Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

STEM RFX 5568-0011

Facility

$8,462.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,315.62
Max. Negotiated Rate	$8,208.14
Rate for Payer: Cash Price	$5,077.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,923.40
Rate for Payer: Health Management Network Commercial	$7,192.70
Rate for Payer: Kaiser Permanente Commercial	$5,331.06
Rate for Payer: Kaiser Permanente Medicaid	$4,315.62
Rate for Payer: MDX Hawaii PPO	$8,208.14
Rate for Payer: University Health Alliance Commercial	$4,738.72

STEM RFX 5568-0011

Facility

$8,462.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,738.72
Max. Negotiated Rate	$8,208.14
Rate for Payer: Cash Price	$5,077.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,923.40
Rate for Payer: Health Management Network Commercial	$7,192.70
Rate for Payer: MDX Hawaii PPO	$8,208.14
Rate for Payer: University Health Alliance Commercial	$4,738.72

STEM SECUR-FIT 6051-0625S

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,236.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: University Health Alliance Commercial	$3,236.80

STEM SECUR-FIT 6051-0625S

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,947.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: Kaiser Permanente Commercial	$3,641.40
Rate for Payer: Kaiser Permanente Medicaid	$2,947.80
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: University Health Alliance Commercial	$3,236.80

STEM TRIATHLON 5565-S-018

Facility

$2,421.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,234.71
Max. Negotiated Rate	$2,348.37
Rate for Payer: Cash Price	$1,452.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,694.70
Rate for Payer: Health Management Network Commercial	$2,057.85
Rate for Payer: Kaiser Permanente Commercial	$1,525.23
Rate for Payer: Kaiser Permanente Medicaid	$1,234.71
Rate for Payer: MDX Hawaii PPO	$2,348.37
Rate for Payer: University Health Alliance Commercial	$1,355.76

STEM TRIATHLON 5565-S-018

Facility

$2,421.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,355.76
Max. Negotiated Rate	$2,348.37
Rate for Payer: Cash Price	$1,452.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,694.70
Rate for Payer: Health Management Network Commercial	$2,057.85
Rate for Payer: MDX Hawaii PPO	$2,348.37
Rate for Payer: University Health Alliance Commercial	$1,355.76

STEM ULNAR SMALL LEFT 70MM

Facility

$10,406.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,307.06
Max. Negotiated Rate	$10,093.82
Rate for Payer: Cash Price	$6,243.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,284.20
Rate for Payer: Health Management Network Commercial	$8,845.10
Rate for Payer: Kaiser Permanente Commercial	$6,555.78
Rate for Payer: Kaiser Permanente Medicaid	$5,307.06
Rate for Payer: MDX Hawaii PPO	$10,093.82
Rate for Payer: University Health Alliance Commercial	$5,827.36

STEM ULNAR SMALL LEFT 70MM

Facility

$10,406.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,827.36
Max. Negotiated Rate	$10,093.82
Rate for Payer: Cash Price	$6,243.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,284.20
Rate for Payer: Health Management Network Commercial	$8,845.10
Rate for Payer: MDX Hawaii PPO	$10,093.82
Rate for Payer: University Health Alliance Commercial	$5,827.36

STEN SYSTEM ENROUTE TRANSCAROT

Facility

$5,400.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$2,754.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: Kaiser Permanente Medicaid	$2,754.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

STEN SYSTEM ENROUTE TRANSCAROT

Facility

$5,400.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$3,024.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

STENT 10X60 BILIARY RX BARE

Facility

$3,357.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$1,879.92
Max. Negotiated Rate	$3,256.29
Rate for Payer: Cash Price	$2,014.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,349.90
Rate for Payer: Health Management Network Commercial	$2,853.45
Rate for Payer: MDX Hawaii PPO	$3,256.29
Rate for Payer: University Health Alliance Commercial	$1,879.92

STENT 10X60 BILIARY RX BARE

Facility

$3,357.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$1,712.07
Max. Negotiated Rate	$3,256.29
Rate for Payer: Cash Price	$2,014.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,349.90
Rate for Payer: Health Management Network Commercial	$2,853.45
Rate for Payer: Kaiser Permanente Commercial	$2,114.91
Rate for Payer: Kaiser Permanente Medicaid	$1,712.07
Rate for Payer: MDX Hawaii PPO	$3,256.29
Rate for Payer: University Health Alliance Commercial	$1,879.92

