Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GUIDE WIRE 1.6X200 02.113.001

Facility

$224.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$114.24
Max. Negotiated Rate	$217.28
Rate for Payer: Cash Price	$134.40
Rate for Payer: Hawaii Western Management Group Commercial	$212.80
Rate for Payer: Health Management Network Commercial	$190.40
Rate for Payer: Kaiser Permanente Commercial	$141.12
Rate for Payer: Kaiser Permanente Medicaid	$114.24
Rate for Payer: MDX Hawaii PPO	$217.28
Rate for Payer: University Health Alliance Commercial	$163.27

GUIDEWIRE 1806-0083S

Facility

$732.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$622.20
Max. Negotiated Rate	$710.04
Rate for Payer: Cash Price	$439.20
Rate for Payer: Health Management Network Commercial	$622.20
Rate for Payer: MDX Hawaii PPO	$710.04

GUIDEWIRE 1806-0083S

Facility

$732.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$373.32
Max. Negotiated Rate	$710.04
Rate for Payer: Cash Price	$439.20
Rate for Payer: Hawaii Western Management Group Commercial	$695.40
Rate for Payer: Health Management Network Commercial	$622.20
Rate for Payer: Kaiser Permanente Commercial	$461.16
Rate for Payer: Kaiser Permanente Medicaid	$373.32
Rate for Payer: MDX Hawaii PPO	$710.04
Rate for Payer: University Health Alliance Commercial	$533.55

GUIDEWIRE 2.0, 240MM

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

GUIDEWIRE 2.0, 240MM

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

GUIDEWIRE 2.0X230MM 292.652

Facility

$238.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$230.86
Rate for Payer: Cash Price	$142.80
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: MDX Hawaii PPO	$230.86

GUIDEWIRE 2.0X230MM 292.652

Facility

$238.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$121.38
Max. Negotiated Rate	$230.86
Rate for Payer: Cash Price	$142.80
Rate for Payer: Hawaii Western Management Group Commercial	$226.10
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Kaiser Permanente Commercial	$149.94
Rate for Payer: Kaiser Permanente Medicaid	$121.38
Rate for Payer: MDX Hawaii PPO	$230.86
Rate for Payer: University Health Alliance Commercial	$173.48

GUIDEWIRE 2.2 150L 03.333.001

Facility

$348.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$177.48
Max. Negotiated Rate	$337.56
Rate for Payer: Cash Price	$208.80
Rate for Payer: Hawaii Western Management Group Commercial	$330.60
Rate for Payer: Health Management Network Commercial	$295.80
Rate for Payer: Kaiser Permanente Commercial	$219.24
Rate for Payer: Kaiser Permanente Medicaid	$177.48
Rate for Payer: MDX Hawaii PPO	$337.56
Rate for Payer: University Health Alliance Commercial	$253.66

GUIDEWIRE 2.2 150L 03.333.001

Facility

$348.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$295.80
Max. Negotiated Rate	$337.56
Rate for Payer: Cash Price	$208.80
Rate for Payer: Health Management Network Commercial	$295.80
Rate for Payer: MDX Hawaii PPO	$337.56

GUIDE WIRE 2.5MMX220MM DWD017

Facility

$435.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$369.75
Max. Negotiated Rate	$421.95
Rate for Payer: Cash Price	$261.00
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: MDX Hawaii PPO	$421.95

GUIDE WIRE 2.5MMX220MM DWD017

Facility

$435.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$221.85
Max. Negotiated Rate	$421.95
Rate for Payer: Cash Price	$261.00
Rate for Payer: Hawaii Western Management Group Commercial	$413.25
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: Kaiser Permanente Commercial	$274.05
Rate for Payer: Kaiser Permanente Medicaid	$221.85
Rate for Payer: MDX Hawaii PPO	$421.95
Rate for Payer: University Health Alliance Commercial	$317.07

GUIDEWIRE 2.5X230MM 900.723

Facility

$294.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$149.94
Max. Negotiated Rate	$285.18
Rate for Payer: Cash Price	$176.40
Rate for Payer: Hawaii Western Management Group Commercial	$279.30
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: Kaiser Permanente Commercial	$185.22
Rate for Payer: Kaiser Permanente Medicaid	$149.94
Rate for Payer: MDX Hawaii PPO	$285.18
Rate for Payer: University Health Alliance Commercial	$214.30

GUIDEWIRE 2.5X230MM 900.723

Facility

$294.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$249.90
Max. Negotiated Rate	$285.18
Rate for Payer: Cash Price	$176.40
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: MDX Hawaii PPO	$285.18

GUIDE WIRE 2.8X300MM 292.68

Facility

$221.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$112.71
Max. Negotiated Rate	$214.37
Rate for Payer: Cash Price	$132.60
Rate for Payer: Hawaii Western Management Group Commercial	$209.95
Rate for Payer: Health Management Network Commercial	$187.85
Rate for Payer: Kaiser Permanente Commercial	$139.23
Rate for Payer: Kaiser Permanente Medicaid	$112.71
Rate for Payer: MDX Hawaii PPO	$214.37
Rate for Payer: University Health Alliance Commercial	$161.09

