Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

WIRE COMP 2.8X10MM 03.118.010

Facility

$279.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$142.29
Max. Negotiated Rate	$270.63
Rate for Payer: Cash Price	$167.40
Rate for Payer: Hawaii Western Management Group Commercial	$265.05
Rate for Payer: Health Management Network Commercial	$237.15
Rate for Payer: Kaiser Permanente Commercial	$175.77
Rate for Payer: Kaiser Permanente Medicaid	$142.29
Rate for Payer: MDX Hawaii PPO	$270.63
Rate for Payer: University Health Alliance Commercial	$203.36

WIRE COMP 2.8X15MM 03.118.015

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X15MM 03.118.015

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X20MM 03.118.020

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X20MM 03.118.020

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X25MM 03.118.025

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X25MM 03.118.025

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X30MM 03.118.030

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X30MM 03.118.030

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X35MM 03.118.035

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X35MM 03.118.035

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X40MM 03.118.040

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X40MM 03.118.040

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X45MM 03.118.045

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X45MM 03.118.045

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X50MM 03.118.050

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X50MM 03.118.050

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X55MM 03.118.055

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X55MM 03.118.055

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X60MM 03.118.060

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE COMP 2.8X60MM 03.118.060

Facility

$350.00

Service Code	HCPCS C1713
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

WIRE DUAL FLEX NITINOL

Facility

$211.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$179.35
Max. Negotiated Rate	$204.67
Rate for Payer: Cash Price	$126.60
Rate for Payer: Health Management Network Commercial	$179.35
Rate for Payer: MDX Hawaii PPO	$204.67

WIRE DUAL FLEX NITINOL

Facility

$211.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$107.61
Max. Negotiated Rate	$204.67
Rate for Payer: Cash Price	$126.60
Rate for Payer: Hawaii Western Management Group Commercial	$200.45
Rate for Payer: Health Management Network Commercial	$179.35
Rate for Payer: Kaiser Permanente Commercial	$132.93
Rate for Payer: Kaiser Permanente Medicaid	$107.61
Rate for Payer: MDX Hawaii PPO	$204.67
Rate for Payer: University Health Alliance Commercial	$153.80

WIRE GUIDE 1.6MMX150MM 292.72

Facility

$204.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
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

WIRE GUIDE 1.6MMX150MM 292.72

Facility

$204.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
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

Know your out-of-pocket cost for care.

All Charges