Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CATH 8FR DRAINAGE APD

Facility

$400.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$388.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Hawaii Western Management Group Commercial	$380.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: Kaiser Permanente Commercial	$252.00
Rate for Payer: Kaiser Permanente Medicaid	$204.00
Rate for Payer: MDX Hawaii PPO	$388.00
Rate for Payer: University Health Alliance Commercial	$291.56

CATH 8FR DRAINAGE APD

Facility

$400.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$340.00
Max. Negotiated Rate	$388.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: MDX Hawaii PPO	$388.00

CATH 8X4 ERCP BDC HURRICANE

Facility

$925.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$786.25
Max. Negotiated Rate	$897.25
Rate for Payer: Cash Price	$555.00
Rate for Payer: Health Management Network Commercial	$786.25
Rate for Payer: MDX Hawaii PPO	$897.25

CATH 8X4 ERCP BDC HURRICANE

Facility

$925.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$471.75
Max. Negotiated Rate	$897.25
Rate for Payer: Cash Price	$555.00
Rate for Payer: Hawaii Western Management Group Commercial	$878.75
Rate for Payer: Health Management Network Commercial	$786.25
Rate for Payer: Kaiser Permanente Commercial	$582.75
Rate for Payer: Kaiser Permanente Medicaid	$471.75
Rate for Payer: MDX Hawaii PPO	$897.25
Rate for Payer: University Health Alliance Commercial	$674.23

CATH ADAPTER 8FR

Facility

$240.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
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	$228.00
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	$174.94

CATH ADAPTER 8FR

Facility

$240.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: MDX Hawaii PPO	$232.80

CATH AND BURR ADVANCE DEVICE 1

Facility

$6,710.00

Service Code	HCPCS C1724
Hospital Revenue Code	272
Min. Negotiated Rate	$5,703.50
Max. Negotiated Rate	$6,508.70
Rate for Payer: Cash Price	$4,026.00
Rate for Payer: Health Management Network Commercial	$5,703.50
Rate for Payer: MDX Hawaii PPO	$6,508.70

CATH AND BURR ADVANCE DEVICE 1

Facility

$6,710.00

Service Code	HCPCS C1724
Hospital Revenue Code	272
Min. Negotiated Rate	$3,422.10
Max. Negotiated Rate	$6,508.70
Rate for Payer: Cash Price	$4,026.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,374.50
Rate for Payer: Health Management Network Commercial	$5,703.50
Rate for Payer: Kaiser Permanente Commercial	$4,227.30
Rate for Payer: Kaiser Permanente Medicaid	$3,422.10
Rate for Payer: MDX Hawaii PPO	$6,508.70
Rate for Payer: University Health Alliance Commercial	$4,890.92

CATH AND BURR ADVANCE DEVICE 2

Facility

$6,692.00

Service Code	HCPCS C1724
Hospital Revenue Code	272
Min. Negotiated Rate	$5,688.20
Max. Negotiated Rate	$6,491.24
Rate for Payer: Cash Price	$4,015.20
Rate for Payer: Health Management Network Commercial	$5,688.20
Rate for Payer: MDX Hawaii PPO	$6,491.24

CATH AND BURR ADVANCE DEVICE 2

Facility

$6,692.00

Service Code	HCPCS C1724
Hospital Revenue Code	272
Min. Negotiated Rate	$3,412.92
Max. Negotiated Rate	$6,491.24
Rate for Payer: Cash Price	$4,015.20
Rate for Payer: Hawaii Western Management Group Commercial	$6,357.40
Rate for Payer: Health Management Network Commercial	$5,688.20
Rate for Payer: Kaiser Permanente Commercial	$4,215.96
Rate for Payer: Kaiser Permanente Medicaid	$3,412.92
Rate for Payer: MDX Hawaii PPO	$6,491.24
Rate for Payer: University Health Alliance Commercial	$4,877.80

CATH ARROW TRIPLE LM

Facility

$432.00

Service Code	HCPCS C1751
Hospital Revenue Code	272
Min. Negotiated Rate	$220.32
Max. Negotiated Rate	$419.04
Rate for Payer: Cash Price	$259.20
Rate for Payer: Hawaii Western Management Group Commercial	$410.40
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: Kaiser Permanente Commercial	$272.16
Rate for Payer: Kaiser Permanente Medicaid	$220.32
Rate for Payer: MDX Hawaii PPO	$419.04
Rate for Payer: University Health Alliance Commercial	$314.88

CATH ARROW TRIPLE LM

Facility

$432.00

Service Code	HCPCS C1751
Hospital Revenue Code	272
Min. Negotiated Rate	$367.20
Max. Negotiated Rate	$419.04
Rate for Payer: Cash Price	$259.20
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: MDX Hawaii PPO	$419.04

