Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

SAFETY PEG KIT 20FR

Facility

$586.00

Hospital Revenue Code	272
Min. Negotiated Rate	$498.10
Max. Negotiated Rate	$568.42
Rate for Payer: Cash Price	$351.60
Rate for Payer: Health Management Network Commercial	$498.10
Rate for Payer: MDX Hawaii PPO	$568.42

SALINE BREAST SIZER SZHP68500

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$110.25
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SALINE BREAST SIZER SZHP68500

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SALINE SIZER SZ10621-470HP

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$110.25
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SALINE SIZER SZ10621-470HP

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SALIVARY GLAND PROCEDURES

Facility

$22,276.19

Service Code	MSDRG 139
Min. Negotiated Rate	$14,055.17
Max. Negotiated Rate	$22,276.19
Rate for Payer: AlohaCare Medicare	$14,055.17
Rate for Payer: Devoted Health Medicare	$15,460.69
Rate for Payer: Hawaii Medical Service Association Commercial	$22,276.19
Rate for Payer: Hawaii Medical Service Association Medicare	$14,055.17
Rate for Payer: Humana Medicare	$14,055.17
Rate for Payer: Kaiser Permanente Commercial	$20,848.35
Rate for Payer: Kaiser Permanente Medicare	$14,055.17
Rate for Payer: Ohana Health Plan Medicare	$14,055.17
Rate for Payer: UnitedHealthcare Medicare	$14,055.17

SAW BLADE 13MM 6113-127-100

Facility

$253.00

Hospital Revenue Code	272
Min. Negotiated Rate	$215.05
Max. Negotiated Rate	$245.41
Rate for Payer: Cash Price	$151.80
Rate for Payer: Health Management Network Commercial	$215.05
Rate for Payer: MDX Hawaii PPO	$245.41

SAW BLADE 13MM 6113-127-100

Facility

$253.00

Hospital Revenue Code	272
Min. Negotiated Rate	$129.03
Max. Negotiated Rate	$245.41
Rate for Payer: Cash Price	$151.80
Rate for Payer: Hawaii Western Management Group Commercial	$240.35
Rate for Payer: Health Management Network Commercial	$215.05
Rate for Payer: Kaiser Permanente Commercial	$159.39
Rate for Payer: Kaiser Permanente Medicaid	$129.03
Rate for Payer: MDX Hawaii PPO	$245.41
Rate for Payer: University Health Alliance Commercial	$184.41

SAWBLADE OXFORD #506269

Facility

$2,550.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,300.50
Max. Negotiated Rate	$2,473.50
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,422.50
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$1,300.50
Rate for Payer: MDX Hawaii PPO	$2,473.50
Rate for Payer: University Health Alliance Commercial	$1,858.69

SAWBLADE OXFORD #506269

Facility

$2,550.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,167.50
Max. Negotiated Rate	$2,473.50
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: MDX Hawaii PPO	$2,473.50

SCALPEL TISSUE HARMONIC HAR9F

Facility

$1,103.00

Hospital Revenue Code	272
Min. Negotiated Rate	$937.55
Max. Negotiated Rate	$1,069.91
Rate for Payer: Cash Price	$661.80
Rate for Payer: Health Management Network Commercial	$937.55
Rate for Payer: MDX Hawaii PPO	$1,069.91

SCALPEL TISSUE HARMONIC HAR9F

Facility

$1,103.00

Hospital Revenue Code	272
Min. Negotiated Rate	$562.53
Max. Negotiated Rate	$1,069.91
Rate for Payer: Cash Price	$661.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,047.85
Rate for Payer: Health Management Network Commercial	$937.55
Rate for Payer: Kaiser Permanente Commercial	$694.89
Rate for Payer: Kaiser Permanente Medicaid	$562.53
Rate for Payer: MDX Hawaii PPO	$1,069.91
Rate for Payer: University Health Alliance Commercial	$803.98

SCANLAN INSRT GRN SM 9009-18

Facility

$257.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$218.45
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$154.20
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: MDX Hawaii PPO	$249.29

