Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC CT SCAN OF PELVIS CONTRAST - CT PELVIS W CONTRAST

Facility

$885.00

Service Code	HCPCS 72193
Hospital Charge Code	3527219301
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	$680.15

HC CT SCAN,ORBIT/SELLA/POST FOSSA/EAR,W/O - CT ORBITS/SELLA WO IV CONT

Facility

$529.00

Service Code	HCPCS 70480
Hospital Charge Code	3517048001
Hospital Revenue Code	351
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 SCAN,ORBIT/SELLA/POST FOSSA/EAR,W/O - CT ORBITS/SELLA WO IV CONT

Facility

$529.00

Service Code	HCPCS 70480
Hospital Charge Code	3517048001
Hospital Revenue Code	351
Min. Negotiated Rate	$123.50
Max. Negotiated Rate	$515.48
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	$155.53
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	$169.03
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	$155.53
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$515.48

HC CT SCAN,PELVIS,W/O CONTRAST - CT PELVIS WO CONTRAST

Facility

$529.00

Service Code	HCPCS 72192
Hospital Charge Code	3527219201
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	$194.84
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	$211.43
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	$194.84
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$496.15

HC CT SCAN,PELVIS,W/O CONTRAST - CT PELVIS WO CONTRAST

Facility

$529.00

Service Code	HCPCS 72192
Hospital Charge Code	3527219201
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 SCANS FACE/JAW COMBO - CT SINUS FACIAL BONES W WO CONTRAST

Facility

$885.00

Service Code	HCPCS 70488
Hospital Charge Code	3517048802
Hospital Revenue Code	351
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	$232.90
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	$253.12
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	$232.90
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$804.23

HC CT SCANS FACE/JAW COMBO - CT SINUS FACIAL BONES W WO CONTRAST

Facility

$885.00

Service Code	HCPCS 70488
Hospital Charge Code	3517048802
Hospital Revenue Code	351
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 SCAN SKULL COMBO - CT ORBITS/SELLA W AND WO IV CONTRAST

Facility

$885.00

Service Code	HCPCS 70482
Hospital Charge Code	3517048201
Hospital Revenue Code	351
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 SCAN SKULL COMBO - CT ORBITS/SELLA W AND WO IV CONTRAST

Facility

$885.00

Service Code	HCPCS 70482
Hospital Charge Code	3517048201
Hospital Revenue Code	351
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	$232.90
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	$253.12
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	$232.90
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$807.73

HC CT SCAN SKULL CONTRAST - CT ORBITS/SELLA W IV CONTRAST

Facility

$885.00

Service Code	HCPCS 70481
Hospital Charge Code	3517048101
Hospital Revenue Code	351
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 SCAN SKULL CONTRAST - CT ORBITS/SELLA W IV CONTRAST

Facility

$885.00

Service Code	HCPCS 70481
Hospital Charge Code	3517048101
Hospital Revenue Code	351
Min. Negotiated Rate	$186.48
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	$186.48
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	$202.46
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	$186.48
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$702.69

HC CT SCAN,SOFT TISSUE NECK,W/O CONTRAST - CT SOFT TISSUE NECK WO CONT

Facility

$529.00

Service Code	HCPCS 70490
Hospital Charge Code	3517049001
Hospital Revenue Code	351
Min. Negotiated Rate	$123.50
Max. Negotiated Rate	$514.61
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	$155.53
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	$169.03
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	$155.53
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$514.61

HC CT SCAN,SOFT TISSUE NECK,W/O CONTRAST - CT SOFT TISSUE NECK WO CONT

Facility

$529.00

Service Code	HCPCS 70490
Hospital Charge Code	3517049001
Hospital Revenue Code	351
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 SCAN,THORACIC SPINE,W/O CONTRAST - CT THORACIC SPINE WO CONTRAST

Facility

$529.00

Service Code	HCPCS 72128
Hospital Charge Code	3527212801
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 SCAN,THORACIC SPINE,W/O CONTRAST - CT THORACIC SPINE WO CONTRAST

Facility

$529.00

Service Code	HCPCS 72128
Hospital Charge Code	3527212801
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	$194.84
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	$211.43
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	$194.84
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$502.27

HC CT SCAN,THORAX,W/O CONTRAST - CT CHEST WO CONTRAST

Facility

$529.00

Service Code	HCPCS 71250
Hospital Charge Code	3527125001
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 SCAN,THORAX,W/O CONTRAST - CT CHEST WO CONTRAST

