Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GUIDE WIRE 3.2X400MM 357.399

Facility

$505.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$429.25
Max. Negotiated Rate	$489.85
Rate for Payer: Cash Price	$303.00
Rate for Payer: Health Management Network Commercial	$429.25
Rate for Payer: MDX Hawaii PPO	$489.85

GUIDE WIRE 3.2X400MM 357.399

Facility

$505.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$257.55
Max. Negotiated Rate	$489.85
Rate for Payer: Cash Price	$303.00
Rate for Payer: Hawaii Western Management Group Commercial	$479.75
Rate for Payer: Health Management Network Commercial	$429.25
Rate for Payer: Kaiser Permanente Commercial	$318.15
Rate for Payer: Kaiser Permanente Medicaid	$257.55
Rate for Payer: MDX Hawaii PPO	$489.85
Rate for Payer: University Health Alliance Commercial	$368.09

GUIDEWIRE AMPL 035X80CM

Facility

$147.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$88.20
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: MDX Hawaii PPO	$142.59

GUIDEWIRE AMPL 035X80CM

Facility

$147.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$74.97
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$88.20
Rate for Payer: Hawaii Western Management Group Commercial	$139.65
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Kaiser Permanente Commercial	$92.61
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: University Health Alliance Commercial	$107.15

GUIDEWIRE AMPLATZ STR TIP .035

Facility

$127.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$64.77
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$76.20
Rate for Payer: Hawaii Western Management Group Commercial	$120.65
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$80.01
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: University Health Alliance Commercial	$92.57

GUIDEWIRE AMPLATZ STR TIP .035

Facility

$127.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$76.20
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: MDX Hawaii PPO	$123.19

GUIDEWIRE ANG 035X450CM

Facility

$695.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$354.45
Max. Negotiated Rate	$674.15
Rate for Payer: Cash Price	$417.00
Rate for Payer: Hawaii Western Management Group Commercial	$660.25
Rate for Payer: Health Management Network Commercial	$590.75
Rate for Payer: Kaiser Permanente Commercial	$437.85
Rate for Payer: Kaiser Permanente Medicaid	$354.45
Rate for Payer: MDX Hawaii PPO	$674.15
Rate for Payer: University Health Alliance Commercial	$506.59

GUIDEWIRE ANG 035X450CM

Facility

$695.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$590.75
Max. Negotiated Rate	$674.15
Rate for Payer: Cash Price	$417.00
Rate for Payer: Health Management Network Commercial	$590.75
Rate for Payer: MDX Hawaii PPO	$674.15

GUIDEWIRE BENTSON 035X80CM

Facility

$117.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$59.67
Max. Negotiated Rate	$113.49
Rate for Payer: Cash Price	$70.20
Rate for Payer: Hawaii Western Management Group Commercial	$111.15
Rate for Payer: Health Management Network Commercial	$99.45
Rate for Payer: Kaiser Permanente Commercial	$73.71
Rate for Payer: Kaiser Permanente Medicaid	$59.67
Rate for Payer: MDX Hawaii PPO	$113.49
Rate for Payer: University Health Alliance Commercial	$85.28

GUIDEWIRE BENTSON 035X80CM

Facility

$117.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$99.45
Max. Negotiated Rate	$113.49
Rate for Payer: Cash Price	$70.20
Rate for Payer: Health Management Network Commercial	$99.45
Rate for Payer: MDX Hawaii PPO	$113.49

GUIDEWIRE BILIARY STR

Facility

$659.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$560.15
Max. Negotiated Rate	$639.23
Rate for Payer: Cash Price	$395.40
Rate for Payer: Health Management Network Commercial	$560.15
Rate for Payer: MDX Hawaii PPO	$639.23

GUIDEWIRE BILIARY STR

Facility

$659.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$336.09
Max. Negotiated Rate	$639.23
Rate for Payer: Cash Price	$395.40
Rate for Payer: Hawaii Western Management Group Commercial	$626.05
Rate for Payer: Health Management Network Commercial	$560.15
Rate for Payer: Kaiser Permanente Commercial	$415.17
Rate for Payer: Kaiser Permanente Medicaid	$336.09
Rate for Payer: MDX Hawaii PPO	$639.23
Rate for Payer: University Health Alliance Commercial	$480.35