SCANLAN INSRT GRN SM 9009-18

Facility

$257.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$131.07
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$154.20
Rate for Payer: Hawaii Western Management Group Commercial	$244.15
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$161.91
Rate for Payer: Kaiser Permanente Medicaid	$131.07
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: University Health Alliance Commercial	$187.33

SCANLAN INSRT YEL SM 9009-23

Facility

$218.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$111.18
Max. Negotiated Rate	$211.46
Rate for Payer: Cash Price	$130.80
Rate for Payer: Hawaii Western Management Group Commercial	$207.10
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Kaiser Permanente Commercial	$137.34
Rate for Payer: Kaiser Permanente Medicaid	$111.18
Rate for Payer: MDX Hawaii PPO	$211.46
Rate for Payer: University Health Alliance Commercial	$158.90

SCANLAN INSRT YEL SM 9009-23

Facility

$218.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$185.30
Max. Negotiated Rate	$211.46
Rate for Payer: Cash Price	$130.80
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: MDX Hawaii PPO	$211.46

SCARF GUIDE ACCUCUT 19511

Facility

$469.00

Hospital Revenue Code	272
Min. Negotiated Rate	$239.19
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$281.40
Rate for Payer: Hawaii Western Management Group Commercial	$445.55
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Kaiser Permanente Commercial	$295.47
Rate for Payer: Kaiser Permanente Medicaid	$239.19
Rate for Payer: MDX Hawaii PPO	$454.93
Rate for Payer: University Health Alliance Commercial	$341.85

SCARF GUIDE ACCUCUT 19511

Facility

$469.00

Hospital Revenue Code	272
Min. Negotiated Rate	$398.65
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$281.40
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: MDX Hawaii PPO	$454.93

SCD FOOT CUFF MED

Facility

$92.00

Hospital Revenue Code	271
Min. Negotiated Rate	$46.92
Max. Negotiated Rate	$89.24
Rate for Payer: Cash Price	$55.20
Rate for Payer: Hawaii Western Management Group Commercial	$87.40
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Kaiser Permanente Commercial	$57.96
Rate for Payer: Kaiser Permanente Medicaid	$46.92
Rate for Payer: MDX Hawaii PPO	$89.24
Rate for Payer: University Health Alliance Commercial	$67.06

SCD FOOT CUFF MED

Facility

$92.00

Hospital Revenue Code	271
Min. Negotiated Rate	$78.20
Max. Negotiated Rate	$89.24
Rate for Payer: Cash Price	$55.20
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: MDX Hawaii PPO	$89.24

SCD KNEE SLEEVE XL

Facility

$102.00

Hospital Revenue Code	271
Min. Negotiated Rate	$52.02
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$61.20
Rate for Payer: Hawaii Western Management Group Commercial	$96.90
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Kaiser Permanente Commercial	$64.26
Rate for Payer: Kaiser Permanente Medicaid	$52.02
Rate for Payer: MDX Hawaii PPO	$98.94
Rate for Payer: University Health Alliance Commercial	$74.35

SCD KNEE SLEEVE XL

Facility

$102.00

Hospital Revenue Code	271
Min. Negotiated Rate	$86.70
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$61.20
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: MDX Hawaii PPO	$98.94

SCD SLEEVE THIGH STERILE 9736

Facility

$204.00

Hospital Revenue Code	271
Min. Negotiated Rate	$173.40
Max. Negotiated Rate	$197.88
Rate for Payer: Cash Price	$122.40
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: MDX Hawaii PPO	$197.88

SCD SLEEVE THIGH STERILE 9736

Facility

$204.00

Hospital Revenue Code	271
Min. Negotiated Rate	$104.04
Max. Negotiated Rate	$197.88
Rate for Payer: Cash Price	$122.40
Rate for Payer: Hawaii Western Management Group Commercial	$193.80
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Kaiser Permanente Commercial	$128.52
Rate for Payer: Kaiser Permanente Medicaid	$104.04
Rate for Payer: MDX Hawaii PPO	$197.88
Rate for Payer: University Health Alliance Commercial	$148.70

SCD THIGH SLEEVE LG

Facility

$96.00

Hospital Revenue Code	271
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$57.60
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: MDX Hawaii PPO	$93.12

Know your out-of-pocket cost for care.

All Charges