Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GUIDEWIRE ST TIP 035X260

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 THR 3.2/300MM 702462

Facility

$223.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$113.73
Max. Negotiated Rate	$216.31
Rate for Payer: Cash Price	$133.80
Rate for Payer: Hawaii Western Management Group Commercial	$211.85
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Kaiser Permanente Commercial	$140.49
Rate for Payer: Kaiser Permanente Medicaid	$113.73
Rate for Payer: MDX Hawaii PPO	$216.31
Rate for Payer: University Health Alliance Commercial	$162.54

GUIDEWIRE THR 3.2/300MM 702462

Facility

$223.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$189.55
Max. Negotiated Rate	$216.31
Rate for Payer: Cash Price	$133.80
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: MDX Hawaii PPO	$216.31

GUIDEWIRE W/TROCAR AR-8945K

Facility

$72.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$36.72
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$43.20
Rate for Payer: Hawaii Western Management Group Commercial	$68.40
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Kaiser Permanente Commercial	$45.36
Rate for Payer: Kaiser Permanente Medicaid	$36.72
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: University Health Alliance Commercial	$52.48

GUIDEWIRE W/TROCAR AR-8945K

Facility

$72.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$43.20
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: MDX Hawaii PPO	$69.84

GUIDEWIRE W/TROCAR TIP .078X8"

Facility

$210.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$203.70
Rate for Payer: Cash Price	$126.00
Rate for Payer: Hawaii Western Management Group Commercial	$199.50
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: Kaiser Permanente Medicaid	$107.10
Rate for Payer: MDX Hawaii PPO	$203.70
Rate for Payer: University Health Alliance Commercial	$153.07

GUIDEWIRE W/TROCAR TIP .078X8"

Facility

$210.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$203.70
Rate for Payer: Cash Price	$126.00
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: MDX Hawaii PPO	$203.70

GUIDING CATH W/ SD HLS 7FR XB3

Facility

$230.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$195.50
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$138.00
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: MDX Hawaii PPO	$223.10

GUIDING CATH W/ SD HLS 7FR XB3

Facility

$230.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$138.00
Rate for Payer: Hawaii Western Management Group Commercial	$218.50
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: Kaiser Permanente Medicaid	$117.30
Rate for Payer: MDX Hawaii PPO	$223.10
Rate for Payer: University Health Alliance Commercial	$167.65

GUIDING CATH W/ SD HLS 7FR XB4

Facility

$230.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$138.00
Rate for Payer: Hawaii Western Management Group Commercial	$218.50
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: Kaiser Permanente Medicaid	$117.30
Rate for Payer: MDX Hawaii PPO	$223.10
Rate for Payer: University Health Alliance Commercial	$167.65

GUIDING CATH W/ SD HLS 7FR XB4

Facility

$230.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$195.50
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$138.00
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: MDX Hawaii PPO	$223.10

G-WIRE 2.5MM DRILL TIP 310.243

Facility

$312.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$265.20
Max. Negotiated Rate	$302.64
Rate for Payer: Cash Price	$187.20
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: MDX Hawaii PPO	$302.64

G-WIRE 2.5MM DRILL TIP 310.243

Facility

$312.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$159.12
Max. Negotiated Rate	$302.64
Rate for Payer: Cash Price	$187.20
Rate for Payer: Hawaii Western Management Group Commercial	$296.40
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Kaiser Permanente Commercial	$196.56
Rate for Payer: Kaiser Permanente Medicaid	$159.12
Rate for Payer: MDX Hawaii PPO	$302.64
Rate for Payer: University Health Alliance Commercial	$227.42

G WIRE W/BDL AR-8950-06

Facility

$168.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$100.80
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: MDX Hawaii PPO	$162.96

G WIRE W/BDL AR-8950-06

Facility

$168.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$85.68
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$100.80
Rate for Payer: Hawaii Western Management Group Commercial	$159.60
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Kaiser Permanente Commercial	$105.84
Rate for Payer: Kaiser Permanente Medicaid	$85.68
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: University Health Alliance Commercial	$122.46

