Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

RETRACTOR ALEXIS-O XLG

Facility

$413.00

Hospital Revenue Code	272
Min. Negotiated Rate	$351.05
Max. Negotiated Rate	$400.61
Rate for Payer: Cash Price	$247.80
Rate for Payer: Health Management Network Commercial	$351.05
Rate for Payer: MDX Hawaii PPO	$400.61

RETRACTOR ELASTIC 12MM

Facility

$82.00

Hospital Revenue Code	272
Min. Negotiated Rate	$41.82
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$49.20
Rate for Payer: Hawaii Western Management Group Commercial	$77.90
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Kaiser Permanente Commercial	$51.66
Rate for Payer: Kaiser Permanente Medicaid	$41.82
Rate for Payer: MDX Hawaii PPO	$79.54
Rate for Payer: University Health Alliance Commercial	$59.77

RETRACTOR ELASTIC 12MM

Facility

$82.00

Hospital Revenue Code	272
Min. Negotiated Rate	$69.70
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$49.20
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: MDX Hawaii PPO	$79.54

RETRACTOR ELASTIC STAYS 5MM

Facility

$85.00

Hospital Revenue Code	272
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$82.45
Rate for Payer: Cash Price	$51.00
Rate for Payer: Hawaii Western Management Group Commercial	$80.75
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Kaiser Permanente Commercial	$53.55
Rate for Payer: Kaiser Permanente Medicaid	$43.35
Rate for Payer: MDX Hawaii PPO	$82.45
Rate for Payer: University Health Alliance Commercial	$61.96

RETRACTOR ELASTIC STAYS 5MM

Facility

$85.00

Hospital Revenue Code	272
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$82.45
Rate for Payer: Cash Price	$51.00
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: MDX Hawaii PPO	$82.45

RETRACTOR RING LONE STAR 3715

Facility

$478.00

Hospital Revenue Code	272
Min. Negotiated Rate	$243.78
Max. Negotiated Rate	$463.66
Rate for Payer: Cash Price	$286.80
Rate for Payer: Hawaii Western Management Group Commercial	$454.10
Rate for Payer: Health Management Network Commercial	$406.30
Rate for Payer: Kaiser Permanente Commercial	$301.14
Rate for Payer: Kaiser Permanente Medicaid	$243.78
Rate for Payer: MDX Hawaii PPO	$463.66
Rate for Payer: University Health Alliance Commercial	$348.41

RETRACTOR RING LONE STAR 3715

Facility

$478.00

Hospital Revenue Code	272
Min. Negotiated Rate	$406.30
Max. Negotiated Rate	$463.66
Rate for Payer: Cash Price	$286.80
Rate for Payer: Health Management Network Commercial	$406.30
Rate for Payer: MDX Hawaii PPO	$463.66

RETREV 10MM ENDO CATCH

Facility

$201.00

Hospital Revenue Code	272
Min. Negotiated Rate	$170.85
Max. Negotiated Rate	$194.97
Rate for Payer: Cash Price	$120.60
Rate for Payer: Health Management Network Commercial	$170.85
Rate for Payer: MDX Hawaii PPO	$194.97

RETREV 10MM ENDO CATCH

Facility

$201.00

Hospital Revenue Code	272
Min. Negotiated Rate	$102.51
Max. Negotiated Rate	$194.97
Rate for Payer: Cash Price	$120.60
Rate for Payer: Hawaii Western Management Group Commercial	$190.95
Rate for Payer: Health Management Network Commercial	$170.85
Rate for Payer: Kaiser Permanente Commercial	$126.63
Rate for Payer: Kaiser Permanente Medicaid	$102.51
Rate for Payer: MDX Hawaii PPO	$194.97
Rate for Payer: University Health Alliance Commercial	$146.51

RETRIEVAL NET DGN-538-5

Facility

$350.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$339.50
Rate for Payer: Cash Price	$210.00
Rate for Payer: Hawaii Western Management Group Commercial	$332.50
Rate for Payer: Health Management Network Commercial	$297.50
Rate for Payer: Kaiser Permanente Commercial	$220.50
Rate for Payer: Kaiser Permanente Medicaid	$178.50
Rate for Payer: MDX Hawaii PPO	$339.50
Rate for Payer: University Health Alliance Commercial	$255.12

RETRIEVAL NET DGN-538-5

Facility

$350.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$339.50
Rate for Payer: Cash Price	$210.00
Rate for Payer: Health Management Network Commercial	$297.50
Rate for Payer: MDX Hawaii PPO	$339.50

