Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC CSF LEAKAGE IMAGING - NM BRAIN CEREBROSPINAL FLUID LEAK

Facility

$6,494.00

Service Code	HCPCS 78650
Hospital Charge Code	3417865001
Hospital Revenue Code	341
Min. Negotiated Rate	$152.79
Max. Negotiated Rate	$6,299.18
Rate for Payer: AlohaCare Medicaid	$1,529.43
Rate for Payer: AlohaCare Medicare	$1,529.43
Rate for Payer: Cash Price	$3,896.40
Rate for Payer: Cash Price	$3,896.40
Rate for Payer: Devoted Health Medicare	$1,682.37
Rate for Payer: Hawaii Medical Service Association ABD	$152.79
Rate for Payer: Hawaii Medical Service Association Commercial	$1,911.79
Rate for Payer: Hawaii Medical Service Association Medicare	$1,529.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$166.03
Rate for Payer: Hawaii Western Management Group Commercial	$1,529.43
Rate for Payer: Health Management Network Commercial	$5,519.90
Rate for Payer: Humana Medicare	$1,529.43
Rate for Payer: Kaiser Permanente Commercial	$4,091.22
Rate for Payer: Kaiser Permanente Medicaid	$3,311.94
Rate for Payer: Kaiser Permanente Medicare	$1,529.43
Rate for Payer: MDX Hawaii PPO	$6,299.18
Rate for Payer: Ohana Health Plan Medicaid	$1,682.37
Rate for Payer: Ohana Health Plan Medicare	$1,529.43
Rate for Payer: UnitedHealthcare Medicaid	$152.79
Rate for Payer: UnitedHealthcare Medicare	$1,529.43
Rate for Payer: University Health Alliance Commercial	$589.47

HC CSF LEAKAGE IMAGING - NM BRAIN CEREBROSPINAL FLUID LEAK

Facility

$6,494.00

Service Code	HCPCS 78650
Hospital Charge Code	3417865001
Hospital Revenue Code	341
Min. Negotiated Rate	$5,519.90
Max. Negotiated Rate	$6,299.18
Rate for Payer: Cash Price	$3,896.40
Rate for Payer: Health Management Network Commercial	$5,519.90
Rate for Payer: MDX Hawaii PPO	$6,299.18

HC CSF SHUNT EVALUATION - NM SHUNT PATENCY

Facility

$2,678.00

Service Code	HCPCS 78645
Hospital Charge Code	3417864501
Hospital Revenue Code	341
Min. Negotiated Rate	$112.93
Max. Negotiated Rate	$2,597.66
Rate for Payer: AlohaCare Medicaid	$641.43
Rate for Payer: AlohaCare Medicare	$641.43
Rate for Payer: Cash Price	$1,606.80
Rate for Payer: Cash Price	$1,606.80
Rate for Payer: Devoted Health Medicare	$705.57
Rate for Payer: Hawaii Medical Service Association ABD	$112.93
Rate for Payer: Hawaii Medical Service Association Commercial	$801.79
Rate for Payer: Hawaii Medical Service Association Medicare	$641.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$122.59
Rate for Payer: Hawaii Western Management Group Commercial	$641.43
Rate for Payer: Health Management Network Commercial	$2,276.30
Rate for Payer: Humana Medicare	$641.43
Rate for Payer: Kaiser Permanente Commercial	$1,687.14
Rate for Payer: Kaiser Permanente Medicaid	$1,365.78
Rate for Payer: Kaiser Permanente Medicare	$641.43
Rate for Payer: MDX Hawaii PPO	$2,597.66
Rate for Payer: Ohana Health Plan Medicaid	$705.57
Rate for Payer: Ohana Health Plan Medicare	$641.43
Rate for Payer: UnitedHealthcare Medicaid	$112.93
Rate for Payer: UnitedHealthcare Medicare	$641.43
Rate for Payer: University Health Alliance Commercial	$479.50

HC CSF SHUNT EVALUATION - NM SHUNT PATENCY

Facility

$2,678.00

Service Code	HCPCS 78645
Hospital Charge Code	3417864501
Hospital Revenue Code	341
Min. Negotiated Rate	$2,276.30
Max. Negotiated Rate	$2,597.66
Rate for Payer: Cash Price	$1,606.80
Rate for Payer: Health Management Network Commercial	$2,276.30
Rate for Payer: MDX Hawaii PPO	$2,597.66

HC CT ABDOMEN W/DYE - CT ABDOMEN W CONTRAST

Facility

$885.00

Service Code	HCPCS 74160
Hospital Charge Code	3527416001
Hospital Revenue Code	352
Min. Negotiated Rate	$752.25
Max. Negotiated Rate	$858.45
Rate for Payer: Cash Price	$531.00
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: MDX Hawaii PPO	$858.45

