Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CHG TRANSCATHETER BIOPSY RS&I

Professional

Both

$4,309.00

Service Code	HCPCS 75970 TC
Min. Negotiated Rate	$413.98
Max. Negotiated Rate	$3,662.65
Rate for Payer: AlohaCare Medicaid	$413.98
Rate for Payer: Cash Price	$2,585.40
Rate for Payer: Cash Price	$2,585.40
Rate for Payer: Hawaii Western Management Group Commercial	$554.51
Rate for Payer: Health Management Network Commercial	$3,662.65
Rate for Payer: Ohana Health Plan Medicaid	$413.98
Rate for Payer: UnitedHealthcare Medicaid	$413.98

CHG TRANSCATHETER BIOPSY RS&I

Professional

Both

$64.00

Service Code	HCPCS 75970 26
Min. Negotiated Rate	$36.95
Max. Negotiated Rate	$554.51
Rate for Payer: AlohaCare Medicaid	$413.98
Rate for Payer: AlohaCare Medicare	$36.95
Rate for Payer: Cash Price	$38.40
Rate for Payer: Cash Price	$38.40
Rate for Payer: Devoted Health Medicare	$40.65
Rate for Payer: Hawaii Medical Service Association Medicare	$36.95
Rate for Payer: Hawaii Western Management Group Commercial	$554.51
Rate for Payer: Health Management Network Commercial	$54.40
Rate for Payer: Kaiser Permanente Commercial	$44.34
Rate for Payer: Kaiser Permanente Medicaid	$44.34
Rate for Payer: Kaiser Permanente Medicare	$44.34
Rate for Payer: Ohana Health Plan Medicaid	$413.98
Rate for Payer: Ohana Health Plan Medicare	$36.95
Rate for Payer: UnitedHealthcare Medicaid	$413.98
Rate for Payer: UnitedHealthcare Medicare	$36.95

CHG TRANSCATHETER BIOPSY RS&I

Professional

Both

$4,373.00

Service Code	HCPCS 75970
Min. Negotiated Rate	$413.98
Max. Negotiated Rate	$3,717.05
Rate for Payer: AlohaCare Medicaid	$413.98
Rate for Payer: Cash Price	$2,623.80
Rate for Payer: Cash Price	$2,623.80
Rate for Payer: Hawaii Western Management Group Commercial	$554.51
Rate for Payer: Health Management Network Commercial	$3,717.05
Rate for Payer: Ohana Health Plan Medicaid	$413.98
Rate for Payer: UnitedHealthcare Medicaid	$413.98

CHG ULTRASONIC GUIDANCE INTRAOPERATIVE

Professional

Both

$84.02

Service Code	HCPCS 76998
Min. Negotiated Rate	$71.42
Max. Negotiated Rate	$71.42
Rate for Payer: Cash Price	$50.41
Rate for Payer: Health Management Network Commercial	$71.42

CHG UNLISTED FLUOROSCOPIC PROCEDURE

Professional

Both

$50.00

Service Code	HCPCS 76496 26
Min. Negotiated Rate	$42.50
Max. Negotiated Rate	$42.50
Rate for Payer: Cash Price	$30.00
Rate for Payer: Health Management Network Commercial	$42.50

CHG UNLISTED FLUOROSCOPIC PROCEDURE

Professional

Both

$358.00

Service Code	HCPCS 76496 TC
Min. Negotiated Rate	$304.30
Max. Negotiated Rate	$304.30
Rate for Payer: Cash Price	$214.80
Rate for Payer: Health Management Network Commercial	$304.30

CHG UNLISTED FLUOROSCOPIC PROCEDURE

Professional

Both

$408.00

Service Code	HCPCS 76496
Min. Negotiated Rate	$346.80
Max. Negotiated Rate	$346.80
Rate for Payer: Cash Price	$244.80
Rate for Payer: Health Management Network Commercial	$346.80

