Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

DILATOR 28FR AMPLATZ

Facility

$207.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$124.20
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: MDX Hawaii PPO	$200.79

DILATOR 30FR AMPLATZ

Facility

$207.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$124.20
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: MDX Hawaii PPO	$200.79

DILATOR 30FR AMPLATZ

Facility

$207.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$105.57
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$124.20
Rate for Payer: Hawaii Western Management Group Commercial	$196.65
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$130.41
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: University Health Alliance Commercial	$150.88

DILATOR 5.5 F.THREAD 72203952

Facility

$875.00

Hospital Revenue Code	272
Min. Negotiated Rate	$743.75
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75

DILATOR 5.5 F.THREAD 72203952

Facility

$875.00

Hospital Revenue Code	272
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$831.25
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$551.25
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$637.79

DILATOR 8-24FR URETHRAL

Facility

$936.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$477.36
Max. Negotiated Rate	$907.92
Rate for Payer: Cash Price	$561.60
Rate for Payer: Hawaii Western Management Group Commercial	$889.20
Rate for Payer: Health Management Network Commercial	$795.60
Rate for Payer: Kaiser Permanente Commercial	$589.68
Rate for Payer: Kaiser Permanente Medicaid	$477.36
Rate for Payer: MDX Hawaii PPO	$907.92
Rate for Payer: University Health Alliance Commercial	$682.25

DILATOR 8-24FR URETHRAL

Facility

$936.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$795.60
Max. Negotiated Rate	$907.92
Rate for Payer: Cash Price	$561.60
Rate for Payer: Health Management Network Commercial	$795.60
Rate for Payer: MDX Hawaii PPO	$907.92

DILATOR 9-16MM SET

Facility

$1,324.00

Hospital Revenue Code	272
Min. Negotiated Rate	$675.24
Max. Negotiated Rate	$1,284.28
Rate for Payer: Cash Price	$794.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,257.80
Rate for Payer: Health Management Network Commercial	$1,125.40
Rate for Payer: Kaiser Permanente Commercial	$834.12
Rate for Payer: Kaiser Permanente Medicaid	$675.24
Rate for Payer: MDX Hawaii PPO	$1,284.28
Rate for Payer: University Health Alliance Commercial	$965.06

DILATOR 9-16MM SET

Facility

$1,324.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,125.40
Max. Negotiated Rate	$1,284.28
Rate for Payer: Cash Price	$794.40
Rate for Payer: Health Management Network Commercial	$1,125.40
Rate for Payer: MDX Hawaii PPO	$1,284.28

DILATOR AMPLATZ RENAL

Facility

$921.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$782.85
Max. Negotiated Rate	$893.37
Rate for Payer: Cash Price	$552.60
Rate for Payer: Health Management Network Commercial	$782.85
Rate for Payer: MDX Hawaii PPO	$893.37

DILATOR AMPLATZ RENAL

Facility

$921.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$469.71
Max. Negotiated Rate	$893.37
Rate for Payer: Cash Price	$552.60
Rate for Payer: Hawaii Western Management Group Commercial	$874.95
Rate for Payer: Health Management Network Commercial	$782.85
Rate for Payer: Kaiser Permanente Commercial	$580.23
Rate for Payer: Kaiser Permanente Medicaid	$469.71
Rate for Payer: MDX Hawaii PPO	$893.37
Rate for Payer: University Health Alliance Commercial	$671.32

DILATORS COONS TAPER 16FR,20CM

Facility

$91.00

Hospital Revenue Code	272
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: MDX Hawaii PPO	$88.27

DILATORS COONS TAPER 16FR,20CM

Facility

$91.00

Hospital Revenue Code	272
Min. Negotiated Rate	$46.41
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$54.60
Rate for Payer: Hawaii Western Management Group Commercial	$86.45
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$57.33
Rate for Payer: Kaiser Permanente Medicaid	$46.41
Rate for Payer: MDX Hawaii PPO	$88.27
Rate for Payer: University Health Alliance Commercial	$66.33

DILATOR SET AMPLATZ RENAL

Facility

$824.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$420.24
Max. Negotiated Rate	$799.28
Rate for Payer: Cash Price	$494.40
Rate for Payer: Hawaii Western Management Group Commercial	$782.80
Rate for Payer: Health Management Network Commercial	$700.40
Rate for Payer: Kaiser Permanente Commercial	$519.12
Rate for Payer: Kaiser Permanente Medicaid	$420.24
Rate for Payer: MDX Hawaii PPO	$799.28
Rate for Payer: University Health Alliance Commercial	$600.61

DILATOR SET AMPLATZ RENAL

Facility

$824.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$700.40
Max. Negotiated Rate	$799.28
Rate for Payer: Cash Price	$494.40
Rate for Payer: Health Management Network Commercial	$700.40
Rate for Payer: MDX Hawaii PPO	$799.28

DILATOR SET S-CURVE

Facility

$839.00

Hospital Revenue Code	272
Min. Negotiated Rate	$713.15
Max. Negotiated Rate	$813.83
Rate for Payer: Cash Price	$503.40
Rate for Payer: Health Management Network Commercial	$713.15
Rate for Payer: MDX Hawaii PPO	$813.83

DILATOR SET S-CURVE

Facility

$839.00

Hospital Revenue Code	272
Min. Negotiated Rate	$427.89
Max. Negotiated Rate	$813.83
Rate for Payer: Cash Price	$503.40
Rate for Payer: Hawaii Western Management Group Commercial	$797.05
Rate for Payer: Health Management Network Commercial	$713.15
Rate for Payer: Kaiser Permanente Commercial	$528.57
Rate for Payer: Kaiser Permanente Medicaid	$427.89
Rate for Payer: MDX Hawaii PPO	$813.83
Rate for Payer: University Health Alliance Commercial	$611.55

DILATOR/SHEATH 8-10FR

Facility

$209.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$177.65
Max. Negotiated Rate	$202.73
Rate for Payer: Cash Price	$125.40
Rate for Payer: Health Management Network Commercial	$177.65
Rate for Payer: MDX Hawaii PPO	$202.73

DILATOR/SHEATH 8-10FR

Facility

$209.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$106.59
Max. Negotiated Rate	$202.73
Rate for Payer: Cash Price	$125.40
Rate for Payer: Hawaii Western Management Group Commercial	$198.55
Rate for Payer: Health Management Network Commercial	$177.65
Rate for Payer: Kaiser Permanente Commercial	$131.67
Rate for Payer: Kaiser Permanente Medicaid	$106.59
Rate for Payer: MDX Hawaii PPO	$202.73
Rate for Payer: University Health Alliance Commercial	$152.34

DILTIAZEM 125 MG/125 ML (1 MG/ML) IN NS (SIMPLE) [4080053]

Facility

$67.00

Service Code	NDC 00004080015
Hospital Revenue Code	250
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$40.20
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: MDX Hawaii PPO	$64.99

DILTIAZEM 30 MG TABLET [2475]

Facility

$2.00

Service Code	NDC 60687071711
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

DILTIAZEM 30 MG TABLET [2475]

Facility

$2.00

Service Code	NDC 60687071701
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

DILTIAZEM 30 MG TABLET [2475]

Facility

$2.00

Service Code	NDC 60687071711
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

DILTIAZEM 30 MG TABLET [2475]

Facility

$2.00

Service Code	NDC 60687071701
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]

Facility

$15.00

Service Code	NDC 00641601310
Hospital Revenue Code	250
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: MDX Hawaii PPO	$14.55

Know your out-of-pocket cost for care.

All Charges