RETRIEVER 2.5MM FOREIGN BODY

Facility

$376.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$191.76
Max. Negotiated Rate	$364.72
Rate for Payer: Cash Price	$225.60
Rate for Payer: Hawaii Western Management Group Commercial	$357.20
Rate for Payer: Health Management Network Commercial	$319.60
Rate for Payer: Kaiser Permanente Commercial	$236.88
Rate for Payer: Kaiser Permanente Medicaid	$191.76
Rate for Payer: MDX Hawaii PPO	$364.72
Rate for Payer: University Health Alliance Commercial	$274.07

RETRIEVER 2.5MM FOREIGN BODY

Facility

$376.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$319.60
Max. Negotiated Rate	$364.72
Rate for Payer: Cash Price	$225.60
Rate for Payer: Health Management Network Commercial	$319.60
Rate for Payer: MDX Hawaii PPO	$364.72

RETRIEVER 3.0MM ROTH ENDO

Facility

$454.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$385.90
Max. Negotiated Rate	$440.38
Rate for Payer: Cash Price	$272.40
Rate for Payer: Health Management Network Commercial	$385.90
Rate for Payer: MDX Hawaii PPO	$440.38

RETRIEVER 3.0MM ROTH ENDO

Facility

$454.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$231.54
Max. Negotiated Rate	$440.38
Rate for Payer: Cash Price	$272.40
Rate for Payer: Hawaii Western Management Group Commercial	$431.30
Rate for Payer: Health Management Network Commercial	$385.90
Rate for Payer: Kaiser Permanente Commercial	$286.02
Rate for Payer: Kaiser Permanente Medicaid	$231.54
Rate for Payer: MDX Hawaii PPO	$440.38
Rate for Payer: University Health Alliance Commercial	$330.92

RETRIEVER ENDO GRASP

Facility

$147.00

Hospital Revenue Code	272
Min. Negotiated Rate	$74.97
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$88.20
Rate for Payer: Hawaii Western Management Group Commercial	$139.65
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Kaiser Permanente Commercial	$92.61
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: University Health Alliance Commercial	$107.15

RETRIEVER ENDO GRASP

Facility

$147.00

Hospital Revenue Code	272
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$88.20
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: MDX Hawaii PPO	$142.59

RETRIEVER FOREIGN BODY

Facility

$924.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$471.24
Max. Negotiated Rate	$896.28
Rate for Payer: Cash Price	$554.40
Rate for Payer: Hawaii Western Management Group Commercial	$877.80
Rate for Payer: Health Management Network Commercial	$785.40
Rate for Payer: Kaiser Permanente Commercial	$582.12
Rate for Payer: Kaiser Permanente Medicaid	$471.24
Rate for Payer: MDX Hawaii PPO	$896.28
Rate for Payer: University Health Alliance Commercial	$673.50

RETRIEVER FOREIGN BODY

Facility

$924.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$785.40
Max. Negotiated Rate	$896.28
Rate for Payer: Cash Price	$554.40
Rate for Payer: Health Management Network Commercial	$785.40
Rate for Payer: MDX Hawaii PPO	$896.28

REUNION HUMERAL 5569-P-2017

Facility

$9,010.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,045.60
Max. Negotiated Rate	$8,739.70
Rate for Payer: Cash Price	$5,406.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,307.00
Rate for Payer: Health Management Network Commercial	$7,658.50
Rate for Payer: MDX Hawaii PPO	$8,739.70
Rate for Payer: University Health Alliance Commercial	$5,045.60

REUNION HUMERAL 5569-P-2017

Facility

$9,010.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,595.10
Max. Negotiated Rate	$8,739.70
Rate for Payer: Cash Price	$5,406.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,307.00
Rate for Payer: Health Management Network Commercial	$7,658.50
Rate for Payer: Kaiser Permanente Commercial	$5,676.30
Rate for Payer: Kaiser Permanente Medicaid	$4,595.10
Rate for Payer: MDX Hawaii PPO	$8,739.70
Rate for Payer: University Health Alliance Commercial	$5,045.60

REUNION INSERT 5571-S-3606

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,792.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

REUNION INSERT 5571-S-3606

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,632.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: Kaiser Permanente Commercial	$2,016.00
Rate for Payer: Kaiser Permanente Medicaid	$1,632.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

REUNION RSA SYS 5571-S-3604-E

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,792.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

REUNION RSA SYS 5571-S-3604-E

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,632.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: Kaiser Permanente Commercial	$2,016.00
Rate for Payer: Kaiser Permanente Medicaid	$1,632.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

Know your out-of-pocket cost for care.

All Charges