CHG UNLISTED PX THER RADIOLOGY CLINICAL TX PLANNING

Professional

Both

$125.00

Service Code	HCPCS 77299
Min. Negotiated Rate	$106.25
Max. Negotiated Rate	$106.25
Rate for Payer: Cash Price	$75.00
Rate for Payer: Health Management Network Commercial	$106.25

CHG UNLISTED US PROCEDURE

Professional

Both

$121.00

Service Code	HCPCS 76999
Min. Negotiated Rate	$102.85
Max. Negotiated Rate	$102.85
Rate for Payer: Cash Price	$72.60
Rate for Payer: Health Management Network Commercial	$102.85

CHG URETHROCYSTOGRAPHY RETROGRADE RS&I

Professional

Both

$962.00

Service Code	HCPCS 74450 TC
Min. Negotiated Rate	$61.21
Max. Negotiated Rate	$817.70
Rate for Payer: AlohaCare Medicaid	$61.21
Rate for Payer: Cash Price	$577.20
Rate for Payer: Cash Price	$577.20
Rate for Payer: Hawaii Western Management Group Commercial	$82.41
Rate for Payer: Health Management Network Commercial	$817.70
Rate for Payer: Ohana Health Plan Medicaid	$61.21
Rate for Payer: UnitedHealthcare Medicaid	$61.21

CHG URETHROCYSTOGRAPHY RETROGRADE RS&I

Professional

Both

$27.00

Service Code	HCPCS 74450 26
Min. Negotiated Rate	$15.63
Max. Negotiated Rate	$82.41
Rate for Payer: AlohaCare Medicaid	$61.21
Rate for Payer: AlohaCare Medicare	$15.63
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$16.20
Rate for Payer: Devoted Health Medicare	$17.19
Rate for Payer: Hawaii Medical Service Association Medicare	$15.63
Rate for Payer: Hawaii Western Management Group Commercial	$82.41
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$18.76
Rate for Payer: Kaiser Permanente Medicaid	$18.76
Rate for Payer: Kaiser Permanente Medicare	$18.76
Rate for Payer: Ohana Health Plan Medicaid	$61.21
Rate for Payer: Ohana Health Plan Medicare	$15.63
Rate for Payer: UnitedHealthcare Medicaid	$61.21
Rate for Payer: UnitedHealthcare Medicare	$15.63

CHG URETHROCYSTOGRAPHY RETROGRADE RS&I

Professional

Both

$989.00

Service Code	HCPCS 74450
Min. Negotiated Rate	$61.21
Max. Negotiated Rate	$840.65
Rate for Payer: AlohaCare Medicaid	$61.21
Rate for Payer: Cash Price	$593.40
Rate for Payer: Cash Price	$593.40
Rate for Payer: Hawaii Western Management Group Commercial	$82.41
Rate for Payer: Health Management Network Commercial	$840.65
Rate for Payer: Ohana Health Plan Medicaid	$61.21
Rate for Payer: UnitedHealthcare Medicaid	$61.21

CHG URETHROCYSTOGRAPHY VOIDING RS&I

Professional

Both

$206.00

Service Code	HCPCS 74455
Min. Negotiated Rate	$70.38
Max. Negotiated Rate	$175.10
Rate for Payer: AlohaCare Medicaid	$70.38
Rate for Payer: AlohaCare Medicare	$117.98
Rate for Payer: Cash Price	$123.60
Rate for Payer: Cash Price	$123.60
Rate for Payer: Devoted Health Medicare	$129.78
Rate for Payer: Hawaii Medical Service Association Medicare	$117.98
Rate for Payer: Hawaii Western Management Group Commercial	$87.58
Rate for Payer: Health Management Network Commercial	$175.10
Rate for Payer: Kaiser Permanente Commercial	$141.58
Rate for Payer: Kaiser Permanente Medicaid	$141.58
Rate for Payer: Kaiser Permanente Medicare	$141.58
Rate for Payer: Ohana Health Plan Medicaid	$70.38
Rate for Payer: Ohana Health Plan Medicare	$117.98
Rate for Payer: UnitedHealthcare Medicaid	$70.38
Rate for Payer: UnitedHealthcare Medicare	$117.98

