Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

SHEATH 7FX10 PINNACLE ROII

Facility

$138.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$70.38
Max. Negotiated Rate	$133.86
Rate for Payer: Cash Price	$82.80
Rate for Payer: Hawaii Western Management Group Commercial	$131.10
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Kaiser Permanente Commercial	$86.94
Rate for Payer: Kaiser Permanente Medicaid	$70.38
Rate for Payer: MDX Hawaii PPO	$133.86
Rate for Payer: University Health Alliance Commercial	$100.59

SHEATH 7FX10 PINNACLE ROII

Facility

$138.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$133.86
Rate for Payer: Cash Price	$82.80
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: MDX Hawaii PPO	$133.86

SHEATH 8FX10 PINNACLE ROII

Facility

$138.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$133.86
Rate for Payer: Cash Price	$82.80
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: MDX Hawaii PPO	$133.86

SHEATH 8FX10 PINNACLE ROII

Facility

$138.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$70.38
Max. Negotiated Rate	$133.86
Rate for Payer: Cash Price	$82.80
Rate for Payer: Hawaii Western Management Group Commercial	$131.10
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Kaiser Permanente Commercial	$86.94
Rate for Payer: Kaiser Permanente Medicaid	$70.38
Rate for Payer: MDX Hawaii PPO	$133.86
Rate for Payer: University Health Alliance Commercial	$100.59

SHEATH CYSTOSCOPE 22.5FR

Facility

$2,022.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,718.70
Max. Negotiated Rate	$1,961.34
Rate for Payer: Cash Price	$1,213.20
Rate for Payer: Health Management Network Commercial	$1,718.70
Rate for Payer: MDX Hawaii PPO	$1,961.34

SHEATH CYSTOSCOPE 22.5FR

Facility

$2,022.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,031.22
Max. Negotiated Rate	$1,961.34
Rate for Payer: Cash Price	$1,213.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,920.90
Rate for Payer: Health Management Network Commercial	$1,718.70
Rate for Payer: Kaiser Permanente Commercial	$1,273.86
Rate for Payer: Kaiser Permanente Medicaid	$1,031.22
Rate for Payer: MDX Hawaii PPO	$1,961.34
Rate for Payer: University Health Alliance Commercial	$1,473.84

SHEATH DRYSEAL 20X30 GDSF2033

Facility

$2,200.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,122.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,090.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$1,386.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: University Health Alliance Commercial	$1,603.58

SHEATH DRYSEAL 20X30 GDSF2033

Facility

$2,200.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,870.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: MDX Hawaii PPO	$2,134.00

SHEATH DRYSEAL 22X33CM DSF2233

Facility

$2,200.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,122.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,090.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$1,386.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: University Health Alliance Commercial	$1,603.58

SHEATH DRYSEAL 22X33CM DSF2233

Facility

$2,200.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,870.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: MDX Hawaii PPO	$2,134.00

SHEATH DRYSEAL 24X33CM DSF2433

Facility

$2,200.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,122.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,090.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$1,386.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: University Health Alliance Commercial	$1,603.58

SHEATH DRYSEAL 24X33CM DSF2433

Facility

$2,200.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,870.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: MDX Hawaii PPO	$2,134.00

SHEATH D/S 12FRX28CM DSL1228

Facility

$963.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$818.55
Max. Negotiated Rate	$934.11
Rate for Payer: Cash Price	$577.80
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: MDX Hawaii PPO	$934.11

SHEATH D/S 12FRX28CM DSL1228

Facility

$963.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$491.13
Max. Negotiated Rate	$934.11
Rate for Payer: Cash Price	$577.80
Rate for Payer: Hawaii Western Management Group Commercial	$914.85
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Kaiser Permanente Commercial	$606.69
Rate for Payer: Kaiser Permanente Medicaid	$491.13
Rate for Payer: MDX Hawaii PPO	$934.11
Rate for Payer: University Health Alliance Commercial	$701.93

SHEATH D/S 16FRX28CM DSL1628

Facility

$963.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$818.55
Max. Negotiated Rate	$934.11
Rate for Payer: Cash Price	$577.80
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: MDX Hawaii PPO	$934.11

SHEATH D/S 16FRX28CM DSL1628

Facility

$963.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$491.13
Max. Negotiated Rate	$934.11
Rate for Payer: Cash Price	$577.80
Rate for Payer: Hawaii Western Management Group Commercial	$914.85
Rate for Payer: Health Management Network Commercial	$818.55
Rate for Payer: Kaiser Permanente Commercial	$606.69
Rate for Payer: Kaiser Permanente Medicaid	$491.13
Rate for Payer: MDX Hawaii PPO	$934.11
Rate for Payer: University Health Alliance Commercial	$701.93

SHEATH LAPAROSCOPIC 5MM CTS02

Facility

$225.00

Hospital Revenue Code	272
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$141.75
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: University Health Alliance Commercial	$164.00

SHEATH LAPAROSCOPIC 5MM CTS02

Facility

$225.00

Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: MDX Hawaii PPO	$218.25

SHEATH RENAL CLEAR

Facility

$229.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$194.65
Max. Negotiated Rate	$222.13
Rate for Payer: Cash Price	$137.40
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: MDX Hawaii PPO	$222.13

SHEATH RENAL CLEAR

Facility

$229.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$116.79
Max. Negotiated Rate	$222.13
Rate for Payer: Cash Price	$137.40
Rate for Payer: Hawaii Western Management Group Commercial	$217.55
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: Kaiser Permanente Commercial	$144.27
Rate for Payer: Kaiser Permanente Medicaid	$116.79
Rate for Payer: MDX Hawaii PPO	$222.13
Rate for Payer: University Health Alliance Commercial	$166.92

SHEATH SET NAVI URETH ACCESS

Facility

$424.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$360.40
Max. Negotiated Rate	$411.28
Rate for Payer: Cash Price	$254.40
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: MDX Hawaii PPO	$411.28

SHEATH SET NAVI URETH ACCESS

Facility

$424.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$216.24
Max. Negotiated Rate	$411.28
Rate for Payer: Cash Price	$254.40
Rate for Payer: Hawaii Western Management Group Commercial	$402.80
Rate for Payer: Health Management Network Commercial	$360.40
Rate for Payer: Kaiser Permanente Commercial	$267.12
Rate for Payer: Kaiser Permanente Medicaid	$216.24
Rate for Payer: MDX Hawaii PPO	$411.28
Rate for Payer: University Health Alliance Commercial	$309.05

SHEATH URETERAL ACCESS 12FRX35

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$345.60
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: MDX Hawaii PPO	$558.72

SHEATH URETERAL ACCESS 12FRX35

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$293.76
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$345.60
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$362.88
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: University Health Alliance Commercial	$419.85

SHEATH URETERAL ACCESS 12FRX45

Facility

$576.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$345.60
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: MDX Hawaii PPO	$558.72

Know your out-of-pocket cost for care.

All Charges