Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

STENT 8.5X7 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 8.5X7 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 8FR URETERAL SOFT

Facility

$254.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$129.54
Max. Negotiated Rate	$246.38
Rate for Payer: Cash Price	$152.40
Rate for Payer: Hawaii Western Management Group Commercial	$177.80
Rate for Payer: Health Management Network Commercial	$215.90
Rate for Payer: Kaiser Permanente Commercial	$160.02
Rate for Payer: Kaiser Permanente Medicaid	$129.54
Rate for Payer: MDX Hawaii PPO	$246.38
Rate for Payer: University Health Alliance Commercial	$142.24

STENT 8FR URETERAL SOFT

Facility

$254.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$142.24
Max. Negotiated Rate	$246.38
Rate for Payer: Cash Price	$152.40
Rate for Payer: Hawaii Western Management Group Commercial	$177.80
Rate for Payer: Health Management Network Commercial	$215.90
Rate for Payer: MDX Hawaii PPO	$246.38
Rate for Payer: University Health Alliance Commercial	$142.24

STENT 8X20 FLEXIMA URETERAL

Facility

$581.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$296.31
Max. Negotiated Rate	$563.57
Rate for Payer: Cash Price	$348.60
Rate for Payer: Hawaii Western Management Group Commercial	$406.70
Rate for Payer: Health Management Network Commercial	$493.85
Rate for Payer: Kaiser Permanente Commercial	$366.03
Rate for Payer: Kaiser Permanente Medicaid	$296.31
Rate for Payer: MDX Hawaii PPO	$563.57
Rate for Payer: University Health Alliance Commercial	$325.36

STENT 8X20 FLEXIMA URETERAL

Facility

$581.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$325.36
Max. Negotiated Rate	$563.57
Rate for Payer: Cash Price	$348.60
Rate for Payer: Hawaii Western Management Group Commercial	$406.70
Rate for Payer: Health Management Network Commercial	$493.85
Rate for Payer: MDX Hawaii PPO	$563.57
Rate for Payer: University Health Alliance Commercial	$325.36

STENT AGILE 18MM 5.9

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,248.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

STENT AGILE 18MM 5.9

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,958.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: Kaiser Permanente Commercial	$3,654.00
Rate for Payer: Kaiser Permanente Medicaid	$2,958.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

STENT AGILE 18MM 9.7

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,248.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

STENT AGILE 18MM 9.7

Facility

$5,800.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,958.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: Kaiser Permanente Commercial	$3,654.00
Rate for Payer: Kaiser Permanente Medicaid	$2,958.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

STENT BILIARY 10F POLYMERIC

Facility

$504.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$257.04
Max. Negotiated Rate	$488.88
Rate for Payer: Cash Price	$302.40
Rate for Payer: Hawaii Western Management Group Commercial	$352.80
Rate for Payer: Health Management Network Commercial	$428.40
Rate for Payer: Kaiser Permanente Commercial	$317.52
Rate for Payer: Kaiser Permanente Medicaid	$257.04
Rate for Payer: MDX Hawaii PPO	$488.88
Rate for Payer: University Health Alliance Commercial	$282.24

STENT BILIARY 10F POLYMERIC

Facility

$504.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$282.24
Max. Negotiated Rate	$488.88
Rate for Payer: Cash Price	$302.40
Rate for Payer: Hawaii Western Management Group Commercial	$352.80
Rate for Payer: Health Management Network Commercial	$428.40
Rate for Payer: MDX Hawaii PPO	$488.88
Rate for Payer: University Health Alliance Commercial	$282.24

STENT BILIARY 10FX9

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 BILIARY 10FX9

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 BILIARY 10MM

Facility

$4,959.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,529.09
Max. Negotiated Rate	$4,810.23
Rate for Payer: Cash Price	$2,975.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,471.30
Rate for Payer: Health Management Network Commercial	$4,215.15
Rate for Payer: Kaiser Permanente Commercial	$3,124.17
Rate for Payer: Kaiser Permanente Medicaid	$2,529.09
Rate for Payer: MDX Hawaii PPO	$4,810.23
Rate for Payer: University Health Alliance Commercial	$2,777.04