GUIDE WIRE 2.8X300MM 292.68

Facility

$221.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$187.85
Max. Negotiated Rate	$214.37
Rate for Payer: Cash Price	$132.60
Rate for Payer: Health Management Network Commercial	$187.85
Rate for Payer: MDX Hawaii PPO	$214.37

GUIDE WIRE 2.8X300MM 900.726

Facility

$409.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$208.59
Max. Negotiated Rate	$396.73
Rate for Payer: Cash Price	$245.40
Rate for Payer: Hawaii Western Management Group Commercial	$388.55
Rate for Payer: Health Management Network Commercial	$347.65
Rate for Payer: Kaiser Permanente Commercial	$257.67
Rate for Payer: Kaiser Permanente Medicaid	$208.59
Rate for Payer: MDX Hawaii PPO	$396.73
Rate for Payer: University Health Alliance Commercial	$298.12

GUIDE WIRE 2.8X300MM 900.726

Facility

$409.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$347.65
Max. Negotiated Rate	$396.73
Rate for Payer: Cash Price	$245.40
Rate for Payer: Health Management Network Commercial	$347.65
Rate for Payer: MDX Hawaii PPO	$396.73

GUIDEWIRE 2.8X450 02.207.001

Facility

$404.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$343.40
Max. Negotiated Rate	$391.88
Rate for Payer: Cash Price	$242.40
Rate for Payer: Health Management Network Commercial	$343.40
Rate for Payer: MDX Hawaii PPO	$391.88

GUIDEWIRE 2.8X450 02.207.001

Facility

$404.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$206.04
Max. Negotiated Rate	$391.88
Rate for Payer: Cash Price	$242.40
Rate for Payer: Hawaii Western Management Group Commercial	$383.80
Rate for Payer: Health Management Network Commercial	$343.40
Rate for Payer: Kaiser Permanente Commercial	$254.52
Rate for Payer: Kaiser Permanente Medicaid	$206.04
Rate for Payer: MDX Hawaii PPO	$391.88
Rate for Payer: University Health Alliance Commercial	$294.48

GUIDE WIRE 2.8X450MM 292.81

Facility

$458.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$389.30
Max. Negotiated Rate	$444.26
Rate for Payer: Cash Price	$274.80
Rate for Payer: Health Management Network Commercial	$389.30
Rate for Payer: MDX Hawaii PPO	$444.26

GUIDE WIRE 2.8X450MM 292.81

Facility

$458.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$233.58
Max. Negotiated Rate	$444.26
Rate for Payer: Cash Price	$274.80
Rate for Payer: Hawaii Western Management Group Commercial	$435.10
Rate for Payer: Health Management Network Commercial	$389.30
Rate for Payer: Kaiser Permanente Commercial	$288.54
Rate for Payer: Kaiser Permanente Medicaid	$233.58
Rate for Payer: MDX Hawaii PPO	$444.26
Rate for Payer: University Health Alliance Commercial	$333.84

GUIDEWIRE 3.2X290MM 03.010.115

Facility

$427.00

Hospital Revenue Code	272
Min. Negotiated Rate	$217.77
Max. Negotiated Rate	$414.19
Rate for Payer: Cash Price	$256.20
Rate for Payer: Hawaii Western Management Group Commercial	$405.65
Rate for Payer: Health Management Network Commercial	$362.95
Rate for Payer: Kaiser Permanente Commercial	$269.01
Rate for Payer: Kaiser Permanente Medicaid	$217.77
Rate for Payer: MDX Hawaii PPO	$414.19
Rate for Payer: University Health Alliance Commercial	$311.24

GUIDEWIRE 3.2X290MM 03.010.115

Facility

$427.00

Hospital Revenue Code	272
Min. Negotiated Rate	$362.95
Max. Negotiated Rate	$414.19
Rate for Payer: Cash Price	$256.20
Rate for Payer: Health Management Network Commercial	$362.95
Rate for Payer: MDX Hawaii PPO	$414.19

GUIDE WIRE 3.2X30 ST 702462S

Facility

$567.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$481.95
Max. Negotiated Rate	$549.99
Rate for Payer: Cash Price	$340.20
Rate for Payer: Health Management Network Commercial	$481.95
Rate for Payer: MDX Hawaii PPO	$549.99

GUIDE WIRE 3.2X30 ST 702462S

Facility

$567.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$289.17
Max. Negotiated Rate	$549.99
Rate for Payer: Cash Price	$340.20
Rate for Payer: Hawaii Western Management Group Commercial	$538.65
Rate for Payer: Health Management Network Commercial	$481.95
Rate for Payer: Kaiser Permanente Commercial	$357.21
Rate for Payer: Kaiser Permanente Medicaid	$289.17
Rate for Payer: MDX Hawaii PPO	$549.99
Rate for Payer: University Health Alliance Commercial	$413.29

Know your out-of-pocket cost for care.

All Charges