G-WIRE W/ TROCAR TIP AR-8941KT

Facility

$158.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$80.58
Max. Negotiated Rate	$153.26
Rate for Payer: Cash Price	$94.80
Rate for Payer: Hawaii Western Management Group Commercial	$150.10
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: Kaiser Permanente Commercial	$99.54
Rate for Payer: Kaiser Permanente Medicaid	$80.58
Rate for Payer: MDX Hawaii PPO	$153.26
Rate for Payer: University Health Alliance Commercial	$115.17

G-WIRE W/ TROCAR TIP AR-8941KT

Facility

$158.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$134.30
Max. Negotiated Rate	$153.26
Rate for Payer: Cash Price	$94.80
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: MDX Hawaii PPO	$153.26

GYNECARE TVT TVTRL

Facility

$4,117.00

Service Code	HCPCS C1771
Hospital Revenue Code	278
Min. Negotiated Rate	$2,305.52
Max. Negotiated Rate	$3,993.49
Rate for Payer: Cash Price	$2,470.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,881.90
Rate for Payer: Health Management Network Commercial	$3,499.45
Rate for Payer: MDX Hawaii PPO	$3,993.49
Rate for Payer: University Health Alliance Commercial	$2,305.52

GYNECARE TVT TVTRL

Facility

$4,117.00

Service Code	HCPCS C1771
Hospital Revenue Code	278
Min. Negotiated Rate	$2,099.67
Max. Negotiated Rate	$3,993.49
Rate for Payer: Cash Price	$2,470.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,881.90
Rate for Payer: Health Management Network Commercial	$3,499.45
Rate for Payer: Kaiser Permanente Commercial	$2,593.71
Rate for Payer: Kaiser Permanente Medicaid	$2,099.67
Rate for Payer: MDX Hawaii PPO	$3,993.49
Rate for Payer: University Health Alliance Commercial	$2,305.52

GYN ESG PLASMLOOPE M WA47706S

Facility

$1,569.00

Hospital Revenue Code	272
Min. Negotiated Rate	$800.19
Max. Negotiated Rate	$1,521.93
Rate for Payer: Cash Price	$941.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,490.55
Rate for Payer: Health Management Network Commercial	$1,333.65
Rate for Payer: Kaiser Permanente Commercial	$988.47
Rate for Payer: Kaiser Permanente Medicaid	$800.19
Rate for Payer: MDX Hawaii PPO	$1,521.93
Rate for Payer: University Health Alliance Commercial	$1,143.64

GYN ESG PLASMLOOPE M WA47706S

Facility

$1,569.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,333.65
Max. Negotiated Rate	$1,521.93
Rate for Payer: Cash Price	$941.40
Rate for Payer: Health Management Network Commercial	$1,333.65
Rate for Payer: MDX Hawaii PPO	$1,521.93

HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN [11931]

Facility

$40.00

Service Code	NDC 49281054503
Hospital Revenue Code	250
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: MDX Hawaii PPO	$38.80

HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN [11931]

Facility

$40.00

Service Code	NDC 49281054758
Hospital Revenue Code	250
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: MDX Hawaii PPO	$38.80

HALF BLOCK SZ 5 TIB 5546-A-501

Facility

$2,173.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,108.23
Max. Negotiated Rate	$2,107.81
Rate for Payer: Cash Price	$1,303.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,521.10
Rate for Payer: Health Management Network Commercial	$1,847.05
Rate for Payer: Kaiser Permanente Commercial	$1,368.99
Rate for Payer: Kaiser Permanente Medicaid	$1,108.23
Rate for Payer: MDX Hawaii PPO	$2,107.81
Rate for Payer: University Health Alliance Commercial	$1,216.88

HALF BLOCK SZ 5 TIB 5546-A-501

Facility

$2,173.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,216.88
Max. Negotiated Rate	$2,107.81
Rate for Payer: Cash Price	$1,303.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,521.10
Rate for Payer: Health Management Network Commercial	$1,847.05
Rate for Payer: MDX Hawaii PPO	$2,107.81
Rate for Payer: University Health Alliance Commercial	$1,216.88

Know your out-of-pocket cost for care.

All Charges