CATH BALLOON MOLD

Facility

$1,779.00

Service Code	HCPCS C2628
Hospital Revenue Code	272
Min. Negotiated Rate	$907.29
Max. Negotiated Rate	$1,725.63
Rate for Payer: Cash Price	$1,067.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,690.05
Rate for Payer: Health Management Network Commercial	$1,512.15
Rate for Payer: Kaiser Permanente Commercial	$1,120.77
Rate for Payer: Kaiser Permanente Medicaid	$907.29
Rate for Payer: MDX Hawaii PPO	$1,725.63
Rate for Payer: University Health Alliance Commercial	$1,296.71

CATH BALLOON MOLD

Facility

$1,779.00

Service Code	HCPCS C2628
Hospital Revenue Code	272
Min. Negotiated Rate	$1,512.15
Max. Negotiated Rate	$1,725.63
Rate for Payer: Cash Price	$1,067.40
Rate for Payer: Health Management Network Commercial	$1,512.15
Rate for Payer: MDX Hawaii PPO	$1,725.63

CATH BALLOON TAMPONADE BTC-100

Facility

$400.00

Service Code	HCPCS C2628
Hospital Revenue Code	272
Min. Negotiated Rate	$340.00
Max. Negotiated Rate	$388.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: MDX Hawaii PPO	$388.00

CATH BALLOON TAMPONADE BTC-100

Facility

$400.00

Service Code	HCPCS C2628
Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$388.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Hawaii Western Management Group Commercial	$380.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: Kaiser Permanente Commercial	$252.00
Rate for Payer: Kaiser Permanente Medicaid	$204.00
Rate for Payer: MDX Hawaii PPO	$388.00
Rate for Payer: University Health Alliance Commercial	$291.56

CATH BDC 10-12MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$615.40
Max. Negotiated Rate	$702.28
Rate for Payer: Cash Price	$434.40
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: MDX Hawaii PPO	$702.28

CATH BDC 10-12MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$369.24
Max. Negotiated Rate	$702.28
Rate for Payer: Cash Price	$434.40
Rate for Payer: Hawaii Western Management Group Commercial	$687.80
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: Kaiser Permanente Commercial	$456.12
Rate for Payer: Kaiser Permanente Medicaid	$369.24
Rate for Payer: MDX Hawaii PPO	$702.28
Rate for Payer: University Health Alliance Commercial	$527.72

CATH BDC 12-15MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$615.40
Max. Negotiated Rate	$702.28
Rate for Payer: Cash Price	$434.40
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: MDX Hawaii PPO	$702.28

CATH BDC 12-15MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$369.24
Max. Negotiated Rate	$702.28
Rate for Payer: Cash Price	$434.40
Rate for Payer: Hawaii Western Management Group Commercial	$687.80
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: Kaiser Permanente Commercial	$456.12
Rate for Payer: Kaiser Permanente Medicaid	$369.24
Rate for Payer: MDX Hawaii PPO	$702.28
Rate for Payer: University Health Alliance Commercial	$527.72

CATH BDC 15-18MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$615.40
Max. Negotiated Rate	$702.28
Rate for Payer: Cash Price	$434.40
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: MDX Hawaii PPO	$702.28

CATH BDC 15-18MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$369.24
Max. Negotiated Rate	$702.28
Rate for Payer: Cash Price	$434.40
Rate for Payer: Hawaii Western Management Group Commercial	$687.80
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: Kaiser Permanente Commercial	$456.12
Rate for Payer: Kaiser Permanente Medicaid	$369.24
Rate for Payer: MDX Hawaii PPO	$702.28
Rate for Payer: University Health Alliance Commercial	$527.72

CATH BDC 8-10MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$369.24
Max. Negotiated Rate	$702.28
Rate for Payer: Cash Price	$434.40
Rate for Payer: Hawaii Western Management Group Commercial	$687.80
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: Kaiser Permanente Commercial	$456.12
Rate for Payer: Kaiser Permanente Medicaid	$369.24
Rate for Payer: MDX Hawaii PPO	$702.28
Rate for Payer: University Health Alliance Commercial	$527.72

CATH BDC 8-10MM ESOPHAGEAL

Facility

$724.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$615.40
Max. Negotiated Rate	$702.28
Rate for Payer: Cash Price	$434.40
Rate for Payer: Health Management Network Commercial	$615.40
Rate for Payer: MDX Hawaii PPO	$702.28

CATH CHOLANGIOGRAM

Facility

$175.00

Hospital Revenue Code	272
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$166.25
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$110.25
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$127.56

Know your out-of-pocket cost for care.

All Charges