Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

STENT CONTOUR 4.8FX22-30CM

Facility

$419.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$213.69
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: Kaiser Permanente Commercial	$263.97
Rate for Payer: Kaiser Permanente Medicaid	$213.69
Rate for Payer: MDX Hawaii PPO	$406.43
Rate for Payer: University Health Alliance Commercial	$234.64

STENT CONTOUR VL URETERAL

Facility

$415.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$232.40
Max. Negotiated Rate	$402.55
Rate for Payer: Cash Price	$249.00
Rate for Payer: Hawaii Western Management Group Commercial	$290.50
Rate for Payer: Health Management Network Commercial	$352.75
Rate for Payer: MDX Hawaii PPO	$402.55
Rate for Payer: University Health Alliance Commercial	$232.40

STENT CONTOUR VL URETERAL

Facility

$415.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$211.65
Max. Negotiated Rate	$402.55
Rate for Payer: Cash Price	$249.00
Rate for Payer: Hawaii Western Management Group Commercial	$290.50
Rate for Payer: Health Management Network Commercial	$352.75
Rate for Payer: Kaiser Permanente Commercial	$261.45
Rate for Payer: Kaiser Permanente Medicaid	$211.65
Rate for Payer: MDX Hawaii PPO	$402.55
Rate for Payer: University Health Alliance Commercial	$232.40

STENT COTTON HUIB 10X12

Facility

$284.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$159.04
Max. Negotiated Rate	$275.48
Rate for Payer: Cash Price	$170.40
Rate for Payer: Hawaii Western Management Group Commercial	$198.80
Rate for Payer: Health Management Network Commercial	$241.40
Rate for Payer: MDX Hawaii PPO	$275.48
Rate for Payer: University Health Alliance Commercial	$159.04

STENT COTTON HUIB 10X12

Facility

$284.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$144.84
Max. Negotiated Rate	$275.48
Rate for Payer: Cash Price	$170.40
Rate for Payer: Hawaii Western Management Group Commercial	$198.80
Rate for Payer: Health Management Network Commercial	$241.40
Rate for Payer: Kaiser Permanente Commercial	$178.92
Rate for Payer: Kaiser Permanente Medicaid	$144.84
Rate for Payer: MDX Hawaii PPO	$275.48
Rate for Payer: University Health Alliance Commercial	$159.04

STENT COTTON HUIB 10X15

Facility

$284.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$144.84
Max. Negotiated Rate	$275.48
Rate for Payer: Cash Price	$170.40
Rate for Payer: Hawaii Western Management Group Commercial	$198.80
Rate for Payer: Health Management Network Commercial	$241.40
Rate for Payer: Kaiser Permanente Commercial	$178.92
Rate for Payer: Kaiser Permanente Medicaid	$144.84
Rate for Payer: MDX Hawaii PPO	$275.48
Rate for Payer: University Health Alliance Commercial	$159.04

STENT COTTON HUIB 10X15

Facility

$284.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$159.04
Max. Negotiated Rate	$275.48
Rate for Payer: Cash Price	$170.40
Rate for Payer: Hawaii Western Management Group Commercial	$198.80
Rate for Payer: Health Management Network Commercial	$241.40
Rate for Payer: MDX Hawaii PPO	$275.48
Rate for Payer: University Health Alliance Commercial	$159.04

STENT COTTON HUIB 10X5

Facility

$312.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$174.72
Max. Negotiated Rate	$302.64
Rate for Payer: Cash Price	$187.20
Rate for Payer: Hawaii Western Management Group Commercial	$218.40
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: MDX Hawaii PPO	$302.64
Rate for Payer: University Health Alliance Commercial	$174.72

STENT COTTON HUIB 10X5

Facility

$312.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$159.12
Max. Negotiated Rate	$302.64
Rate for Payer: Cash Price	$187.20
Rate for Payer: Hawaii Western Management Group Commercial	$218.40
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Kaiser Permanente Commercial	$196.56
Rate for Payer: Kaiser Permanente Medicaid	$159.12
Rate for Payer: MDX Hawaii PPO	$302.64
Rate for Payer: University Health Alliance Commercial	$174.72

