Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GUIDE PIN 1.3MMX140CM 128047

Facility

$262.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$222.70
Max. Negotiated Rate	$254.14
Rate for Payer: Cash Price	$157.20
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: MDX Hawaii PPO	$254.14

GUIDE PIN 1.3X140MM 1280309

Facility

$228.00

Hospital Revenue Code	272
Min. Negotiated Rate	$116.28
Max. Negotiated Rate	$221.16
Rate for Payer: Cash Price	$136.80
Rate for Payer: Hawaii Western Management Group Commercial	$216.60
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Kaiser Permanente Commercial	$143.64
Rate for Payer: Kaiser Permanente Medicaid	$116.28
Rate for Payer: MDX Hawaii PPO	$221.16
Rate for Payer: University Health Alliance Commercial	$166.19

GUIDE PIN 1.3X140MM 1280309

Facility

$228.00

Hospital Revenue Code	272
Min. Negotiated Rate	$193.80
Max. Negotiated Rate	$221.16
Rate for Payer: Cash Price	$136.80
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: MDX Hawaii PPO	$221.16

GUIDE PIN 3X100 7000-30-100

Facility

$775.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$658.75
Max. Negotiated Rate	$751.75
Rate for Payer: Cash Price	$465.00
Rate for Payer: Health Management Network Commercial	$658.75
Rate for Payer: MDX Hawaii PPO	$751.75

GUIDE PIN 3X100 7000-30-100

Facility

$775.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$395.25
Max. Negotiated Rate	$751.75
Rate for Payer: Cash Price	$465.00
Rate for Payer: Hawaii Western Management Group Commercial	$736.25
Rate for Payer: Health Management Network Commercial	$658.75
Rate for Payer: Kaiser Permanente Commercial	$488.25
Rate for Payer: Kaiser Permanente Medicaid	$395.25
Rate for Payer: MDX Hawaii PPO	$751.75
Rate for Payer: University Health Alliance Commercial	$564.90

GUIDE ROD 3.0/950MM 355.041S

Facility

$784.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$399.84
Max. Negotiated Rate	$760.48
Rate for Payer: Cash Price	$470.40
Rate for Payer: Hawaii Western Management Group Commercial	$744.80
Rate for Payer: Health Management Network Commercial	$666.40
Rate for Payer: Kaiser Permanente Commercial	$493.92
Rate for Payer: Kaiser Permanente Medicaid	$399.84
Rate for Payer: MDX Hawaii PPO	$760.48
Rate for Payer: University Health Alliance Commercial	$571.46

GUIDE ROD 3.0/950MM 355.041S

Facility

$784.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$666.40
Max. Negotiated Rate	$760.48
Rate for Payer: Cash Price	$470.40
Rate for Payer: Health Management Network Commercial	$666.40
Rate for Payer: MDX Hawaii PPO	$760.48

GUIDE ROD 3.0MM, 950MM

Facility

$561.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$476.85
Max. Negotiated Rate	$544.17
Rate for Payer: Cash Price	$336.60
Rate for Payer: Health Management Network Commercial	$476.85
Rate for Payer: MDX Hawaii PPO	$544.17

GUIDE ROD 3.0MM, 950MM

Facility

$561.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$286.11
Max. Negotiated Rate	$544.17
Rate for Payer: Cash Price	$336.60
Rate for Payer: Hawaii Western Management Group Commercial	$532.95
Rate for Payer: Health Management Network Commercial	$476.85
Rate for Payer: Kaiser Permanente Commercial	$353.43
Rate for Payer: Kaiser Permanente Medicaid	$286.11
Rate for Payer: MDX Hawaii PPO	$544.17
Rate for Payer: University Health Alliance Commercial	$408.91

GUIDE RS 2.5DRL 47-4309-046-01

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$669.80
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: MDX Hawaii PPO	$764.36

GUIDE RS 2.5DRL 47-4309-046-01

Facility

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$401.88
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Hawaii Western Management Group Commercial	$748.60
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Kaiser Permanente Commercial	$496.44
Rate for Payer: Kaiser Permanente Medicaid	$401.88
Rate for Payer: MDX Hawaii PPO	$764.36
Rate for Payer: University Health Alliance Commercial	$574.37

GUIDE RS 2.5PIN 47-4309-025-01

Facility

$599.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$305.49
Max. Negotiated Rate	$581.03
Rate for Payer: Cash Price	$359.40
Rate for Payer: Hawaii Western Management Group Commercial	$419.30
Rate for Payer: Health Management Network Commercial	$509.15
Rate for Payer: Kaiser Permanente Commercial	$377.37
Rate for Payer: Kaiser Permanente Medicaid	$305.49
Rate for Payer: MDX Hawaii PPO	$581.03
Rate for Payer: University Health Alliance Commercial	$335.44

GUIDE RS 2.5PIN 47-4309-025-01

Facility

$599.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$335.44
Max. Negotiated Rate	$581.03
Rate for Payer: Cash Price	$359.40
Rate for Payer: Hawaii Western Management Group Commercial	$419.30
Rate for Payer: Health Management Network Commercial	$509.15
Rate for Payer: MDX Hawaii PPO	$581.03
Rate for Payer: University Health Alliance Commercial	$335.44

GUIDEWIRE 0.014 SR-014-GW

Facility

$750.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$546.67

GUIDEWIRE 0.014 SR-014-GW

Facility

$750.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: MDX Hawaii PPO	$727.50

GUIDEWIRE 0.045X6" 316-0004

Facility

$126.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: MDX Hawaii PPO	$122.22

GUIDEWIRE 0.045X6" 316-0004

Facility

$126.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$64.26
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Hawaii Western Management Group Commercial	$119.70
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$79.38
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: University Health Alliance Commercial	$91.84

GUIDEWIRE 035X150 PTFE COATED

Facility

$69.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$35.19
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$41.40
Rate for Payer: Hawaii Western Management Group Commercial	$65.55
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$43.47
Rate for Payer: Kaiser Permanente Medicaid	$35.19
Rate for Payer: MDX Hawaii PPO	$66.93
Rate for Payer: University Health Alliance Commercial	$50.29

GUIDEWIRE 035X150 PTFE COATED

Facility

$69.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$41.40
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: MDX Hawaii PPO	$66.93

GUIDEWIRE 035X260 BENTSON

Facility

$140.00

Service Code	HCPCS C1769
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

GUIDEWIRE 035X260 BENTSON

Facility

$140.00

Service Code	HCPCS C1769
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

GUIDE WIRE .035X4" LONG

Facility

$126.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: MDX Hawaii PPO	$122.22

GUIDE WIRE .035X4" LONG

Facility

$126.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$64.26
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Hawaii Western Management Group Commercial	$119.70
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$79.38
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: University Health Alliance Commercial	$91.84

GUIDE WIRE 0.45X4 #316-0003

Facility

$126.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: MDX Hawaii PPO	$122.22

GUIDE WIRE 0.45X4 #316-0003

Facility

$126.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$64.26
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Hawaii Western Management Group Commercial	$119.70
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$79.38
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: University Health Alliance Commercial	$91.84

Know your out-of-pocket cost for care.

All Charges