Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

BALLOON 3.5X30 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: MDX Hawaii PPO	$11,979.50

BALLOON 3.5X30 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,298.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$7,780.50
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: University Health Alliance Commercial	$9,001.92

BALLOON 3X20 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,298.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$7,780.50
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: University Health Alliance Commercial	$9,001.92

BALLOON 3X20 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: MDX Hawaii PPO	$11,979.50

BALLOON 3X30 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: MDX Hawaii PPO	$11,979.50

BALLOON 3X30 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,298.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$7,780.50
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: University Health Alliance Commercial	$9,001.92

BALLOON 4X15 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: MDX Hawaii PPO	$11,979.50

BALLOON 4X15 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,298.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$7,780.50
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: University Health Alliance Commercial	$9,001.92

BALLOON 4X20 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: MDX Hawaii PPO	$11,979.50

BALLOON 4X20 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,298.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$7,780.50
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: University Health Alliance Commercial	$9,001.92

BALLOON 4X30 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$6,298.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,732.50
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: Kaiser Permanente Commercial	$7,780.50
Rate for Payer: Kaiser Permanente Medicaid	$6,298.50
Rate for Payer: MDX Hawaii PPO	$11,979.50
Rate for Payer: University Health Alliance Commercial	$9,001.92

BALLOON 4X30 AGENT DCB

Facility

$12,350.00

Service Code	HCPCS C9610
Hospital Revenue Code	272
Min. Negotiated Rate	$10,497.50
Max. Negotiated Rate	$11,979.50
Rate for Payer: Cash Price	$7,410.00
Rate for Payer: Health Management Network Commercial	$10,497.50
Rate for Payer: MDX Hawaii PPO	$11,979.50

BALLOON 6X40X75 MUSTANG PTA

Facility

$619.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$526.15
Max. Negotiated Rate	$600.43
Rate for Payer: Cash Price	$371.40
Rate for Payer: Health Management Network Commercial	$526.15
Rate for Payer: MDX Hawaii PPO	$600.43

BALLOON 6X40X75 MUSTANG PTA

Facility

$619.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$315.69
Max. Negotiated Rate	$600.43
Rate for Payer: Cash Price	$371.40
Rate for Payer: Hawaii Western Management Group Commercial	$588.05
Rate for Payer: Health Management Network Commercial	$526.15
Rate for Payer: Kaiser Permanente Commercial	$389.97
Rate for Payer: Kaiser Permanente Medicaid	$315.69
Rate for Payer: MDX Hawaii PPO	$600.43
Rate for Payer: University Health Alliance Commercial	$451.19

BALLOON 7X40X75 MUSTANG PTA

Facility

$619.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$526.15
Max. Negotiated Rate	$600.43
Rate for Payer: Cash Price	$371.40
Rate for Payer: Health Management Network Commercial	$526.15
Rate for Payer: MDX Hawaii PPO	$600.43

BALLOON 7X40X75 MUSTANG PTA

Facility

$619.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$315.69
Max. Negotiated Rate	$600.43
Rate for Payer: Cash Price	$371.40
Rate for Payer: Hawaii Western Management Group Commercial	$588.05
Rate for Payer: Health Management Network Commercial	$526.15
Rate for Payer: Kaiser Permanente Commercial	$389.97
Rate for Payer: Kaiser Permanente Medicaid	$315.69
Rate for Payer: MDX Hawaii PPO	$600.43
Rate for Payer: University Health Alliance Commercial	$451.19

BALLOON 8X40X75 MUSTANG PTA

Facility

$619.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$526.15
Max. Negotiated Rate	$600.43
Rate for Payer: Cash Price	$371.40
Rate for Payer: Health Management Network Commercial	$526.15
Rate for Payer: MDX Hawaii PPO	$600.43

BALLOON 8X40X75 MUSTANG PTA

Facility

$619.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$315.69
Max. Negotiated Rate	$600.43
Rate for Payer: Cash Price	$371.40
Rate for Payer: Hawaii Western Management Group Commercial	$588.05
Rate for Payer: Health Management Network Commercial	$526.15
Rate for Payer: Kaiser Permanente Commercial	$389.97
Rate for Payer: Kaiser Permanente Medicaid	$315.69
Rate for Payer: MDX Hawaii PPO	$600.43
Rate for Payer: University Health Alliance Commercial	$451.19

BALLOON ACHALASIA 30MM

Facility

$1,845.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$1,568.25
Max. Negotiated Rate	$1,789.65
Rate for Payer: Cash Price	$1,107.00
Rate for Payer: Health Management Network Commercial	$1,568.25
Rate for Payer: MDX Hawaii PPO	$1,789.65

BALLOON ACHALASIA 30MM

Facility

$1,845.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$940.95
Max. Negotiated Rate	$1,789.65
Rate for Payer: Cash Price	$1,107.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,752.75
Rate for Payer: Health Management Network Commercial	$1,568.25
Rate for Payer: Kaiser Permanente Commercial	$1,162.35
Rate for Payer: Kaiser Permanente Medicaid	$940.95
Rate for Payer: MDX Hawaii PPO	$1,789.65
Rate for Payer: University Health Alliance Commercial	$1,344.82

BALLOON BUTTON MINI M1-5-1820

Facility

$368.00

Hospital Revenue Code	272
Min. Negotiated Rate	$187.68
Max. Negotiated Rate	$356.96
Rate for Payer: Cash Price	$220.80
Rate for Payer: Hawaii Western Management Group Commercial	$349.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Kaiser Permanente Commercial	$231.84
Rate for Payer: Kaiser Permanente Medicaid	$187.68
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: University Health Alliance Commercial	$268.24

BALLOON BUTTON MINI M1-5-1820

Facility

$368.00

Hospital Revenue Code	272
Min. Negotiated Rate	$312.80
Max. Negotiated Rate	$356.96
Rate for Payer: Cash Price	$220.80
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: MDX Hawaii PPO	$356.96

BALLOON CATH 4.5X35 SR-4535-BC

Facility

$1,397.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$1,187.45
Max. Negotiated Rate	$1,355.09
Rate for Payer: Cash Price	$838.20
Rate for Payer: Health Management Network Commercial	$1,187.45
Rate for Payer: MDX Hawaii PPO	$1,355.09

BALLOON CATH 4.5X35 SR-4535-BC

Facility

$1,397.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$712.47
Max. Negotiated Rate	$1,355.09
Rate for Payer: Cash Price	$838.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,327.15
Rate for Payer: Health Management Network Commercial	$1,187.45
Rate for Payer: Kaiser Permanente Commercial	$880.11
Rate for Payer: Kaiser Permanente Medicaid	$712.47
Rate for Payer: MDX Hawaii PPO	$1,355.09
Rate for Payer: University Health Alliance Commercial	$1,018.27

BALLOON CATH 5.0X35 SR-5035-BC

Facility

$2,565.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$2,180.25
Max. Negotiated Rate	$2,488.05
Rate for Payer: Cash Price	$1,539.00
Rate for Payer: Health Management Network Commercial	$2,180.25
Rate for Payer: MDX Hawaii PPO	$2,488.05

Know your out-of-pocket cost for care.

All Charges