CHG URETHROCYSTOGRAPHY VOIDING RS&I

Professional

Both

$179.00

Service Code	HCPCS 74455 TC
Min. Negotiated Rate	$70.38
Max. Negotiated Rate	$152.15
Rate for Payer: AlohaCare Medicaid	$70.38
Rate for Payer: AlohaCare Medicare	$101.97
Rate for Payer: Cash Price	$107.40
Rate for Payer: Cash Price	$107.40
Rate for Payer: Devoted Health Medicare	$112.17
Rate for Payer: Hawaii Medical Service Association Medicare	$101.97
Rate for Payer: Hawaii Western Management Group Commercial	$87.58
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$122.36
Rate for Payer: Kaiser Permanente Medicaid	$122.36
Rate for Payer: Kaiser Permanente Medicare	$122.36
Rate for Payer: Ohana Health Plan Medicaid	$70.38
Rate for Payer: Ohana Health Plan Medicare	$101.97
Rate for Payer: UnitedHealthcare Medicaid	$70.38
Rate for Payer: UnitedHealthcare Medicare	$101.97

CHG URETHROCYSTOGRAPHY VOIDING RS&I

Professional

Both

$27.00

Service Code	HCPCS 74455 26
Min. Negotiated Rate	$16.01
Max. Negotiated Rate	$87.58
Rate for Payer: AlohaCare Medicaid	$70.38
Rate for Payer: AlohaCare Medicare	$16.01
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$16.20
Rate for Payer: Devoted Health Medicare	$17.61
Rate for Payer: Hawaii Medical Service Association Medicare	$16.01
Rate for Payer: Hawaii Western Management Group Commercial	$87.58
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$19.21
Rate for Payer: Kaiser Permanente Medicaid	$19.21
Rate for Payer: Kaiser Permanente Medicare	$19.21
Rate for Payer: Ohana Health Plan Medicaid	$70.38
Rate for Payer: Ohana Health Plan Medicare	$16.01
Rate for Payer: UnitedHealthcare Medicaid	$70.38
Rate for Payer: UnitedHealthcare Medicare	$16.01

CHG URINALYSIS MICROSCOPIC ONLY

Professional

Both

$5.00

Service Code	HCPCS 81015
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$4.25
Rate for Payer: AlohaCare Medicaid	$4.20
Rate for Payer: AlohaCare Medicare	$3.05
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$3.00
Rate for Payer: Devoted Health Medicare	$3.35
Rate for Payer: Hawaii Medical Service Association Medicare	$3.05
Rate for Payer: Hawaii Western Management Group Commercial	$4.20
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.66
Rate for Payer: Kaiser Permanente Medicaid	$3.66
Rate for Payer: Kaiser Permanente Medicare	$3.66
Rate for Payer: Ohana Health Plan Medicaid	$4.20
Rate for Payer: Ohana Health Plan Medicare	$3.05
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: UnitedHealthcare Medicare	$3.05

CHG URINARY BLADDER RESIDUAL STUDY

Professional

Both

$130.00

Service Code	HCPCS 78730 TC
Min. Negotiated Rate	$46.48
Max. Negotiated Rate	$110.50
Rate for Payer: AlohaCare Medicaid	$46.48
Rate for Payer: AlohaCare Medicare	$74.25
Rate for Payer: Cash Price	$78.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Devoted Health Medicare	$81.67
Rate for Payer: Hawaii Medical Service Association Medicare	$74.25
Rate for Payer: Hawaii Western Management Group Commercial	$83.96
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: Kaiser Permanente Commercial	$89.10
Rate for Payer: Kaiser Permanente Medicaid	$89.10
Rate for Payer: Kaiser Permanente Medicare	$89.10
Rate for Payer: Ohana Health Plan Medicaid	$46.48
Rate for Payer: Ohana Health Plan Medicare	$74.25
Rate for Payer: UnitedHealthcare Medicaid	$46.48
Rate for Payer: UnitedHealthcare Medicare	$74.25

