payer: Kaiser Permanente Medicaid	$1,318.86
Rate for Payer: MDX Hawaii PPO	$2,508.42
Rate for Payer: University Health Alliance Commercial	$1,448.16

BLADE HELI TI 11X105MM 456.306

Facility

$2,586.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,448.16
Max. Negotiated Rate	$2,508.42
Rate for Payer: Cash Price	$1,551.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,810.20
Rate for Payer: Health Management Network Commercial	$2,198.10
Rate for Payer: MDX Hawaii PPO	$2,508.42
Rate for Payer: University Health Alliance Commercial	$1,448.16

BLADE HELI TI 11X110MM 456.307

Facility

$2,859.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,458.09
Max. Negotiated Rate	$2,773.23
Rate for Payer: Cash Price	$1,715.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,001.30
Rate for Payer: Health Management Network Commercial	$2,430.15
Rate for Payer: Kaiser Permanente Commercial	$1,801.17
Rate for Payer: Kaiser Permanente Medicaid	$1,458.09
Rate for Payer: MDX Hawaii PPO	$2,773.23
Rate for Payer: University Health Alliance Commercial	$1,601.04

BLADE HELI TI 11X110MM 456.307

Facility

$2,859.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,601.04
Max. Negotiated Rate	$2,773.23
Rate for Payer: Cash Price	$1,715.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,001.30
Rate for Payer: Health Management Network Commercial	$2,430.15
Rate for Payer: MDX Hawaii PPO	$2,773.23
Rate for Payer: University Health Alliance Commercial	$1,601.04

BLADE HELI TI 11X115MM 456.308

Facility

$2,586.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,318.86
Max. Negotiated Rate	$2,508.42
Rate for Payer: Cash Price	$1,551.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,810.20
Rate for Payer: Health Management Network Commercial	$2,198.10
Rate for Payer: Kaiser Permanente Commercial	$1,629.18
Rate for Payer: Kaiser Permanente Medicaid	$1,318.86
Rate for Payer: MDX Hawaii PPO	$2,508.42
Rate for Payer: University Health Alliance Commercial	$1,448.16

BLADE HELI TI 11X115MM 456.308

Facility

$2,586.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,448.16
Max. Negotiated Rate	$2,508.42
Rate for Payer: Cash Price	$1,551.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,810.20
Rate for Payer: Health Management Network Commercial	$2,198.10
Rate for Payer: MDX Hawaii PPO	$2,508.42
Rate for Payer: University Health Alliance Commercial	$1,448.16

BLADE HELI TI 11X80MM 456.301

Facility

$2,258.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,151.58
Max. Negotiated Rate	$2,190.26
Rate for Payer: Cash Price	$1,354.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,580.60
Rate for Payer: Health Management Network Commercial	$1,919.30
Rate for Payer: Kaiser Permanente Commercial	$1,422.54
Rate for Payer: Kaiser Permanente Medicaid	$1,151.58
Rate for Payer: MDX Hawaii PPO	$2,190.26
Rate for Payer: University Health Alliance Commercial	$1,264.48

BLADE HELI TI 11X80MM 456.301

Facility

$2,258.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,264.48
Max. Negotiated Rate	$2,190.26
Rate for Payer: Cash Price	$1,354.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,580.60
Rate for Payer: Health Management Network Commercial	$1,919.30
Rate for Payer: MDX Hawaii PPO	$2,190.26
Rate for Payer: University Health Alliance Commercial	$1,264.48

BLADE HELI TI 11X90MM 456.303

Facility

$2,859.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,601.04
Max. Negotiated Rate	$2,773.23
Rate for Payer: Cash Price	$1,715.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,001.30
Rate for Payer: Health Management Network Commercial	$2,430.15
Rate for Payer: MDX Hawaii PPO	$2,773.23
Rate for Payer: University Health Alliance Commercial	$1,601.04

BLADE HELI TI 11X90MM 456.303

Facility

$2,859.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,458.09
Max. Negotiated Rate	$2,773.23
Rate for Payer: Cash Price	$1,715.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,001.30
Rate for Payer: Health Management Network Commercial	$2,430.15
Rate for Payer: Kaiser Permanente Commercial	$1,801.17
Rate for Payer: Kaiser Permanente Medicaid	$1,458.09
Rate for Payer: MDX Hawaii PPO	$2,773.23
Rate for Payer: University Health Alliance Commercial	$1,601.04

BLADE HELI TI 11X95MM 456.304

Facility

$2,859.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,458.09
Max. Negotiated Rate	$2,773.23
Rate for Payer: Cash Price	$1,715.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,001.30
Rate for Payer: Health Management Network Commercial	$2,430.15
Rate for Payer: Kaiser Permanente Commercial	$1,801.17
Rate for Payer: Kaiser Permanente Medicaid	$1,458.09
Rate for Payer: MDX Hawaii PPO	$2,773.23
Rate for Payer: University Health Alliance Commercial	$1,601.04

BLADE HELI TI 11X95MM 456.304

Facility

$2,859.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,601.04
Max. Negotiated Rate	$2,773.23
Rate for Payer: Cash Price	$1,715.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,001.30
Rate for Payer: Health Management Network Commercial	$2,430.15
Rate for Payer: MDX Hawaii PPO	$2,773.23
Rate for Payer: University Health Alliance Commercial	$1,601.04

BLADELESS OPTICAL 12M ONB12LGF

Facility

$151.00

Hospital Revenue Code	272
Min. Negotiated Rate	$128.35
Max. Negotiated Rate	$146.47
Rate for Payer: Cash Price	$90.60
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: MDX Hawaii PPO	$146.47

BLADELESS OPTICAL 12M ONB12LGF

Facility

$151.00

Hospital Revenue Code	272
Min. Negotiated Rate	$77.01
Max. Negotiated Rate	$146.47
Rate for Payer: Cash Price	$90.60
Rate for Payer: Hawaii Western Management Group Commercial	$143.45
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Kaiser Permanente Commercial	$95.13
Rate for Payer: Kaiser Permanente Medicaid	$77.01
Rate for Payer: MDX Hawaii PPO	$146.47
Rate for Payer: University Health Alliance Commercial	$110.06

BLADE MICRODEBRIDER SINUS

Facility

$945.00

Hospital Revenue Code	272
Min. Negotiated Rate	$803.25
Max. Negotiated Rate	$916.65
Rate for Payer: Cash Price	$567.00
Rate for Payer: Health Management Network Commercial	$803.25
Rate for Payer: MDX Hawaii PPO	$916.65

BLADE MICRODEBRIDER SINUS

Facility

$945.00

Hospital Revenue Code	272
Min. Negotiated Rate	$481.95
Max. Negotiated Rate	$916.65
Rate for Payer: Cash Price	$567.00
Rate for Payer: Hawaii Western Management Group Commercial	$897.75
Rate for Payer: Health Management Network Commercial	$803.25
Rate for Payer: Kaiser Permanente Commercial	$595.35
Rate for Payer: Kaiser Permanente Medicaid	$481.95
Rate for Payer: MDX Hawaii PPO	$916.65
Rate for Payer: University Health Alliance Commercial	$688.81

Know your out-of-pocket cost for care.

All Charges