Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

RANGER DCB 4X60X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,890.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: MDX Hawaii PPO	$3,298.00

RANGER DCB 5X100X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,734.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,230.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$2,478.26

RANGER DCB 5X100X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,890.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: MDX Hawaii PPO	$3,298.00

RANGER DCB 5X120X150

Facility

$3,590.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,830.90
Max. Negotiated Rate	$3,482.30
Rate for Payer: Cash Price	$2,154.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,410.50
Rate for Payer: Health Management Network Commercial	$3,051.50
Rate for Payer: Kaiser Permanente Commercial	$2,261.70
Rate for Payer: Kaiser Permanente Medicaid	$1,830.90
Rate for Payer: MDX Hawaii PPO	$3,482.30
Rate for Payer: University Health Alliance Commercial	$2,616.75

RANGER DCB 5X120X150

Facility

$3,590.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,051.50
Max. Negotiated Rate	$3,482.30
Rate for Payer: Cash Price	$2,154.00
Rate for Payer: Health Management Network Commercial	$3,051.50
Rate for Payer: MDX Hawaii PPO	$3,482.30

RANGER DCB 5X150X150

Facility

$3,700.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,145.00
Max. Negotiated Rate	$3,589.00
Rate for Payer: Cash Price	$2,220.00
Rate for Payer: Health Management Network Commercial	$3,145.00
Rate for Payer: MDX Hawaii PPO	$3,589.00

RANGER DCB 5X150X150

Facility

$3,700.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,887.00
Max. Negotiated Rate	$3,589.00
Rate for Payer: Cash Price	$2,220.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,515.00
Rate for Payer: Health Management Network Commercial	$3,145.00
Rate for Payer: Kaiser Permanente Commercial	$2,331.00
Rate for Payer: Kaiser Permanente Medicaid	$1,887.00
Rate for Payer: MDX Hawaii PPO	$3,589.00
Rate for Payer: University Health Alliance Commercial	$2,696.93

RANGER DCB 5X200X150

Facility

$4,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,244.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,180.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$2,772.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$3,207.16

RANGER DCB 5X200X150

Facility

$4,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,740.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: MDX Hawaii PPO	$4,268.00

RANGER DCB 5X40X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,734.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,230.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$2,478.26

RANGER DCB 5X40X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,890.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: MDX Hawaii PPO	$3,298.00

RANGER DCB 5X60X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,734.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,230.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$2,478.26

RANGER DCB 5X60X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,890.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: MDX Hawaii PPO	$3,298.00

RANGER DCB 5X80X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,734.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,230.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$2,478.26

RANGER DCB 5X80X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,890.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: MDX Hawaii PPO	$3,298.00

RANGER DCB 6X100X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,734.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,230.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$2,478.26

RANGER DCB 6X100X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,890.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: MDX Hawaii PPO	$3,298.00

RANGER DCB 6X120X150

Facility

$3,590.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,051.50
Max. Negotiated Rate	$3,482.30
Rate for Payer: Cash Price	$2,154.00
Rate for Payer: Health Management Network Commercial	$3,051.50
Rate for Payer: MDX Hawaii PPO	$3,482.30

RANGER DCB 6X120X150

Facility

$3,590.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,830.90
Max. Negotiated Rate	$3,482.30
Rate for Payer: Cash Price	$2,154.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,410.50
Rate for Payer: Health Management Network Commercial	$3,051.50
Rate for Payer: Kaiser Permanente Commercial	$2,261.70
Rate for Payer: Kaiser Permanente Medicaid	$1,830.90
Rate for Payer: MDX Hawaii PPO	$3,482.30
Rate for Payer: University Health Alliance Commercial	$2,616.75

RANGER DCB 6X150X150

Facility

$3,700.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,887.00
Max. Negotiated Rate	$3,589.00
Rate for Payer: Cash Price	$2,220.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,515.00
Rate for Payer: Health Management Network Commercial	$3,145.00
Rate for Payer: Kaiser Permanente Commercial	$2,331.00
Rate for Payer: Kaiser Permanente Medicaid	$1,887.00
Rate for Payer: MDX Hawaii PPO	$3,589.00
Rate for Payer: University Health Alliance Commercial	$2,696.93

RANGER DCB 6X150X150

Facility

$3,700.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,145.00
Max. Negotiated Rate	$3,589.00
Rate for Payer: Cash Price	$2,220.00
Rate for Payer: Health Management Network Commercial	$3,145.00
Rate for Payer: MDX Hawaii PPO	$3,589.00

RANGER DCB 6X200X150

Facility

$4,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,740.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: MDX Hawaii PPO	$4,268.00

RANGER DCB 6X200X150

Facility

$4,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,244.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,180.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$2,772.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$3,207.16

RANGER DCB 6X40X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,734.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,230.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$2,478.26

RANGER DCB 6X40X135

Facility

$3,400.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,890.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: MDX Hawaii PPO	$3,298.00

Know your out-of-pocket cost for care.

All Charges