CHG URINARY BLADDER RESIDUAL STUDY

Professional

Both

$144.00

Service Code	HCPCS 78730
Min. Negotiated Rate	$46.48
Max. Negotiated Rate	$122.40
Rate for Payer: AlohaCare Medicaid	$46.48
Rate for Payer: AlohaCare Medicare	$82.30
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cash Price	$86.40
Rate for Payer: Devoted Health Medicare	$90.53
Rate for Payer: Hawaii Medical Service Association Medicare	$82.30
Rate for Payer: Hawaii Western Management Group Commercial	$83.96
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Kaiser Permanente Commercial	$98.76
Rate for Payer: Kaiser Permanente Medicaid	$98.76
Rate for Payer: Kaiser Permanente Medicare	$98.76
Rate for Payer: Ohana Health Plan Medicaid	$46.48
Rate for Payer: Ohana Health Plan Medicare	$82.30
Rate for Payer: UnitedHealthcare Medicaid	$46.48
Rate for Payer: UnitedHealthcare Medicare	$82.30

CHG URINARY BLADDER RESIDUAL STUDY

Professional

Both

$14.00

Service Code	HCPCS 78730 26
Min. Negotiated Rate	$8.05
Max. Negotiated Rate	$83.96
Rate for Payer: AlohaCare Medicaid	$46.48
Rate for Payer: AlohaCare Medicare	$8.05
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cash Price	$8.40
Rate for Payer: Devoted Health Medicare	$8.86
Rate for Payer: Hawaii Medical Service Association Medicare	$8.05
Rate for Payer: Hawaii Western Management Group Commercial	$83.96
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$9.66
Rate for Payer: Kaiser Permanente Medicaid	$9.66
Rate for Payer: Kaiser Permanente Medicare	$9.66
Rate for Payer: Ohana Health Plan Medicaid	$46.48
Rate for Payer: Ohana Health Plan Medicare	$8.05
Rate for Payer: UnitedHealthcare Medicaid	$46.48
Rate for Payer: UnitedHealthcare Medicare	$8.05

CHG URINE PREGNANCY TEST VISUAL COLOR CMPRSN METHS

Professional

Both

$15.00

Service Code	HCPCS 81025
Min. Negotiated Rate	$8.61
Max. Negotiated Rate	$12.75
Rate for Payer: AlohaCare Medicaid	$8.74
Rate for Payer: AlohaCare Medicare	$8.61
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$9.47
Rate for Payer: Hawaii Medical Service Association Medicare	$8.61
Rate for Payer: Hawaii Western Management Group Commercial	$8.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$10.33
Rate for Payer: Kaiser Permanente Medicaid	$10.33
Rate for Payer: Kaiser Permanente Medicare	$10.33
Rate for Payer: Ohana Health Plan Medicaid	$8.74
Rate for Payer: Ohana Health Plan Medicare	$8.61
Rate for Payer: UnitedHealthcare Medicaid	$8.74
Rate for Payer: UnitedHealthcare Medicare	$8.61

CHG URINLS DIP STICK/TABLET REAGNT NON-AUTO MICRSCPY

Professional

Both

$7.00

Service Code	HCPCS 81000
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$5.95
Rate for Payer: AlohaCare Medicaid	$4.37
Rate for Payer: AlohaCare Medicare	$4.02
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$4.20
Rate for Payer: Devoted Health Medicare	$4.42
Rate for Payer: Hawaii Medical Service Association Medicare	$4.02
Rate for Payer: Hawaii Western Management Group Commercial	$4.38
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$4.82
Rate for Payer: Kaiser Permanente Medicaid	$4.82
Rate for Payer: Kaiser Permanente Medicare	$4.82
Rate for Payer: Ohana Health Plan Medicaid	$4.37
Rate for Payer: Ohana Health Plan Medicare	$4.02
Rate for Payer: UnitedHealthcare Medicaid	$4.37
Rate for Payer: UnitedHealthcare Medicare	$4.02