GUIDEWIRE L150MM 03.333.002

Facility

$377.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$192.27
Max. Negotiated Rate	$365.69
Rate for Payer: Cash Price	$226.20
Rate for Payer: Hawaii Western Management Group Commercial	$358.15
Rate for Payer: Health Management Network Commercial	$320.45
Rate for Payer: Kaiser Permanente Commercial	$237.51
Rate for Payer: Kaiser Permanente Medicaid	$192.27
Rate for Payer: MDX Hawaii PPO	$365.69
Rate for Payer: University Health Alliance Commercial	$274.80

GUIDEWIRE L150MM 03.333.002

Facility

$377.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$320.45
Max. Negotiated Rate	$365.69
Rate for Payer: Cash Price	$226.20
Rate for Payer: Health Management Network Commercial	$320.45
Rate for Payer: MDX Hawaii PPO	$365.69

GUIDEWIRE LONG .062X6

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 LONG .062X6

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

GUIDEWIRE SMOOTH 1806-0093S

Facility

$709.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$602.65
Max. Negotiated Rate	$687.73
Rate for Payer: Cash Price	$425.40
Rate for Payer: Health Management Network Commercial	$602.65
Rate for Payer: MDX Hawaii PPO	$687.73

GUIDEWIRE SMOOTH 1806-0093S

Facility

$709.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$361.59
Max. Negotiated Rate	$687.73
Rate for Payer: Cash Price	$425.40
Rate for Payer: Hawaii Western Management Group Commercial	$673.55
Rate for Payer: Health Management Network Commercial	$602.65
Rate for Payer: Kaiser Permanente Commercial	$446.67
Rate for Payer: Kaiser Permanente Medicaid	$361.59
Rate for Payer: MDX Hawaii PPO	$687.73
Rate for Payer: University Health Alliance Commercial	$516.79

GUIDEWIRE SPRING ARROW .25

Facility

$73.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$37.23
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$43.80
Rate for Payer: Hawaii Western Management Group Commercial	$69.35
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Kaiser Permanente Commercial	$45.99
Rate for Payer: Kaiser Permanente Medicaid	$37.23
Rate for Payer: MDX Hawaii PPO	$70.81
Rate for Payer: University Health Alliance Commercial	$53.21

GUIDEWIRE SPRING ARROW .25

Facility

$73.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$62.05
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$43.80
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: MDX Hawaii PPO	$70.81

GUIDEWIRE STANDARD

Facility

$694.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$589.90
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$416.40
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: MDX Hawaii PPO	$673.18

GUIDEWIRE STANDARD

Facility

$694.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$353.94
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$416.40
Rate for Payer: Hawaii Western Management Group Commercial	$659.30
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Kaiser Permanente Commercial	$437.22
Rate for Payer: Kaiser Permanente Medicaid	$353.94
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: University Health Alliance Commercial	$505.86

GUIDEWIRE STR 035X450CM

Facility

$432.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$367.20
Max. Negotiated Rate	$419.04
Rate for Payer: Cash Price	$259.20
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: MDX Hawaii PPO	$419.04

GUIDEWIRE STR 035X450CM

Facility

$432.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$220.32
Max. Negotiated Rate	$419.04
Rate for Payer: Cash Price	$259.20
Rate for Payer: Hawaii Western Management Group Commercial	$410.40
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: Kaiser Permanente Commercial	$272.16
Rate for Payer: Kaiser Permanente Medicaid	$220.32
Rate for Payer: MDX Hawaii PPO	$419.04
Rate for Payer: University Health Alliance Commercial	$314.88

GUIDEWIRE ST TIP 035X260

Facility

$659.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$560.15
Max. Negotiated Rate	$639.23
Rate for Payer: Cash Price	$395.40
Rate for Payer: Health Management Network Commercial	$560.15
Rate for Payer: MDX Hawaii PPO	$639.23

Know your out-of-pocket cost for care.

All Charges