Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

SFC COMBO 27/14MM SFCBP.27/14

Facility

$1,593.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$892.08
Max. Negotiated Rate	$1,545.21
Rate for Payer: Cash Price	$955.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,115.10
Rate for Payer: Health Management Network Commercial	$1,354.05
Rate for Payer: MDX Hawaii PPO	$1,545.21
Rate for Payer: University Health Alliance Commercial	$892.08

SFC IN COM 24/10MM SFCIC.24/10

Facility

$1,295.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$725.20
Max. Negotiated Rate	$1,256.15
Rate for Payer: Cash Price	$777.00
Rate for Payer: Hawaii Western Management Group Commercial	$906.50
Rate for Payer: Health Management Network Commercial	$1,100.75
Rate for Payer: MDX Hawaii PPO	$1,256.15
Rate for Payer: University Health Alliance Commercial	$725.20

SFC IN COM 24/10MM SFCIC.24/10

Facility

$1,295.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$660.45
Max. Negotiated Rate	$1,256.15
Rate for Payer: Cash Price	$777.00
Rate for Payer: Hawaii Western Management Group Commercial	$906.50
Rate for Payer: Health Management Network Commercial	$1,100.75
Rate for Payer: Kaiser Permanente Commercial	$815.85
Rate for Payer: Kaiser Permanente Medicaid	$660.45
Rate for Payer: MDX Hawaii PPO	$1,256.15
Rate for Payer: University Health Alliance Commercial	$725.20

SFC IN COM 24/14MM SFCIC.24/14

Facility

$1,295.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$660.45
Max. Negotiated Rate	$1,256.15
Rate for Payer: Cash Price	$777.00
Rate for Payer: Hawaii Western Management Group Commercial	$906.50
Rate for Payer: Health Management Network Commercial	$1,100.75
Rate for Payer: Kaiser Permanente Commercial	$815.85
Rate for Payer: Kaiser Permanente Medicaid	$660.45
Rate for Payer: MDX Hawaii PPO	$1,256.15
Rate for Payer: University Health Alliance Commercial	$725.20

SFC IN COM 24/14MM SFCIC.24/14

Facility

$1,295.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$725.20
Max. Negotiated Rate	$1,256.15
Rate for Payer: Cash Price	$777.00
Rate for Payer: Hawaii Western Management Group Commercial	$906.50
Rate for Payer: Health Management Network Commercial	$1,100.75
Rate for Payer: MDX Hawaii PPO	$1,256.15
Rate for Payer: University Health Alliance Commercial	$725.20

SFC OUTER COM 28MM SFCOC.28/28

Facility

$1,015.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$568.40
Max. Negotiated Rate	$984.55
Rate for Payer: Cash Price	$609.00
Rate for Payer: Hawaii Western Management Group Commercial	$710.50
Rate for Payer: Health Management Network Commercial	$862.75
Rate for Payer: MDX Hawaii PPO	$984.55
Rate for Payer: University Health Alliance Commercial	$568.40

SFC OUTER COM 28MM SFCOC.28/28

Facility

$1,015.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$517.65
Max. Negotiated Rate	$984.55
Rate for Payer: Cash Price	$609.00
Rate for Payer: Hawaii Western Management Group Commercial	$710.50
Rate for Payer: Health Management Network Commercial	$862.75
Rate for Payer: Kaiser Permanente Commercial	$639.45
Rate for Payer: Kaiser Permanente Medicaid	$517.65
Rate for Payer: MDX Hawaii PPO	$984.55
Rate for Payer: University Health Alliance Commercial	$568.40

SFC OUTER COM 32MM SFCOC.32/32

Facility

$1,015.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$517.65
Max. Negotiated Rate	$984.55
Rate for Payer: Cash Price	$609.00
Rate for Payer: Hawaii Western Management Group Commercial	$710.50
Rate for Payer: Health Management Network Commercial	$862.75
Rate for Payer: Kaiser Permanente Commercial	$639.45
Rate for Payer: Kaiser Permanente Medicaid	$517.65
Rate for Payer: MDX Hawaii PPO	$984.55
Rate for Payer: University Health Alliance Commercial	$568.40

SFC OUTER COM 32MM SFCOC.32/32

Facility

$1,015.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$568.40
Max. Negotiated Rate	$984.55
Rate for Payer: Cash Price	$609.00
Rate for Payer: Hawaii Western Management Group Commercial	$710.50
Rate for Payer: Health Management Network Commercial	$862.75
Rate for Payer: MDX Hawaii PPO	$984.55
Rate for Payer: University Health Alliance Commercial	$568.40

SHAFT DRIVR T15 AR-9545-T15-02

Facility

$1,575.00

Hospital Revenue Code	272
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	$1,496.25
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	$1,148.02

SHAFT DRIVR T15 AR-9545-T15-02

Facility

$1,575.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,338.75
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: MDX Hawaii PPO	$1,527.75

SHAFT REAMER 08X510 0227-8510S

Facility

$1,971.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,675.35
Max. Negotiated Rate	$1,911.87
Rate for Payer: Cash Price	$1,182.60
Rate for Payer: Health Management Network Commercial	$1,675.35
Rate for Payer: MDX Hawaii PPO	$1,911.87

