Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

WIRE GUIDE 200CM SAVARY

Facility

$380.00

Hospital Revenue Code	272
Min. Negotiated Rate	$193.80
Max. Negotiated Rate	$368.60
Rate for Payer: Cash Price	$228.00
Rate for Payer: Hawaii Western Management Group Commercial	$361.00
Rate for Payer: Health Management Network Commercial	$323.00
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: Kaiser Permanente Medicaid	$193.80
Rate for Payer: MDX Hawaii PPO	$368.60
Rate for Payer: University Health Alliance Commercial	$276.98

WIRE GUIDE 200CM SAVARY

Facility

$380.00

Hospital Revenue Code	272
Min. Negotiated Rate	$323.00
Max. Negotiated Rate	$368.60
Rate for Payer: Cash Price	$228.00
Rate for Payer: Health Management Network Commercial	$323.00
Rate for Payer: MDX Hawaii PPO	$368.60

WIRE GUIDE 2.5X300 03.120.026

Facility

$331.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$281.35
Max. Negotiated Rate	$321.07
Rate for Payer: Cash Price	$198.60
Rate for Payer: Health Management Network Commercial	$281.35
Rate for Payer: MDX Hawaii PPO	$321.07

WIRE GUIDE 2.5X300 03.120.026

Facility

$331.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$168.81
Max. Negotiated Rate	$321.07
Rate for Payer: Cash Price	$198.60
Rate for Payer: Hawaii Western Management Group Commercial	$314.45
Rate for Payer: Health Management Network Commercial	$281.35
Rate for Payer: Kaiser Permanente Commercial	$208.53
Rate for Payer: Kaiser Permanente Medicaid	$168.81
Rate for Payer: MDX Hawaii PPO	$321.07
Rate for Payer: University Health Alliance Commercial	$241.27

WIRE GUIDE 3X800 ST 1806-0080S

Facility

$751.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$383.01
Max. Negotiated Rate	$728.47
Rate for Payer: Cash Price	$450.60
Rate for Payer: Hawaii Western Management Group Commercial	$713.45
Rate for Payer: Health Management Network Commercial	$638.35
Rate for Payer: Kaiser Permanente Commercial	$473.13
Rate for Payer: Kaiser Permanente Medicaid	$383.01
Rate for Payer: MDX Hawaii PPO	$728.47
Rate for Payer: University Health Alliance Commercial	$547.40

WIRE GUIDE 3X800 ST 1806-0080S

Facility

$751.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$638.35
Max. Negotiated Rate	$728.47
Rate for Payer: Cash Price	$450.60
Rate for Payer: Health Management Network Commercial	$638.35
Rate for Payer: MDX Hawaii PPO	$728.47

WIRE GUIDE 3X800 ST 1806-0090S

Facility

$986.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$838.10
Max. Negotiated Rate	$956.42
Rate for Payer: Cash Price	$591.60
Rate for Payer: Health Management Network Commercial	$838.10
Rate for Payer: MDX Hawaii PPO	$956.42

WIRE GUIDE 3X800 ST 1806-0090S

Facility

$986.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$502.86
Max. Negotiated Rate	$956.42
Rate for Payer: Cash Price	$591.60
Rate for Payer: Hawaii Western Management Group Commercial	$936.70
Rate for Payer: Health Management Network Commercial	$838.10
Rate for Payer: Kaiser Permanente Commercial	$621.18
Rate for Payer: Kaiser Permanente Medicaid	$502.86
Rate for Payer: MDX Hawaii PPO	$956.42
Rate for Payer: University Health Alliance Commercial	$718.70

WIRE GUIDE W/TROCAR AR-8941K

Facility

$95.00

Hospital Revenue Code	272
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$57.00
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: MDX Hawaii PPO	$92.15

