Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

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

BALLOON CATH 5.5X35 SR-5535-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 5.5X35 SR-5535-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: Kaiser Permanente Medicaid	$712.47
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: MDX Hawaii PPO	$1,355.09
Rate for Payer: University Health Alliance Commercial	$1,018.27

BALLOON DILATION CATH 4.0X35

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

BALLOON DILATION CATH 4.0X35

Facility

$2,565.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$1,308.15
Max. Negotiated Rate	$2,488.05
Rate for Payer: Cash Price	$1,539.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,436.75
Rate for Payer: Health Management Network Commercial	$2,180.25
Rate for Payer: Kaiser Permanente Commercial	$1,615.95
Rate for Payer: Kaiser Permanente Medicaid	$1,308.15
Rate for Payer: MDX Hawaii PPO	$2,488.05
Rate for Payer: University Health Alliance Commercial	$1,869.63

BALLOON ENFLATE SR-6025-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 ENFLATE SR-6025-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 ESOPHA/COLON 10-12

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$701.25
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: MDX Hawaii PPO	$800.25

BALLOON ESOPHA/COLON 10-12

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$420.75
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Hawaii Western Management Group Commercial	$783.75
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: Kaiser Permanente Commercial	$519.75
Rate for Payer: Kaiser Permanente Medicaid	$420.75
Rate for Payer: MDX Hawaii PPO	$800.25
Rate for Payer: University Health Alliance Commercial	$601.34

BALLOON ESOPHA/COLON 15-18

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$701.25
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: MDX Hawaii PPO	$800.25

BALLOON ESOPHA/COLON 15-18

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$420.75
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Hawaii Western Management Group Commercial	$783.75
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: Kaiser Permanente Commercial	$519.75
Rate for Payer: Kaiser Permanente Medicaid	$420.75
Rate for Payer: MDX Hawaii PPO	$800.25
Rate for Payer: University Health Alliance Commercial	$601.34

BALLOON ESOPHA/COLON 18-20

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$420.75
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Hawaii Western Management Group Commercial	$783.75
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: Kaiser Permanente Commercial	$519.75
Rate for Payer: Kaiser Permanente Medicaid	$420.75
Rate for Payer: MDX Hawaii PPO	$800.25
Rate for Payer: University Health Alliance Commercial	$601.34

BALLOON ESOPHA/COLON 18-20

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$701.25
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: MDX Hawaii PPO	$800.25

BALLOON ESOPHA/COLON 6-8

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$420.75
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Hawaii Western Management Group Commercial	$783.75
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: Kaiser Permanente Commercial	$519.75
Rate for Payer: Kaiser Permanente Medicaid	$420.75
Rate for Payer: MDX Hawaii PPO	$800.25
Rate for Payer: University Health Alliance Commercial	$601.34

BALLOON ESOPHA/COLON 6-8

Facility

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$701.25
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: MDX Hawaii PPO	$800.25

BALLOON RETRIEVAL 12X15

Facility

$560.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$543.20
Rate for Payer: Cash Price	$336.00
Rate for Payer: Hawaii Western Management Group Commercial	$532.00
Rate for Payer: Health Management Network Commercial	$476.00
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$285.60
Rate for Payer: MDX Hawaii PPO	$543.20
Rate for Payer: University Health Alliance Commercial	$408.18

BALLOON RETRIEVAL 12X15

Facility

$560.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$476.00
Max. Negotiated Rate	$543.20
Rate for Payer: Cash Price	$336.00
Rate for Payer: Health Management Network Commercial	$476.00
Rate for Payer: MDX Hawaii PPO	$543.20

BALLOON RETRIEVAL 12X9

Facility

$560.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$543.20
Rate for Payer: Cash Price	$336.00
Rate for Payer: Hawaii Western Management Group Commercial	$532.00
Rate for Payer: Health Management Network Commercial	$476.00
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$285.60
Rate for Payer: MDX Hawaii PPO	$543.20
Rate for Payer: University Health Alliance Commercial	$408.18

BALLOON RETRIEVAL 12X9

Facility

$560.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$476.00
Max. Negotiated Rate	$543.20
Rate for Payer: Cash Price	$336.00
Rate for Payer: Health Management Network Commercial	$476.00
Rate for Payer: MDX Hawaii PPO	$543.20

BALLOON RETRIEVAL 15X18

Facility

$560.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$313.60
Max. Negotiated Rate	$543.20
Rate for Payer: Cash Price	$336.00
Rate for Payer: Hawaii Western Management Group Commercial	$392.00
Rate for Payer: Health Management Network Commercial	$476.00
Rate for Payer: MDX Hawaii PPO	$543.20
Rate for Payer: University Health Alliance Commercial	$313.60

BALLOON RETRIEVAL 15X18

Facility

$560.00

Service Code	HCPCS C1889
Hospital Revenue Code	278
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$543.20
Rate for Payer: Cash Price	$336.00
Rate for Payer: Hawaii Western Management Group Commercial	$392.00
Rate for Payer: Health Management Network Commercial	$476.00
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$285.60
Rate for Payer: MDX Hawaii PPO	$543.20
Rate for Payer: University Health Alliance Commercial	$313.60

BALL TIP GUIDE ROD #71631626

Facility

$1,428.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$728.28
Max. Negotiated Rate	$1,385.16
Rate for Payer: Cash Price	$856.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,356.60
Rate for Payer: Health Management Network Commercial	$1,213.80
Rate for Payer: Kaiser Permanente Commercial	$899.64
Rate for Payer: Kaiser Permanente Medicaid	$728.28
Rate for Payer: MDX Hawaii PPO	$1,385.16
Rate for Payer: University Health Alliance Commercial	$1,040.87

BALL TIP GUIDE ROD #71631626

Facility

$1,428.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$1,213.80
Max. Negotiated Rate	$1,385.16
Rate for Payer: Cash Price	$856.80
Rate for Payer: Health Management Network Commercial	$1,213.80
Rate for Payer: MDX Hawaii PPO	$1,385.16

BAND LIGATOR MULTIPLE

Facility

$541.00

Hospital Revenue Code	272
Min. Negotiated Rate	$459.85
Max. Negotiated Rate	$524.77
Rate for Payer: Cash Price	$324.60
Rate for Payer: Health Management Network Commercial	$459.85
Rate for Payer: MDX Hawaii PPO	$524.77

BAND LIGATOR MULTIPLE

Facility

$541.00

Hospital Revenue Code	272
Min. Negotiated Rate	$275.91
Max. Negotiated Rate	$524.77
Rate for Payer: Cash Price	$324.60
Rate for Payer: Hawaii Western Management Group Commercial	$513.95
Rate for Payer: Health Management Network Commercial	$459.85
Rate for Payer: Kaiser Permanente Commercial	$340.83
Rate for Payer: Kaiser Permanente Medicaid	$275.91
Rate for Payer: MDX Hawaii PPO	$524.77
Rate for Payer: University Health Alliance Commercial	$394.33

Know your out-of-pocket cost for care.

All Charges