STENT COTTON HUIB 10X7

Facility

$312.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$174.72
Max. Negotiated Rate	$302.64
Rate for Payer: Cash Price	$187.20
Rate for Payer: Hawaii Western Management Group Commercial	$218.40
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: MDX Hawaii PPO	$302.64
Rate for Payer: University Health Alliance Commercial	$174.72

STENT COTTON HUIB 10X7

Facility

$312.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$159.12
Max. Negotiated Rate	$302.64
Rate for Payer: Cash Price	$187.20
Rate for Payer: Hawaii Western Management Group Commercial	$218.40
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Kaiser Permanente Commercial	$196.56
Rate for Payer: Kaiser Permanente Medicaid	$159.12
Rate for Payer: MDX Hawaii PPO	$302.64
Rate for Payer: University Health Alliance Commercial	$174.72

STENT COTTON HUIB 10X9

Facility

$284.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$159.04
Max. Negotiated Rate	$275.48
Rate for Payer: Cash Price	$170.40
Rate for Payer: Hawaii Western Management Group Commercial	$198.80
Rate for Payer: Health Management Network Commercial	$241.40
Rate for Payer: MDX Hawaii PPO	$275.48
Rate for Payer: University Health Alliance Commercial	$159.04

STENT COTTON HUIB 10X9

Facility

$284.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$144.84
Max. Negotiated Rate	$275.48
Rate for Payer: Cash Price	$170.40
Rate for Payer: Hawaii Western Management Group Commercial	$198.80
Rate for Payer: Health Management Network Commercial	$241.40
Rate for Payer: Kaiser Permanente Commercial	$178.92
Rate for Payer: Kaiser Permanente Medicaid	$144.84
Rate for Payer: MDX Hawaii PPO	$275.48
Rate for Payer: University Health Alliance Commercial	$159.04

STENT ENDOPYELOTOMY

Facility

$738.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$413.28
Max. Negotiated Rate	$715.86
Rate for Payer: Cash Price	$442.80
Rate for Payer: Hawaii Western Management Group Commercial	$516.60
Rate for Payer: Health Management Network Commercial	$627.30
Rate for Payer: MDX Hawaii PPO	$715.86
Rate for Payer: University Health Alliance Commercial	$413.28

STENT ENDOPYELOTOMY

Facility

$738.00

Service Code	HCPCS C2617
Hospital Revenue Code	278
Min. Negotiated Rate	$376.38
Max. Negotiated Rate	$715.86
Rate for Payer: Cash Price	$442.80
Rate for Payer: Hawaii Western Management Group Commercial	$516.60
Rate for Payer: Health Management Network Commercial	$627.30
Rate for Payer: Kaiser Permanente Commercial	$464.94
Rate for Payer: Kaiser Permanente Medicaid	$376.38
Rate for Payer: MDX Hawaii PPO	$715.86
Rate for Payer: University Health Alliance Commercial	$413.28

STENT ERCP BILIARY 11.5X7

Facility

$1,530.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$780.30
Max. Negotiated Rate	$1,484.10
Rate for Payer: Cash Price	$918.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,071.00
Rate for Payer: Health Management Network Commercial	$1,300.50
Rate for Payer: Kaiser Permanente Commercial	$963.90
Rate for Payer: Kaiser Permanente Medicaid	$780.30
Rate for Payer: MDX Hawaii PPO	$1,484.10
Rate for Payer: University Health Alliance Commercial	$856.80

STENT ERCP BILIARY 11.5X7

Facility

$1,530.00

Service Code	HCPCS C2625
Hospital Revenue Code	278
Min. Negotiated Rate	$856.80
Max. Negotiated Rate	$1,484.10
Rate for Payer: Cash Price	$918.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,071.00
Rate for Payer: Health Management Network Commercial	$1,300.50
Rate for Payer: MDX Hawaii PPO	$1,484.10
Rate for Payer: University Health Alliance Commercial	$856.80