HC CT ABDOMEN W/DYE - CT ABDOMEN W CONTRAST

Facility

$885.00

Service Code	HCPCS 74160
Hospital Charge Code	3527416001
Hospital Revenue Code	352
Min. Negotiated Rate	$207.21
Max. Negotiated Rate	$858.45
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$531.00
Rate for Payer: Cash Price	$531.00
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$225.48
Rate for Payer: Hawaii Medical Service Association Commercial	$259.01
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$245.18
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$557.55
Rate for Payer: Kaiser Permanente Medicaid	$451.35
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$858.45
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$225.48
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$691.79

HC CT ABDOMEN W/O DYE - CT ABDOMEN WO CONTRAST

Facility

$529.00

Service Code	HCPCS 74150
Hospital Charge Code	3527415001
Hospital Revenue Code	352
Min. Negotiated Rate	$449.65
Max. Negotiated Rate	$513.13
Rate for Payer: Cash Price	$317.40
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: MDX Hawaii PPO	$513.13

HC CT ABDOMEN W/O DYE - CT ABDOMEN WO CONTRAST

Facility

$529.00

Service Code	HCPCS 74150
Hospital Charge Code	3527415001
Hospital Revenue Code	352
Min. Negotiated Rate	$123.50
Max. Negotiated Rate	$513.13
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$317.40
Rate for Payer: Cash Price	$317.40
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$186.48
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$202.46
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$333.27
Rate for Payer: Kaiser Permanente Medicaid	$269.79
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$513.13
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$186.48
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$505.20

HC CT ABDOMEN W/O & W/DYE - CT ABDOMEN W WO CONTRAST

Facility

$885.00

Service Code	HCPCS 74170
Hospital Charge Code	3527417001
Hospital Revenue Code	352
Min. Negotiated Rate	$752.25
Max. Negotiated Rate	$858.45
Rate for Payer: Cash Price	$531.00
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: MDX Hawaii PPO	$858.45

HC CT ABDOMEN W/O & W/DYE - CT ABDOMEN W WO CONTRAST

Facility

$885.00

Service Code	HCPCS 74170
Hospital Charge Code	3527417001
Hospital Revenue Code	352
Min. Negotiated Rate	$207.21
Max. Negotiated Rate	$858.45
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$531.00
Rate for Payer: Cash Price	$531.00
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$279.37
Rate for Payer: Hawaii Medical Service Association Commercial	$259.01
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$303.49
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$557.55
Rate for Payer: Kaiser Permanente Medicaid	$451.35
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$858.45
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$279.37
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$803.12

HC CT ABD & PELV 1/> REGNS - CT ABDOMEN PELVIS W WO CONTRAST

Facility

$1,776.00

Service Code	HCPCS 74178
Hospital Charge Code	3527417801
Hospital Revenue Code	352
Min. Negotiated Rate	$238.75
Max. Negotiated Rate	$1,722.72
Rate for Payer: AlohaCare Medicaid	$412.14
Rate for Payer: AlohaCare Medicare	$412.14
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Devoted Health Medicare	$453.35
Rate for Payer: Hawaii Medical Service Association ABD	$238.75
Rate for Payer: Hawaii Medical Service Association Commercial	$515.17
Rate for Payer: Hawaii Medical Service Association Medicare	$412.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$606.98
Rate for Payer: Hawaii Western Management Group Commercial	$412.14
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: Humana Medicare	$412.14
Rate for Payer: Kaiser Permanente Commercial	$1,118.88
Rate for Payer: Kaiser Permanente Medicaid	$905.76
Rate for Payer: Kaiser Permanente Medicare	$412.14
Rate for Payer: MDX Hawaii PPO	$1,722.72
Rate for Payer: Ohana Health Plan Medicaid	$453.35
Rate for Payer: Ohana Health Plan Medicare	$412.14
Rate for Payer: UnitedHealthcare Medicaid	$238.75
Rate for Payer: UnitedHealthcare Medicare	$412.14
Rate for Payer: University Health Alliance Commercial	$924.87

HC CT ABD & PELV 1/> REGNS - CT ABDOMEN PELVIS W WO CONTRAST

Facility

$1,776.00

Service Code	HCPCS 74178
Hospital Charge Code	3527417801
Hospital Revenue Code	352
Min. Negotiated Rate	$1,509.60
Max. Negotiated Rate	$1,722.72
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: MDX Hawaii PPO	$1,722.72

HC CT ABD & PELVIS W/O CONTRAST - CT ABDOMEN PELVIS WO CONTRAST

Facility

$1,203.00

Service Code	HCPCS 74176
Hospital Charge Code	3527417601
Hospital Revenue Code	352
Min. Negotiated Rate	$1,022.55
Max. Negotiated Rate	$1,166.91
Rate for Payer: Cash Price	$721.80
Rate for Payer: Health Management Network Commercial	$1,022.55
Rate for Payer: MDX Hawaii PPO	$1,166.91