WIRE GUIDE W/TROCAR AR-8941K

Facility

$95.00

Hospital Revenue Code	272
Min. Negotiated Rate	$48.45
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$57.00
Rate for Payer: Hawaii Western Management Group Commercial	$90.25
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Kaiser Permanente Commercial	$59.85
Rate for Payer: Kaiser Permanente Medicaid	$48.45
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: University Health Alliance Commercial	$69.25

WIRE K 1.6MM AR-5050K-1

Facility

$230.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$138.00
Rate for Payer: Hawaii Western Management Group Commercial	$218.50
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: Kaiser Permanente Medicaid	$117.30
Rate for Payer: MDX Hawaii PPO	$223.10
Rate for Payer: University Health Alliance Commercial	$167.65

WIRE K 1.6MM AR-5050K-1

Facility

$230.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$195.50
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$138.00
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: MDX Hawaii PPO	$223.10

WIRE-K 1.6X150MM 292.16

Facility

$70.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$67.90
Rate for Payer: Cash Price	$42.00
Rate for Payer: Hawaii Western Management Group Commercial	$66.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: Kaiser Permanente Medicaid	$35.70
Rate for Payer: MDX Hawaii PPO	$67.90
Rate for Payer: University Health Alliance Commercial	$51.02

WIRE-K 1.6X150MM 292.16

Facility

$70.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$67.90
Rate for Payer: Cash Price	$42.00
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: MDX Hawaii PPO	$67.90

WIRE KIRSCHNER 2.0 290.20.280

Facility

$260.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$132.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$247.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$163.80
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$189.51

WIRE KIRSCHNER 2.0 290.20.280

Facility

$260.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$221.00
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: MDX Hawaii PPO	$252.20

WIRE K #WIRE-1.1/120

Facility

$140.00

Service Code	HCPCS C1713
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

WIRE K #WIRE-1.1/120

Facility

$140.00

Service Code	HCPCS C1713
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

WIRE LOOP 2.4MM AR-1594D-24

Facility

$1,722.00

Hospital Revenue Code	272
Min. Negotiated Rate	$878.22
Max. Negotiated Rate	$1,670.34
Rate for Payer: Cash Price	$1,033.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,635.90
Rate for Payer: Health Management Network Commercial	$1,463.70
Rate for Payer: Kaiser Permanente Commercial	$1,084.86
Rate for Payer: Kaiser Permanente Medicaid	$878.22
Rate for Payer: MDX Hawaii PPO	$1,670.34
Rate for Payer: University Health Alliance Commercial	$1,255.17

WIRE LOOP 2.4MM AR-1594D-24

Facility

$1,722.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,463.70
Max. Negotiated Rate	$1,670.34
Rate for Payer: Cash Price	$1,033.20
Rate for Payer: Health Management Network Commercial	$1,463.70
Rate for Payer: MDX Hawaii PPO	$1,670.34

WIRE OLIVE 1.3MM P99-200-1306

Facility

$478.00

Service Code	HCPCS C1713
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

WIRE OLIVE 1.3MM P99-200-1306

Facility

$478.00

Service Code	HCPCS C1713
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

WIRE PILOT NITINOL 5901-6072

Facility

$150.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$127.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$90.00
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: MDX Hawaii PPO	$145.50

WIRE PILOT NITINOL 5901-6072

Facility

$150.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$90.00
Rate for Payer: Hawaii Western Management Group Commercial	$142.50
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Kaiser Permanente Commercial	$94.50
Rate for Payer: Kaiser Permanente Medicaid	$76.50
Rate for Payer: MDX Hawaii PPO	$145.50
Rate for Payer: University Health Alliance Commercial	$109.33

WIRE PRECUT 0.6X175 291.240.98

Facility

$121.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$67.76
Max. Negotiated Rate	$117.37
Rate for Payer: Cash Price	$72.60
Rate for Payer: Hawaii Western Management Group Commercial	$84.70
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: MDX Hawaii PPO	$117.37
Rate for Payer: University Health Alliance Commercial	$67.76

Know your out-of-pocket cost for care.

All Charges