STENT BILIARY 10MM

Facility

$4,959.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,777.04
Max. Negotiated Rate	$4,810.23
Rate for Payer: Cash Price	$2,975.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,471.30
Rate for Payer: Health Management Network Commercial	$4,215.15
Rate for Payer: MDX Hawaii PPO	$4,810.23
Rate for Payer: University Health Alliance Commercial	$2,777.04

STENT BILIARY 10X60

Facility

$4,984.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,791.04
Max. Negotiated Rate	$4,834.48
Rate for Payer: Cash Price	$2,990.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,488.80
Rate for Payer: Health Management Network Commercial	$4,236.40
Rate for Payer: MDX Hawaii PPO	$4,834.48
Rate for Payer: University Health Alliance Commercial	$2,791.04

STENT BILIARY 10X60

Facility

$4,984.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,541.84
Max. Negotiated Rate	$4,834.48
Rate for Payer: Cash Price	$2,990.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,488.80
Rate for Payer: Health Management Network Commercial	$4,236.40
Rate for Payer: Kaiser Permanente Commercial	$3,139.92
Rate for Payer: Kaiser Permanente Medicaid	$2,541.84
Rate for Payer: MDX Hawaii PPO	$4,834.48
Rate for Payer: University Health Alliance Commercial	$2,791.04

STENT BILIARY 10X80

Facility

$4,984.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,541.84
Max. Negotiated Rate	$4,834.48
Rate for Payer: Cash Price	$2,990.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,488.80
Rate for Payer: Health Management Network Commercial	$4,236.40
Rate for Payer: Kaiser Permanente Commercial	$3,139.92
Rate for Payer: Kaiser Permanente Medicaid	$2,541.84
Rate for Payer: MDX Hawaii PPO	$4,834.48
Rate for Payer: University Health Alliance Commercial	$2,791.04

STENT BILIARY 10X80

Facility

$4,984.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,791.04
Max. Negotiated Rate	$4,834.48
Rate for Payer: Cash Price	$2,990.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,488.80
Rate for Payer: Health Management Network Commercial	$4,236.40
Rate for Payer: MDX Hawaii PPO	$4,834.48
Rate for Payer: University Health Alliance Commercial	$2,791.04

STENT BILIARY 7FX9

Facility

$2,123.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,082.73
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Kaiser Permanente Commercial	$1,337.49
Rate for Payer: Kaiser Permanente Medicaid	$1,082.73
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

STENT BILIARY 7FX9

Facility

$2,123.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$1,188.88
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

STENT COLON WALLFLEX 25X90

Facility

$5,075.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$2,588.25
Max. Negotiated Rate	$4,922.75
Rate for Payer: Cash Price	$3,045.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,552.50
Rate for Payer: Health Management Network Commercial	$4,313.75
Rate for Payer: Kaiser Permanente Commercial	$3,197.25
Rate for Payer: Kaiser Permanente Medicaid	$2,588.25
Rate for Payer: MDX Hawaii PPO	$4,922.75
Rate for Payer: University Health Alliance Commercial	$2,842.00

STENT COLON WALLFLEX 25X90

Facility

$5,075.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$2,842.00
Max. Negotiated Rate	$4,922.75
Rate for Payer: Cash Price	$3,045.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,552.50
Rate for Payer: Health Management Network Commercial	$4,313.75
Rate for Payer: MDX Hawaii PPO	$4,922.75
Rate for Payer: University Health Alliance Commercial	$2,842.00

STENT CONTOUR 4.8FX22-30CM

Facility

$419.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$234.64
Max. Negotiated Rate	$406.43
Rate for Payer: Cash Price	$251.40
Rate for Payer: Hawaii Western Management Group Commercial	$293.30
Rate for Payer: Health Management Network Commercial	$356.15
Rate for Payer: MDX Hawaii PPO	$406.43
Rate for Payer: University Health Alliance Commercial	$234.64

Know your out-of-pocket cost for care.

All Charges