Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PS FEMORAL SZ #2 5515-F-202

Facility

$4,325.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,422.00
Max. Negotiated Rate	$4,195.25
Rate for Payer: Cash Price	$2,595.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,027.50
Rate for Payer: Health Management Network Commercial	$3,676.25
Rate for Payer: MDX Hawaii PPO	$4,195.25
Rate for Payer: University Health Alliance Commercial	$2,422.00

PS FEMORAL SZ #2 5515-F-202

Facility

$4,325.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,205.75
Max. Negotiated Rate	$4,195.25
Rate for Payer: Cash Price	$2,595.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,027.50
Rate for Payer: Health Management Network Commercial	$3,676.25
Rate for Payer: Kaiser Permanente Commercial	$2,724.75
Rate for Payer: Kaiser Permanente Medicaid	$2,205.75
Rate for Payer: MDX Hawaii PPO	$4,195.25
Rate for Payer: University Health Alliance Commercial	$2,422.00

PSN ALL POLY PAT PLY 26MM

Facility

$1,500.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$840.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: University Health Alliance Commercial	$840.00

PSN ALL POLY PAT PLY 26MM

Facility

$1,500.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$765.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: University Health Alliance Commercial	$840.00

PSN ALL POLY PAT PLY 32MM

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

PSN ALL POLY PAT PLY 32MM

Facility

$1,575.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$803.25
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$992.25
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

PSN ALL POLY PAT PLY 38MM

Facility

$1,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$756.00
Max. Negotiated Rate	$1,309.50
Rate for Payer: Cash Price	$810.00
Rate for Payer: Hawaii Western Management Group Commercial	$945.00
Rate for Payer: Health Management Network Commercial	$1,147.50
Rate for Payer: MDX Hawaii PPO	$1,309.50
Rate for Payer: University Health Alliance Commercial	$756.00

PSN ALL POLY PAT PLY 38MM

Facility

$1,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$688.50
Max. Negotiated Rate	$1,309.50
Rate for Payer: Cash Price	$810.00
Rate for Payer: Hawaii Western Management Group Commercial	$945.00
Rate for Payer: Health Management Network Commercial	$1,147.50
Rate for Payer: Kaiser Permanente Commercial	$850.50
Rate for Payer: Kaiser Permanente Medicaid	$688.50
Rate for Payer: MDX Hawaii PPO	$1,309.50
Rate for Payer: University Health Alliance Commercial	$756.00

PSN ALL POLY PAT VE 26MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 26MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,676.88
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Kaiser Permanente Commercial	$2,071.44
Rate for Payer: Kaiser Permanente Medicaid	$1,676.88
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 29MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,676.88
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Kaiser Permanente Commercial	$2,071.44
Rate for Payer: Kaiser Permanente Medicaid	$1,676.88
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 29MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 32MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 32MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,676.88
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Kaiser Permanente Commercial	$2,071.44
Rate for Payer: Kaiser Permanente Medicaid	$1,676.88
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 35MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,676.88
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Kaiser Permanente Commercial	$2,071.44
Rate for Payer: Kaiser Permanente Medicaid	$1,676.88
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 35MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 38MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,676.88
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Kaiser Permanente Commercial	$2,071.44
Rate for Payer: Kaiser Permanente Medicaid	$1,676.88
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 38MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 41MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,676.88
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: Kaiser Permanente Commercial	$2,071.44
Rate for Payer: Kaiser Permanente Medicaid	$1,676.88
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ALL POLY PAT VE 41MM DIA

Facility

$3,288.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.28
Max. Negotiated Rate	$3,189.36
Rate for Payer: Cash Price	$1,972.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,301.60
Rate for Payer: Health Management Network Commercial	$2,794.80
Rate for Payer: MDX Hawaii PPO	$3,189.36
Rate for Payer: University Health Alliance Commercial	$1,841.28

PSN ASF 4-11 RT 42-5212-005-13

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,020.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,260.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PSN ASF 4-11 RT 42-5212-005-13

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PSN ASF CR 10MM PLY L 3-11EF

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PSN ASF CR 10MM PLY L 3-11EF

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,020.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,260.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PSN ASF CR 10MM PLY L 3-9CD

Facility

$2,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,020.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,260.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

Know your out-of-pocket cost for care.

All Charges