CHG URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY

Professional

Both

$4.00

Service Code	HCPCS 81003
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$3.40
Rate for Payer: AlohaCare Medicaid	$3.10
Rate for Payer: AlohaCare Medicare	$2.25
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$2.48
Rate for Payer: Hawaii Medical Service Association Medicare	$2.25
Rate for Payer: Hawaii Western Management Group Commercial	$3.10
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$2.70
Rate for Payer: Kaiser Permanente Medicare	$2.70
Rate for Payer: Ohana Health Plan Medicaid	$3.10
Rate for Payer: Ohana Health Plan Medicare	$2.25
Rate for Payer: UnitedHealthcare Medicaid	$3.10
Rate for Payer: UnitedHealthcare Medicare	$2.25

CHG URNLS DIP STICK/TABLET RGNT NON-AUTO W/O MICRSCP

Professional

Both

$6.00

Service Code	HCPCS 81002
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$5.10
Rate for Payer: AlohaCare Medicaid	$3.54
Rate for Payer: AlohaCare Medicare	$3.48
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$3.60
Rate for Payer: Devoted Health Medicare	$3.83
Rate for Payer: Hawaii Medical Service Association Medicare	$3.48
Rate for Payer: Hawaii Western Management Group Commercial	$3.55
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$4.18
Rate for Payer: Kaiser Permanente Medicaid	$4.18
Rate for Payer: Kaiser Permanente Medicare	$4.18
Rate for Payer: Ohana Health Plan Medicaid	$3.54
Rate for Payer: Ohana Health Plan Medicare	$3.48
Rate for Payer: UnitedHealthcare Medicaid	$3.54
Rate for Payer: UnitedHealthcare Medicare	$3.48

CHG UROGRAPHY IV W/WO KUB W/WO TOMOGRAPHY

Professional

Both

$39.00

Service Code	HCPCS 74400 26
Min. Negotiated Rate	$23.07
Max. Negotiated Rate	$100.84
Rate for Payer: AlohaCare Medicaid	$90.90
Rate for Payer: AlohaCare Medicare	$23.07
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Devoted Health Medicare	$25.38
Rate for Payer: Hawaii Medical Service Association Medicare	$23.07
Rate for Payer: Hawaii Western Management Group Commercial	$100.84
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Kaiser Permanente Commercial	$27.68
Rate for Payer: Kaiser Permanente Medicaid	$27.68
Rate for Payer: Kaiser Permanente Medicare	$27.68
Rate for Payer: Ohana Health Plan Medicaid	$90.90
Rate for Payer: Ohana Health Plan Medicare	$23.07
Rate for Payer: UnitedHealthcare Medicaid	$90.90
Rate for Payer: UnitedHealthcare Medicare	$23.07

CHG UROGRAPHY IV W/WO KUB W/WO TOMOGRAPHY

Professional

Both

$411.00

Service Code	HCPCS 74400 TC
Min. Negotiated Rate	$90.90
Max. Negotiated Rate	$349.35
Rate for Payer: AlohaCare Medicaid	$90.90
Rate for Payer: AlohaCare Medicare	$123.81
Rate for Payer: Cash Price	$246.60
Rate for Payer: Cash Price	$246.60
Rate for Payer: Devoted Health Medicare	$136.19
Rate for Payer: Hawaii Medical Service Association Medicare	$123.81
Rate for Payer: Hawaii Western Management Group Commercial	$100.84
Rate for Payer: Health Management Network Commercial	$349.35
Rate for Payer: Kaiser Permanente Commercial	$148.57
Rate for Payer: Kaiser Permanente Medicaid	$148.57
Rate for Payer: Kaiser Permanente Medicare	$148.57
Rate for Payer: Ohana Health Plan Medicaid	$90.90
Rate for Payer: Ohana Health Plan Medicare	$123.81
Rate for Payer: UnitedHealthcare Medicaid	$90.90
Rate for Payer: UnitedHealthcare Medicare	$123.81

Know your out-of-pocket cost for care.

All Charges