Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GUIDEWIRE 0.62X12 AR-8941-12

Facility

$300.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$153.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: University Health Alliance Commercial	$218.67

GUIDEWIRE 0.62X12 AR-8941-12

Facility

$300.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: MDX Hawaii PPO	$291.00

GUIDE WIRE .062X7 #AR-8941-7

Facility

$268.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$227.80
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: MDX Hawaii PPO	$259.96

GUIDE WIRE .062X7 #AR-8941-7

Facility

$268.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$136.68
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$160.80
Rate for Payer: Hawaii Western Management Group Commercial	$254.60
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: Kaiser Permanente Commercial	$168.84
Rate for Payer: Kaiser Permanente Medicaid	$136.68
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: University Health Alliance Commercial	$195.35

GUIDEWIRE 1.1MMX150MM #292.622

Facility

$179.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$100.24
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$107.40
Rate for Payer: Hawaii Western Management Group Commercial	$125.30
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: University Health Alliance Commercial	$100.24

GUIDEWIRE 1.1MMX150MM #292.622

Facility

$179.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$91.29
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$107.40
Rate for Payer: Hawaii Western Management Group Commercial	$125.30
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$112.77
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: University Health Alliance Commercial	$100.24

GUIDEWIRE 1.1X150MM #292.623

Facility

$169.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$143.65
Max. Negotiated Rate	$163.93
Rate for Payer: Cash Price	$101.40
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: MDX Hawaii PPO	$163.93

GUIDEWIRE 1.1X150MM #292.623

Facility

$169.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$86.19
Max. Negotiated Rate	$163.93
Rate for Payer: Cash Price	$101.40
Rate for Payer: Hawaii Western Management Group Commercial	$160.55
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Kaiser Permanente Commercial	$106.47
Rate for Payer: Kaiser Permanente Medicaid	$86.19
Rate for Payer: MDX Hawaii PPO	$163.93
Rate for Payer: University Health Alliance Commercial	$123.18

GUIDE WIRE 1.25MM #900.721

Facility

$169.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$143.65
Max. Negotiated Rate	$163.93
Rate for Payer: Cash Price	$101.40
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: MDX Hawaii PPO	$163.93

GUIDE WIRE 1.25MM #900.721

Facility

$169.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$86.19
Max. Negotiated Rate	$163.93
Rate for Payer: Cash Price	$101.40
Rate for Payer: Hawaii Western Management Group Commercial	$160.55
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Kaiser Permanente Commercial	$106.47
Rate for Payer: Kaiser Permanente Medicaid	$86.19
Rate for Payer: MDX Hawaii PPO	$163.93
Rate for Payer: University Health Alliance Commercial	$123.18

GUIDE WIRE 1.25X150MM 900.722

Facility

$186.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$94.86
Max. Negotiated Rate	$180.42
Rate for Payer: Cash Price	$111.60
Rate for Payer: Hawaii Western Management Group Commercial	$176.70
Rate for Payer: Health Management Network Commercial	$158.10
Rate for Payer: Kaiser Permanente Commercial	$117.18
Rate for Payer: Kaiser Permanente Medicaid	$94.86
Rate for Payer: MDX Hawaii PPO	$180.42
Rate for Payer: University Health Alliance Commercial	$135.58

GUIDE WIRE 1.25X150MM 900.722

Facility

$186.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$158.10
Max. Negotiated Rate	$180.42
Rate for Payer: Cash Price	$111.60
Rate for Payer: Health Management Network Commercial	$158.10
Rate for Payer: MDX Hawaii PPO	$180.42

GUIDEWIRE 1.35MM AR-5050-01

Facility

$215.00

Hospital Revenue Code	272
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$208.55
Rate for Payer: Cash Price	$129.00
Rate for Payer: Hawaii Western Management Group Commercial	$204.25
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: Kaiser Permanente Commercial	$135.45
Rate for Payer: Kaiser Permanente Medicaid	$109.65
Rate for Payer: MDX Hawaii PPO	$208.55
Rate for Payer: University Health Alliance Commercial	$156.71

GUIDEWIRE 1.35MM AR-5050-01

Facility

$215.00

Hospital Revenue Code	272
Min. Negotiated Rate	$182.75
Max. Negotiated Rate	$208.55
Rate for Payer: Cash Price	$129.00
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: MDX Hawaii PPO	$208.55

GUIDE WIRE, 1.35MM AR-8943-01

Facility

$120.00

Hospital Revenue Code	272
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: MDX Hawaii PPO	$116.40

GUIDE WIRE, 1.35MM AR-8943-01

Facility

$120.00

Hospital Revenue Code	272
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Hawaii Western Management Group Commercial	$114.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: University Health Alliance Commercial	$87.47

GUIDEWIRE 1.35X150 AR-8943-38

Facility

$126.00

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 1.35X150 AR-8943-38

Facility

$126.00

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 1.6 01-1050-0039

Facility

$200.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: MDX Hawaii PPO	$194.00

GUIDEWIRE 1.6 01-1050-0039

Facility

$200.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: University Health Alliance Commercial	$145.78

GUIDEWIRE 1.60MM 01-1010-007

Facility

$272.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$231.20
Max. Negotiated Rate	$263.84
Rate for Payer: Cash Price	$163.20
Rate for Payer: Health Management Network Commercial	$231.20
Rate for Payer: MDX Hawaii PPO	$263.84

GUIDEWIRE 1.60MM 01-1010-007

Facility

$272.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$138.72
Max. Negotiated Rate	$263.84
Rate for Payer: Cash Price	$163.20
Rate for Payer: Hawaii Western Management Group Commercial	$258.40
Rate for Payer: Health Management Network Commercial	$231.20
Rate for Payer: Kaiser Permanente Commercial	$171.36
Rate for Payer: Kaiser Permanente Medicaid	$138.72
Rate for Payer: MDX Hawaii PPO	$263.84
Rate for Payer: University Health Alliance Commercial	$198.26

GUIDE WIRE 1.6MM 220MM TROCAR

Facility

$408.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$346.80
Max. Negotiated Rate	$395.76
Rate for Payer: Cash Price	$244.80
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: MDX Hawaii PPO	$395.76

GUIDE WIRE 1.6MM 220MM TROCAR

Facility

$408.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$208.08
Max. Negotiated Rate	$395.76
Rate for Payer: Cash Price	$244.80
Rate for Payer: Hawaii Western Management Group Commercial	$387.60
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Kaiser Permanente Commercial	$257.04
Rate for Payer: Kaiser Permanente Medicaid	$208.08
Rate for Payer: MDX Hawaii PPO	$395.76
Rate for Payer: University Health Alliance Commercial	$297.39

GUIDE WIRE 1.6X200 02.113.001

Facility

$224.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$190.40
Max. Negotiated Rate	$217.28
Rate for Payer: Cash Price	$134.40
Rate for Payer: Health Management Network Commercial	$190.40
Rate for Payer: MDX Hawaii PPO	$217.28

Know your out-of-pocket cost for care.

All Charges