Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

STENT 4.5FRX24 URETER OPEN TIP

Facility

$555.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$283.05
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$333.00
Rate for Payer: Hawaii Western Management Group Commercial	$388.50
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: Kaiser Permanente Commercial	$349.65
Rate for Payer: Kaiser Permanente Medicaid	$283.05
Rate for Payer: MDX Hawaii PPO	$538.35
Rate for Payer: University Health Alliance Commercial	$310.80

STENT 4.5FRX26 URETER OPEN TIP

Facility

$555.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$310.80
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$333.00
Rate for Payer: Hawaii Western Management Group Commercial	$388.50
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: MDX Hawaii PPO	$538.35
Rate for Payer: University Health Alliance Commercial	$310.80

STENT 4.5FRX26 URETER OPEN TIP

Facility

$555.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$283.05
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$333.00
Rate for Payer: Hawaii Western Management Group Commercial	$388.50
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: Kaiser Permanente Commercial	$349.65
Rate for Payer: Kaiser Permanente Medicaid	$283.05
Rate for Payer: MDX Hawaii PPO	$538.35
Rate for Payer: University Health Alliance Commercial	$310.80

STENT 4.5FRX28 URETER OPEN TIP

Facility

$555.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$283.05
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$333.00
Rate for Payer: Hawaii Western Management Group Commercial	$388.50
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: Kaiser Permanente Commercial	$349.65
Rate for Payer: Kaiser Permanente Medicaid	$283.05
Rate for Payer: MDX Hawaii PPO	$538.35
Rate for Payer: University Health Alliance Commercial	$310.80

STENT 4.5FRX28 URETER OPEN TIP

Facility

$555.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$310.80
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$333.00
Rate for Payer: Hawaii Western Management Group Commercial	$388.50
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: MDX Hawaii PPO	$538.35
Rate for Payer: University Health Alliance Commercial	$310.80

STENT 5FRX5 PANREATIC FLEXI

Facility

$240.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$134.40
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Hawaii Western Management Group Commercial	$168.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: University Health Alliance Commercial	$134.40

STENT 5FRX5 PANREATIC FLEXI

Facility

$240.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Hawaii Western Management Group Commercial	$168.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: University Health Alliance Commercial	$134.40

STENT 6X20 URETERAL DBL PIG

Facility

$532.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$297.92
Max. Negotiated Rate	$516.04
Rate for Payer: Cash Price	$319.20
Rate for Payer: Hawaii Western Management Group Commercial	$372.40
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: MDX Hawaii PPO	$516.04
Rate for Payer: University Health Alliance Commercial	$297.92

STENT 6X20 URETERAL DBL PIG

Facility

$532.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$271.32
Max. Negotiated Rate	$516.04
Rate for Payer: Cash Price	$319.20
Rate for Payer: Hawaii Western Management Group Commercial	$372.40
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: Kaiser Permanente Commercial	$335.16
Rate for Payer: Kaiser Permanente Medicaid	$271.32
Rate for Payer: MDX Hawaii PPO	$516.04
Rate for Payer: University Health Alliance Commercial	$297.92

STENT 6X24 FILIFORM DBL PIG

Facility

$532.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$297.92
Max. Negotiated Rate	$516.04
Rate for Payer: Cash Price	$319.20
Rate for Payer: Hawaii Western Management Group Commercial	$372.40
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: MDX Hawaii PPO	$516.04
Rate for Payer: University Health Alliance Commercial	$297.92

STENT 6X24 FILIFORM DBL PIG

Facility

$532.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$271.32
Max. Negotiated Rate	$516.04
Rate for Payer: Cash Price	$319.20
Rate for Payer: Hawaii Western Management Group Commercial	$372.40
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: Kaiser Permanente Commercial	$335.16
Rate for Payer: Kaiser Permanente Medicaid	$271.32
Rate for Payer: MDX Hawaii PPO	$516.04
Rate for Payer: University Health Alliance Commercial	$297.92

STENT 7FRX22CM URO DBL PIG

Facility

$473.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$241.23
Max. Negotiated Rate	$458.81
Rate for Payer: Cash Price	$283.80
Rate for Payer: Hawaii Western Management Group Commercial	$331.10
Rate for Payer: Health Management Network Commercial	$402.05
Rate for Payer: Kaiser Permanente Commercial	$297.99
Rate for Payer: Kaiser Permanente Medicaid	$241.23
Rate for Payer: MDX Hawaii PPO	$458.81
Rate for Payer: University Health Alliance Commercial	$264.88

STENT 7FRX22CM URO DBL PIG

Facility

$473.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$264.88
Max. Negotiated Rate	$458.81
Rate for Payer: Cash Price	$283.80
Rate for Payer: Hawaii Western Management Group Commercial	$331.10
Rate for Payer: Health Management Network Commercial	$402.05
Rate for Payer: MDX Hawaii PPO	$458.81
Rate for Payer: University Health Alliance Commercial	$264.88

STENT 7FRX24CM URO DBL PIG

Facility

$473.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$241.23
Max. Negotiated Rate	$458.81
Rate for Payer: Cash Price	$283.80
Rate for Payer: Hawaii Western Management Group Commercial	$331.10
Rate for Payer: Health Management Network Commercial	$402.05
Rate for Payer: Kaiser Permanente Commercial	$297.99
Rate for Payer: Kaiser Permanente Medicaid	$241.23
Rate for Payer: MDX Hawaii PPO	$458.81
Rate for Payer: University Health Alliance Commercial	$264.88

