Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

SMOKE PENCIL W/EDGE 10FT

Facility

$155.00

Hospital Revenue Code	272
Min. Negotiated Rate	$131.75
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$93.00
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: MDX Hawaii PPO	$150.35

SMOKE PENCIL W/EDGE 10FT

Facility

$155.00

Hospital Revenue Code	272
Min. Negotiated Rate	$79.05
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$93.00
Rate for Payer: Hawaii Western Management Group Commercial	$147.25
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Kaiser Permanente Commercial	$97.65
Rate for Payer: Kaiser Permanente Medicaid	$79.05
Rate for Payer: MDX Hawaii PPO	$150.35
Rate for Payer: University Health Alliance Commercial	$112.98

SMOOTH RND MODE RT 10721-255MP

Facility

$2,685.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,369.35
Max. Negotiated Rate	$2,604.45
Rate for Payer: Cash Price	$1,611.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,879.50
Rate for Payer: Health Management Network Commercial	$2,282.25
Rate for Payer: Kaiser Permanente Commercial	$1,691.55
Rate for Payer: Kaiser Permanente Medicaid	$1,369.35
Rate for Payer: MDX Hawaii PPO	$2,604.45
Rate for Payer: University Health Alliance Commercial	$1,503.60

SMOOTH RND MODE RT 10721-255MP

Facility

$2,685.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,503.60
Max. Negotiated Rate	$2,604.45
Rate for Payer: Cash Price	$1,611.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,879.50
Rate for Payer: Health Management Network Commercial	$2,282.25
Rate for Payer: MDX Hawaii PPO	$2,604.45
Rate for Payer: University Health Alliance Commercial	$1,503.60

SNARE 10MM ROTATABLE

Facility

$90.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$54.00
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: MDX Hawaii PPO	$87.30

SNARE 10MM ROTATABLE

Facility

$90.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$54.00
Rate for Payer: Hawaii Western Management Group Commercial	$85.50
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$45.90
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: University Health Alliance Commercial	$65.60

SNARE 6FR ATRIEVE VASCULAR

Facility

$1,770.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$1,504.50
Max. Negotiated Rate	$1,716.90
Rate for Payer: Cash Price	$1,062.00
Rate for Payer: Health Management Network Commercial	$1,504.50
Rate for Payer: MDX Hawaii PPO	$1,716.90

SNARE 6FR ATRIEVE VASCULAR

Facility

$1,770.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$902.70
Max. Negotiated Rate	$1,716.90
Rate for Payer: Cash Price	$1,062.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,681.50
Rate for Payer: Health Management Network Commercial	$1,504.50
Rate for Payer: Kaiser Permanente Commercial	$1,115.10
Rate for Payer: Kaiser Permanente Medicaid	$902.70
Rate for Payer: MDX Hawaii PPO	$1,716.90
Rate for Payer: University Health Alliance Commercial	$1,290.15

SNARE 6FX15X120 AMPLATZ GN

Facility

$631.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$536.35
Max. Negotiated Rate	$612.07
Rate for Payer: Cash Price	$378.60
Rate for Payer: Health Management Network Commercial	$536.35
Rate for Payer: MDX Hawaii PPO	$612.07

SNARE 6FX15X120 AMPLATZ GN

Facility

$631.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$321.81
Max. Negotiated Rate	$612.07
Rate for Payer: Cash Price	$378.60
Rate for Payer: Hawaii Western Management Group Commercial	$599.45
Rate for Payer: Health Management Network Commercial	$536.35
Rate for Payer: Kaiser Permanente Commercial	$397.53
Rate for Payer: Kaiser Permanente Medicaid	$321.81
Rate for Payer: MDX Hawaii PPO	$612.07
Rate for Payer: University Health Alliance Commercial	$459.94

SNARE 6FX25X120 AMPLATZ GN

Facility

$630.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$321.30
Max. Negotiated Rate	$611.10
Rate for Payer: Cash Price	$378.00
Rate for Payer: Hawaii Western Management Group Commercial	$598.50
Rate for Payer: Health Management Network Commercial	$535.50
Rate for Payer: Kaiser Permanente Commercial	$396.90
Rate for Payer: Kaiser Permanente Medicaid	$321.30
Rate for Payer: MDX Hawaii PPO	$611.10
Rate for Payer: University Health Alliance Commercial	$459.21