HC CT ABD & PELVIS W/O CONTRAST - CT ABDOMEN PELVIS WO CONTRAST

Facility

$1,203.00

Service Code	HCPCS 74176
Hospital Charge Code	3527417601
Hospital Revenue Code	352
Min. Negotiated Rate	$94.66
Max. Negotiated Rate	$1,166.91
Rate for Payer: AlohaCare Medicaid	$281.87
Rate for Payer: AlohaCare Medicare	$281.87
Rate for Payer: Cash Price	$721.80
Rate for Payer: Cash Price	$721.80
Rate for Payer: Devoted Health Medicare	$310.06
Rate for Payer: Hawaii Medical Service Association ABD	$94.66
Rate for Payer: Hawaii Medical Service Association Commercial	$352.34
Rate for Payer: Hawaii Medical Service Association Medicare	$281.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$413.89
Rate for Payer: Hawaii Western Management Group Commercial	$281.87
Rate for Payer: Health Management Network Commercial	$1,022.55
Rate for Payer: Humana Medicare	$281.87
Rate for Payer: Kaiser Permanente Commercial	$757.89
Rate for Payer: Kaiser Permanente Medicaid	$613.53
Rate for Payer: Kaiser Permanente Medicare	$281.87
Rate for Payer: MDX Hawaii PPO	$1,166.91
Rate for Payer: Ohana Health Plan Medicaid	$310.06
Rate for Payer: Ohana Health Plan Medicare	$281.87
Rate for Payer: UnitedHealthcare Medicaid	$94.66
Rate for Payer: UnitedHealthcare Medicare	$281.87
Rate for Payer: University Health Alliance Commercial	$454.47

HC CT ABD & PELV W/CONTRAST - CT ABDOMEN PELVIS W CONTRAST

Facility

$1,776.00

Service Code	HCPCS 74177
Hospital Charge Code	3527417701
Hospital Revenue Code	352
Min. Negotiated Rate	$180.62
Max. Negotiated Rate	$1,722.72
Rate for Payer: AlohaCare Medicaid	$412.14
Rate for Payer: AlohaCare Medicare	$412.14
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Devoted Health Medicare	$453.35
Rate for Payer: Hawaii Medical Service Association ABD	$180.62
Rate for Payer: Hawaii Medical Service Association Commercial	$515.17
Rate for Payer: Hawaii Medical Service Association Medicare	$412.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$490.36
Rate for Payer: Hawaii Western Management Group Commercial	$412.14
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: Humana Medicare	$412.14
Rate for Payer: Kaiser Permanente Commercial	$1,118.88
Rate for Payer: Kaiser Permanente Medicaid	$905.76
Rate for Payer: Kaiser Permanente Medicare	$412.14
Rate for Payer: MDX Hawaii PPO	$1,722.72
Rate for Payer: Ohana Health Plan Medicaid	$453.35
Rate for Payer: Ohana Health Plan Medicare	$412.14
Rate for Payer: UnitedHealthcare Medicaid	$180.62
Rate for Payer: UnitedHealthcare Medicare	$412.14
Rate for Payer: University Health Alliance Commercial	$727.57

HC CT ABD & PELV W/CONTRAST - CT ABDOMEN PELVIS W CONTRAST

Facility

$1,776.00

Service Code	HCPCS 74177
Hospital Charge Code	3527417701
Hospital Revenue Code	352
Min. Negotiated Rate	$1,509.60
Max. Negotiated Rate	$1,722.72
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: MDX Hawaii PPO	$1,722.72

HC CTA LWR EXT BIL W/WO CONTRAST

Facility

$1,770.00

Service Code	HCPCS 73706
Hospital Charge Code	3527370603
Hospital Revenue Code	352
Min. Negotiated Rate	$1,504.50
Max. Negotiated Rate	$1,716.90
Rate for Payer: Cash Price	$1,062.00
Rate for Payer: Health Management Network Commercial	$1,504.50
Rate for Payer: MDX Hawaii PPO	$1,716.90

HC CTA LWR EXT BIL W/WO CONTRAST

Facility

$1,770.00

Service Code	HCPCS 73706
Hospital Charge Code	3527370603
Hospital Revenue Code	352
Min. Negotiated Rate	$207.21
Max. Negotiated Rate	$1,716.90
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$1,062.00
Rate for Payer: Cash Price	$1,062.00
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$284.73
Rate for Payer: Hawaii Medical Service Association Commercial	$259.01
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$388.44
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$1,504.50
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$1,115.10
Rate for Payer: Kaiser Permanente Medicaid	$902.70
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$1,716.90
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$284.73
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$859.34