SHAFT REAMER 08X510 0227-8510S

Facility

$1,971.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,005.21
Max. Negotiated Rate	$1,911.87
Rate for Payer: Cash Price	$1,182.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,872.45
Rate for Payer: Health Management Network Commercial	$1,675.35
Rate for Payer: Kaiser Permanente Commercial	$1,241.73
Rate for Payer: Kaiser Permanente Medicaid	$1,005.21
Rate for Payer: MDX Hawaii PPO	$1,911.87
Rate for Payer: University Health Alliance Commercial	$1,436.66

SHAVER EXCALIBER AR-8400EX

Facility

$208.00

Hospital Revenue Code	272
Min. Negotiated Rate	$176.80
Max. Negotiated Rate	$201.76
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: MDX Hawaii PPO	$201.76

SHAVER EXCALIBER AR-8400EX

Facility

$208.00

Hospital Revenue Code	272
Min. Negotiated Rate	$106.08
Max. Negotiated Rate	$201.76
Rate for Payer: Cash Price	$124.80
Rate for Payer: Hawaii Western Management Group Commercial	$197.60
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Kaiser Permanente Commercial	$131.04
Rate for Payer: Kaiser Permanente Medicaid	$106.08
Rate for Payer: MDX Hawaii PPO	$201.76
Rate for Payer: University Health Alliance Commercial	$151.61

SHEARS HARMONIC 1100 HAR1136

Facility

$2,965.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,520.25
Max. Negotiated Rate	$2,876.05
Rate for Payer: Cash Price	$1,779.00
Rate for Payer: Health Management Network Commercial	$2,520.25
Rate for Payer: MDX Hawaii PPO	$2,876.05

SHEARS HARMONIC 1100 HAR1136

Facility

$2,965.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,512.15
Max. Negotiated Rate	$2,876.05
Rate for Payer: Cash Price	$1,779.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,816.75
Rate for Payer: Health Management Network Commercial	$2,520.25
Rate for Payer: Kaiser Permanente Commercial	$1,867.95
Rate for Payer: Kaiser Permanente Medicaid	$1,512.15
Rate for Payer: MDX Hawaii PPO	$2,876.05
Rate for Payer: University Health Alliance Commercial	$2,161.19

SHEARS LAPARASCOPE HAR736

Facility

$2,348.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,197.48
Max. Negotiated Rate	$2,277.56
Rate for Payer: Cash Price	$1,408.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,230.60
Rate for Payer: Health Management Network Commercial	$1,995.80
Rate for Payer: Kaiser Permanente Commercial	$1,479.24
Rate for Payer: Kaiser Permanente Medicaid	$1,197.48
Rate for Payer: MDX Hawaii PPO	$2,277.56
Rate for Payer: University Health Alliance Commercial	$1,711.46

SHEARS LAPARASCOPE HAR736

Facility

$2,348.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,995.80
Max. Negotiated Rate	$2,277.56
Rate for Payer: Cash Price	$1,408.80
Rate for Payer: Health Management Network Commercial	$1,995.80
Rate for Payer: MDX Hawaii PPO	$2,277.56

SHEARS MONOPOLOAR 470179

Facility

$6,720.00

Hospital Revenue Code	272
Min. Negotiated Rate	$5,712.00
Max. Negotiated Rate	$6,518.40
Rate for Payer: Cash Price	$4,032.00
Rate for Payer: Health Management Network Commercial	$5,712.00
Rate for Payer: MDX Hawaii PPO	$6,518.40

SHEARS MONOPOLOAR 470179

Facility

$6,720.00

Hospital Revenue Code	272
Min. Negotiated Rate	$3,427.20
Max. Negotiated Rate	$6,518.40
Rate for Payer: Cash Price	$4,032.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,384.00
Rate for Payer: Health Management Network Commercial	$5,712.00
Rate for Payer: Kaiser Permanente Commercial	$4,233.60
Rate for Payer: Kaiser Permanente Medicaid	$3,427.20
Rate for Payer: MDX Hawaii PPO	$6,518.40
Rate for Payer: University Health Alliance Commercial	$4,898.21

SHEATH 5FX10 PINNACLE ROII

Facility

$140.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Hawaii Western Management Group Commercial	$133.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: Kaiser Permanente Medicaid	$71.40
Rate for Payer: MDX Hawaii PPO	$135.80
Rate for Payer: University Health Alliance Commercial	$102.05

SHEATH 5FX10 PINNACLE ROII

Facility

$140.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$119.00
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: MDX Hawaii PPO	$135.80

SHEATH 6FX10 PINNACLE ROII

Facility

$138.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$133.86
Rate for Payer: Cash Price	$82.80
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: MDX Hawaii PPO	$133.86

SHEATH 6FX10 PINNACLE ROII

Facility

$138.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$70.38
Max. Negotiated Rate	$133.86
Rate for Payer: Cash Price	$82.80
Rate for Payer: Hawaii Western Management Group Commercial	$131.10
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Kaiser Permanente Commercial	$86.94
Rate for Payer: Kaiser Permanente Medicaid	$70.38
Rate for Payer: MDX Hawaii PPO	$133.86
Rate for Payer: University Health Alliance Commercial	$100.59

Know your out-of-pocket cost for care.

All Charges