STENT 10X7 ADVANIX BILIARY RX

Facility

$490.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$249.90
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$294.00
Rate for Payer: Hawaii Western Management Group Commercial	$343.00
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Kaiser Permanente Commercial	$308.70
Rate for Payer: Kaiser Permanente Medicaid	$249.90
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: University Health Alliance Commercial	$274.40

STENT 10X7 ADVANIX BILIARY RX

Facility

$490.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$274.40
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$294.00
Rate for Payer: Hawaii Western Management Group Commercial	$343.00
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: University Health Alliance Commercial	$274.40

STENT 10X80 8F WALLFLEX

Facility

$2,849.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$1,452.99
Max. Negotiated Rate	$2,763.53
Rate for Payer: Cash Price	$1,709.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,994.30
Rate for Payer: Health Management Network Commercial	$2,421.65
Rate for Payer: Kaiser Permanente Commercial	$1,794.87
Rate for Payer: Kaiser Permanente Medicaid	$1,452.99
Rate for Payer: MDX Hawaii PPO	$2,763.53
Rate for Payer: University Health Alliance Commercial	$1,595.44

STENT 10X80 8F WALLFLEX

Facility

$2,849.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$1,595.44
Max. Negotiated Rate	$2,763.53
Rate for Payer: Cash Price	$1,709.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,994.30
Rate for Payer: Health Management Network Commercial	$2,421.65
Rate for Payer: MDX Hawaii PPO	$2,763.53
Rate for Payer: University Health Alliance Commercial	$1,595.44

STENT 18X97 ESOPHAGEAL

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,958.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: Kaiser Permanente Commercial	$3,654.00
Rate for Payer: Kaiser Permanente Medicaid	$2,958.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

STENT 18X97 ESOPHAGEAL

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,248.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

STENT 22X90 WALLFLEX

Facility

$5,075.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$2,842.00
Max. Negotiated Rate	$4,922.75
Rate for Payer: Cash Price	$3,045.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,552.50
Rate for Payer: Health Management Network Commercial	$4,313.75
Rate for Payer: MDX Hawaii PPO	$4,922.75
Rate for Payer: University Health Alliance Commercial	$2,842.00

STENT 22X90 WALLFLEX

Facility

$5,075.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$2,588.25
Max. Negotiated Rate	$4,922.75
Rate for Payer: Cash Price	$3,045.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,552.50
Rate for Payer: Health Management Network Commercial	$4,313.75
Rate for Payer: Kaiser Permanente Commercial	$3,197.25
Rate for Payer: Kaiser Permanente Medicaid	$2,588.25
Rate for Payer: MDX Hawaii PPO	$4,922.75
Rate for Payer: University Health Alliance Commercial	$2,842.00

STENT 4.5FRX20 URETER OPEN TIP

Facility

$555.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$310.80
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$333.00
Rate for Payer: Hawaii Western Management Group Commercial	$388.50
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: MDX Hawaii PPO	$538.35
Rate for Payer: University Health Alliance Commercial	$310.80

STENT 4.5FRX20 URETER OPEN TIP

Facility

$555.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$283.05
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$333.00
Rate for Payer: Hawaii Western Management Group Commercial	$388.50
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: Kaiser Permanente Commercial	$349.65
Rate for Payer: Kaiser Permanente Medicaid	$283.05
Rate for Payer: MDX Hawaii PPO	$538.35
Rate for Payer: University Health Alliance Commercial	$310.80

STENT 4.5FRX22 URETER OPEN TIP

Facility

$769.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$392.19
Max. Negotiated Rate	$745.93
Rate for Payer: Cash Price	$461.40
Rate for Payer: Hawaii Western Management Group Commercial	$538.30
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Kaiser Permanente Commercial	$484.47
Rate for Payer: Kaiser Permanente Medicaid	$392.19
Rate for Payer: MDX Hawaii PPO	$745.93
Rate for Payer: University Health Alliance Commercial	$430.64

STENT 4.5FRX22 URETER OPEN TIP

Facility

$769.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$430.64
Max. Negotiated Rate	$745.93
Rate for Payer: Cash Price	$461.40
Rate for Payer: Hawaii Western Management Group Commercial	$538.30
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: MDX Hawaii PPO	$745.93
Rate for Payer: University Health Alliance Commercial	$430.64

STENT 4.5FRX24 URETER OPEN TIP

Facility

$555.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$310.80
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$333.00
Rate for Payer: Hawaii Western Management Group Commercial	$388.50
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: MDX Hawaii PPO	$538.35
Rate for Payer: University Health Alliance Commercial	$310.80

Know your out-of-pocket cost for care.

All Charges