STENT ESOPHAGEAL 18MM

Facility

$4,841.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,710.96
Max. Negotiated Rate	$4,695.77
Rate for Payer: Cash Price	$2,904.60
Rate for Payer: Cash Price	$2,904.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,388.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,388.70
Rate for Payer: Health Management Network Commercial	$4,114.00
Rate for Payer: Health Management Network Commercial	$4,114.85
Rate for Payer: MDX Hawaii PPO	$4,694.80
Rate for Payer: MDX Hawaii PPO	$4,695.77
Rate for Payer: University Health Alliance Commercial	$2,710.96
Rate for Payer: University Health Alliance Commercial	$2,710.40

STENT ESOPHAGEAL 18MM

Facility

$4,841.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,468.91
Max. Negotiated Rate	$4,695.77
Rate for Payer: Cash Price	$2,904.60
Rate for Payer: Cash Price	$2,904.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,388.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,388.00
Rate for Payer: Health Management Network Commercial	$4,114.85
Rate for Payer: Health Management Network Commercial	$4,114.00
Rate for Payer: Kaiser Permanente Commercial	$3,049.20
Rate for Payer: Kaiser Permanente Commercial	$3,049.83
Rate for Payer: Kaiser Permanente Medicaid	$2,468.40
Rate for Payer: Kaiser Permanente Medicaid	$2,468.91
Rate for Payer: MDX Hawaii PPO	$4,695.77
Rate for Payer: MDX Hawaii PPO	$4,694.80
Rate for Payer: University Health Alliance Commercial	$2,710.40
Rate for Payer: University Health Alliance Commercial	$2,710.96

STENT ESOPHAGEAL 18MMX153

Facility

$4,841.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,710.96
Max. Negotiated Rate	$4,695.77
Rate for Payer: Cash Price	$2,904.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,388.70
Rate for Payer: Health Management Network Commercial	$4,114.85
Rate for Payer: MDX Hawaii PPO	$4,695.77
Rate for Payer: University Health Alliance Commercial	$2,710.96

STENT ESOPHAGEAL 18MMX153

Facility

$4,841.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,468.91
Max. Negotiated Rate	$4,695.77
Rate for Payer: Cash Price	$2,904.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,388.70
Rate for Payer: Health Management Network Commercial	$4,114.85
Rate for Payer: Kaiser Permanente Commercial	$3,049.83
Rate for Payer: Kaiser Permanente Medicaid	$2,468.91
Rate for Payer: MDX Hawaii PPO	$4,695.77
Rate for Payer: University Health Alliance Commercial	$2,710.96

STENT ESOPHAGEAL 23MM

Facility

$5,160.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,889.60
Max. Negotiated Rate	$5,005.20
Rate for Payer: Cash Price	$3,096.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,612.00
Rate for Payer: Health Management Network Commercial	$4,386.00
Rate for Payer: MDX Hawaii PPO	$5,005.20
Rate for Payer: University Health Alliance Commercial	$2,889.60

STENT ESOPHAGEAL 23MM

Facility

$5,160.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,631.60
Max. Negotiated Rate	$5,005.20
Rate for Payer: Cash Price	$3,096.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,612.00
Rate for Payer: Health Management Network Commercial	$4,386.00
Rate for Payer: Kaiser Permanente Commercial	$3,250.80
Rate for Payer: Kaiser Permanente Medicaid	$2,631.60
Rate for Payer: MDX Hawaii PPO	$5,005.20
Rate for Payer: University Health Alliance Commercial	$2,889.60

STENT GASTROINTESTINAL DUODENL

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 GASTROINTESTINAL DUODENL

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

Know your out-of-pocket cost for care.

All Charges