STENT 7FRX24CM URO DBL PIG

Facility

$473.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$264.88
Max. Negotiated Rate	$458.81
Rate for Payer: Cash Price	$283.80
Rate for Payer: Hawaii Western Management Group Commercial	$331.10
Rate for Payer: Health Management Network Commercial	$402.05
Rate for Payer: MDX Hawaii PPO	$458.81
Rate for Payer: University Health Alliance Commercial	$264.88

STENT 7FRX26CM URO DBL PIG

Facility

$473.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$264.88
Max. Negotiated Rate	$458.81
Rate for Payer: Cash Price	$283.80
Rate for Payer: Hawaii Western Management Group Commercial	$331.10
Rate for Payer: Health Management Network Commercial	$402.05
Rate for Payer: MDX Hawaii PPO	$458.81
Rate for Payer: University Health Alliance Commercial	$264.88

STENT 7FRX26CM URO DBL PIG

Facility

$473.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$241.23
Max. Negotiated Rate	$458.81
Rate for Payer: Cash Price	$283.80
Rate for Payer: Hawaii Western Management Group Commercial	$331.10
Rate for Payer: Health Management Network Commercial	$402.05
Rate for Payer: Kaiser Permanente Commercial	$297.99
Rate for Payer: Kaiser Permanente Medicaid	$241.23
Rate for Payer: MDX Hawaii PPO	$458.81
Rate for Payer: University Health Alliance Commercial	$264.88

STENT 7X10 ZIMMON BILIARY

Facility

$518.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$264.18
Max. Negotiated Rate	$502.46
Rate for Payer: Cash Price	$310.80
Rate for Payer: Hawaii Western Management Group Commercial	$362.60
Rate for Payer: Health Management Network Commercial	$440.30
Rate for Payer: Kaiser Permanente Commercial	$326.34
Rate for Payer: Kaiser Permanente Medicaid	$264.18
Rate for Payer: MDX Hawaii PPO	$502.46
Rate for Payer: University Health Alliance Commercial	$290.08

STENT 7X10 ZIMMON BILIARY

Facility

$518.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$290.08
Max. Negotiated Rate	$502.46
Rate for Payer: Cash Price	$310.80
Rate for Payer: Hawaii Western Management Group Commercial	$362.60
Rate for Payer: Health Management Network Commercial	$440.30
Rate for Payer: MDX Hawaii PPO	$502.46
Rate for Payer: University Health Alliance Commercial	$290.08

STENT 7X4 ZIMMON BILIARY

Facility

$570.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$319.20
Max. Negotiated Rate	$552.90
Rate for Payer: Cash Price	$342.00
Rate for Payer: Hawaii Western Management Group Commercial	$399.00
Rate for Payer: Health Management Network Commercial	$484.50
Rate for Payer: MDX Hawaii PPO	$552.90
Rate for Payer: University Health Alliance Commercial	$319.20

STENT 7X4 ZIMMON BILIARY

Facility

$570.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$290.70
Max. Negotiated Rate	$552.90
Rate for Payer: Cash Price	$342.00
Rate for Payer: Hawaii Western Management Group Commercial	$399.00
Rate for Payer: Health Management Network Commercial	$484.50
Rate for Payer: Kaiser Permanente Commercial	$359.10
Rate for Payer: Kaiser Permanente Medicaid	$290.70
Rate for Payer: MDX Hawaii PPO	$552.90
Rate for Payer: University Health Alliance Commercial	$319.20

STENT 7X5 ADVANIX BILIARY RX

Facility

$490.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$274.40
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$294.00
Rate for Payer: Hawaii Western Management Group Commercial	$343.00
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: University Health Alliance Commercial	$274.40

STENT 7X5 ADVANIX BILIARY RX

Facility

$490.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$249.90
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$294.00
Rate for Payer: Hawaii Western Management Group Commercial	$343.00
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Kaiser Permanente Commercial	$308.70
Rate for Payer: Kaiser Permanente Medicaid	$249.90
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: University Health Alliance Commercial	$274.40

STENT 7X7 ZIMMON BILIARY

Facility

$570.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$290.70
Max. Negotiated Rate	$552.90
Rate for Payer: Cash Price	$342.00
Rate for Payer: Hawaii Western Management Group Commercial	$399.00
Rate for Payer: Health Management Network Commercial	$484.50
Rate for Payer: Kaiser Permanente Commercial	$359.10
Rate for Payer: Kaiser Permanente Medicaid	$290.70
Rate for Payer: MDX Hawaii PPO	$552.90
Rate for Payer: University Health Alliance Commercial	$319.20

STENT 7X7 ZIMMON BILIARY

Facility

$570.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$319.20
Max. Negotiated Rate	$552.90
Rate for Payer: Cash Price	$342.00
Rate for Payer: Hawaii Western Management Group Commercial	$399.00
Rate for Payer: Health Management Network Commercial	$484.50
Rate for Payer: MDX Hawaii PPO	$552.90
Rate for Payer: University Health Alliance Commercial	$319.20

Know your out-of-pocket cost for care.

All Charges