SNARE 6FX25X120 AMPLATZ GN

Facility

$630.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$611.10
Rate for Payer: Cash Price	$378.00
Rate for Payer: Health Management Network Commercial	$535.50
Rate for Payer: MDX Hawaii PPO	$611.10

SNARE COLD EXACTO

Facility

$72.00

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

SNARE COLD EXACTO

Facility

$72.00

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

SNARE FOREIGN BODY KATZ

Facility

$320.00

Service Code	HCPCS L8499
Hospital Revenue Code	274
Min. Negotiated Rate	$38.93
Max. Negotiated Rate	$310.40
Rate for Payer: Cash Price	$192.00
Rate for Payer: Cash Price	$192.00
Rate for Payer: Hawaii Western Management Group Commercial	$224.00
Rate for Payer: Health Management Network Commercial	$272.00
Rate for Payer: Kaiser Permanente Commercial	$201.60
Rate for Payer: Kaiser Permanente Medicaid	$163.20
Rate for Payer: MDX Hawaii PPO	$310.40
Rate for Payer: UnitedHealthcare Medicaid	$38.93
Rate for Payer: University Health Alliance Commercial	$179.20

SNARE FOREIGN BODY KATZ

Facility

$320.00

Service Code	HCPCS L8499
Hospital Revenue Code	274
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$310.40
Rate for Payer: Cash Price	$192.00
Rate for Payer: Hawaii Western Management Group Commercial	$224.00
Rate for Payer: Health Management Network Commercial	$272.00
Rate for Payer: MDX Hawaii PPO	$310.40
Rate for Payer: University Health Alliance Commercial	$179.20

SNARE POLYP 10MM

Facility

$94.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$47.94
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$56.40
Rate for Payer: Hawaii Western Management Group Commercial	$89.30
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Kaiser Permanente Commercial	$59.22
Rate for Payer: Kaiser Permanente Medicaid	$47.94
Rate for Payer: MDX Hawaii PPO	$91.18
Rate for Payer: University Health Alliance Commercial	$68.52

SNARE POLYP 10MM

Facility

$94.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$79.90
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$56.40
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: MDX Hawaii PPO	$91.18

SNARE POLYP 20MM

Facility

$91.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$46.41
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$54.60
Rate for Payer: Hawaii Western Management Group Commercial	$86.45
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$57.33
Rate for Payer: Kaiser Permanente Medicaid	$46.41
Rate for Payer: MDX Hawaii PPO	$88.27
Rate for Payer: University Health Alliance Commercial	$66.33

SNARE POLYP 20MM

Facility

$91.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: MDX Hawaii PPO	$88.27

SNARE POLYPECTOMY 30MM

Facility

$91.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: MDX Hawaii PPO	$88.27

SNARE POLYPECTOMY 30MM

Facility

$91.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$46.41
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$54.60
Rate for Payer: Hawaii Western Management Group Commercial	$86.45
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$57.33
Rate for Payer: Kaiser Permanente Medicaid	$46.41
Rate for Payer: MDX Hawaii PPO	$88.27
Rate for Payer: University Health Alliance Commercial	$66.33

SNARE POLYPECTOMY 33MM

Facility

$91.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: MDX Hawaii PPO	$88.27

SNARE POLYPECTOMY 33MM

Facility

$91.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$46.41
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$54.60
Rate for Payer: Hawaii Western Management Group Commercial	$86.45
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$57.33
Rate for Payer: Kaiser Permanente Medicaid	$46.41
Rate for Payer: MDX Hawaii PPO	$88.27
Rate for Payer: University Health Alliance Commercial	$66.33

SOD BICARB-CITRIC AC-SIMETH 2.21 GRAM-1.53 GRAM/4 GRAM GRANULES EFFERV [97293]

Facility

$12.00

Service Code	NDC 10361079301
Hospital Revenue Code	250
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.20
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: MDX Hawaii PPO	$11.64

Know your out-of-pocket cost for care.

All Charges