HC CT ANGIO ABDOMINAL ARTERIES - CT ANGIO AORTA & BILAT ILIOFEMORAL RUN

Facility

$885.00

Service Code	HCPCS 75635
Hospital Charge Code	3527563501
Hospital Revenue Code	352
Min. Negotiated Rate	$752.25
Max. Negotiated Rate	$858.45
Rate for Payer: Cash Price	$531.00
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: MDX Hawaii PPO	$858.45

HC CT ANGIO ABDOMINAL ARTERIES - CT ANGIO AORTA & BILAT ILIOFEMORAL RUN

Facility

$885.00

Service Code	HCPCS 75635
Hospital Charge Code	3527563501
Hospital Revenue Code	352
Min. Negotiated Rate	$207.21
Max. Negotiated Rate	$907.28
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$531.00
Rate for Payer: Cash Price	$531.00
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$410.29
Rate for Payer: Hawaii Medical Service Association Commercial	$259.01
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$559.38
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$557.55
Rate for Payer: Kaiser Permanente Medicaid	$451.35
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$858.45
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$410.29
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$907.28

HC CT ANGIO ABDOM W/O & W/DYE - CT ANGIO AORTA

Facility

$885.00

Service Code	HCPCS 74175
Hospital Charge Code	3527417502
Hospital Revenue Code	352
Min. Negotiated Rate	$752.25
Max. Negotiated Rate	$858.45
Rate for Payer: Cash Price	$531.00
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: MDX Hawaii PPO	$858.45

HC CT ANGIO ABDOM W/O & W/DYE - CT ANGIO AORTA

Facility

$885.00

Service Code	HCPCS 74175
Hospital Charge Code	3527417502
Hospital Revenue Code	352
Min. Negotiated Rate	$207.21
Max. Negotiated Rate	$858.45
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$531.00
Rate for Payer: Cash Price	$531.00
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$311.76
Rate for Payer: Hawaii Medical Service Association Commercial	$259.01
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$424.97
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$557.55
Rate for Payer: Kaiser Permanente Medicaid	$451.35
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$858.45
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$311.76
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$858.03

HC CT ANGIO ABDOM W/O & W/DYE - CT ANGIOGRAM ABDOMEN W CONTRAST

Facility

$885.00

Service Code	HCPCS 74175
Hospital Charge Code	3527417501
Hospital Revenue Code	352
Min. Negotiated Rate	$752.25
Max. Negotiated Rate	$858.45
Rate for Payer: Cash Price	$531.00
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: MDX Hawaii PPO	$858.45

HC CT ANGIO ABDOM W/O & W/DYE - CT ANGIOGRAM ABDOMEN W CONTRAST

Facility

$885.00

Service Code	HCPCS 74175
Hospital Charge Code	3527417501
Hospital Revenue Code	352
Min. Negotiated Rate	$207.21
Max. Negotiated Rate	$858.45
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$531.00
Rate for Payer: Cash Price	$531.00
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$311.76
Rate for Payer: Hawaii Medical Service Association Commercial	$259.01
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$424.97
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$557.55
Rate for Payer: Kaiser Permanente Medicaid	$451.35
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$858.45
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$311.76
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$858.03

HC CT ANGIO ABD&PELV W/O&W/DYE - CT ANGIOGRAM ABDOMEN PELVIS W CONTRAST

Facility

$1,776.00

Service Code	HCPCS 74174
Hospital Charge Code	3527417401
Hospital Revenue Code	352
Min. Negotiated Rate	$316.18
Max. Negotiated Rate	$1,722.72
Rate for Payer: AlohaCare Medicaid	$412.14
Rate for Payer: AlohaCare Medicare	$412.14
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Devoted Health Medicare	$453.35
Rate for Payer: Hawaii Medical Service Association ABD	$316.18
Rate for Payer: Hawaii Medical Service Association Commercial	$515.17
Rate for Payer: Hawaii Medical Service Association Medicare	$412.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$430.85
Rate for Payer: Hawaii Western Management Group Commercial	$412.14
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: Humana Medicare	$412.14
Rate for Payer: Kaiser Permanente Commercial	$1,118.88
Rate for Payer: Kaiser Permanente Medicaid	$905.76
Rate for Payer: Kaiser Permanente Medicare	$412.14
Rate for Payer: MDX Hawaii PPO	$1,722.72
Rate for Payer: Ohana Health Plan Medicaid	$453.35
Rate for Payer: Ohana Health Plan Medicare	$412.14
Rate for Payer: UnitedHealthcare Medicaid	$316.18
Rate for Payer: UnitedHealthcare Medicare	$412.14
Rate for Payer: University Health Alliance Commercial	$851.02

Know your out-of-pocket cost for care.

All Charges