Facility

$529.00

Service Code	HCPCS 71250
Hospital Charge Code	3527125001
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	$194.84
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	$211.43
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	$194.84
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$502.27

HC CT SCAN UPPER EXTREMITY W/O DYE - CT UPPER EXT WO IV CONTRAST

Facility

$529.00

Service Code	HCPCS 73200
Hospital Charge Code	3527320010
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 SCAN UPPER EXTREMITY W/O DYE - CT UPPER EXT WO IV CONTRAST

Facility

$529.00

Service Code	HCPCS 73200
Hospital Charge Code	3527320010
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	$163.33
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	$177.42
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	$163.33
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$497.32

HC CULT AFB BLOOD SO

Facility

$91.00

Service Code	HCPCS 87116
Hospital Charge Code	3068711602
Hospital Revenue Code	306
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: MDX Hawaii PPO	$88.27

HC CULT AFB BLOOD SO

Facility

$91.00

Service Code	HCPCS 87116
Hospital Charge Code	3068711602
Hospital Revenue Code	306
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$88.27
Rate for Payer: AlohaCare Medicaid	$10.80
Rate for Payer: AlohaCare Medicare	$10.80
Rate for Payer: Cash Price	$54.60
Rate for Payer: Cash Price	$54.60
Rate for Payer: Devoted Health Medicare	$11.88
Rate for Payer: Hawaii Medical Service Association ABD	$13.63
Rate for Payer: Hawaii Medical Service Association Commercial	$13.50
Rate for Payer: Hawaii Medical Service Association Medicare	$10.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.31
Rate for Payer: Hawaii Western Management Group Commercial	$10.80
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Humana Medicare	$10.80
Rate for Payer: Kaiser Permanente Commercial	$57.33
Rate for Payer: Kaiser Permanente Medicaid	$46.41
Rate for Payer: Kaiser Permanente Medicare	$10.80
Rate for Payer: MDX Hawaii PPO	$88.27
Rate for Payer: Ohana Health Plan Medicaid	$11.88
Rate for Payer: Ohana Health Plan Medicare	$10.80
Rate for Payer: UnitedHealthcare Medicaid	$13.63
Rate for Payer: UnitedHealthcare Medicare	$10.80
Rate for Payer: University Health Alliance Commercial	$25.49

HC CULT AFB NON-BLOOD SO

Facility

$91.00

Service Code	HCPCS 87116
Hospital Charge Code	3068711601
Hospital Revenue Code	306
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$88.27
Rate for Payer: AlohaCare Medicaid	$10.80
Rate for Payer: AlohaCare Medicare	$10.80
Rate for Payer: Cash Price	$54.60
Rate for Payer: Cash Price	$54.60
Rate for Payer: Devoted Health Medicare	$11.88
Rate for Payer: Hawaii Medical Service Association ABD	$13.63
Rate for Payer: Hawaii Medical Service Association Commercial	$13.50
Rate for Payer: Hawaii Medical Service Association Medicare	$10.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.31
Rate for Payer: Hawaii Western Management Group Commercial	$10.80
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Humana Medicare	$10.80
Rate for Payer: Kaiser Permanente Commercial	$57.33
Rate for Payer: Kaiser Permanente Medicaid	$46.41
Rate for Payer: Kaiser Permanente Medicare	$10.80
Rate for Payer: MDX Hawaii PPO	$88.27
Rate for Payer: Ohana Health Plan Medicaid	$11.88
Rate for Payer: Ohana Health Plan Medicare	$10.80
Rate for Payer: UnitedHealthcare Medicaid	$13.63
Rate for Payer: UnitedHealthcare Medicare	$10.80
Rate for Payer: University Health Alliance Commercial	$25.49

HC CULT AFB NON-BLOOD SO

Facility

$91.00

Service Code	HCPCS 87116
Hospital Charge Code	3068711601
Hospital Revenue Code	306
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: MDX Hawaii PPO	$88.27

HC CULT ALL OTHER ISOL

Facility

$72.00

Service Code	HCPCS 87070
Hospital Charge Code	3068707009
Hospital Revenue Code	306
Min. Negotiated Rate	$8.62
Max. Negotiated Rate	$69.84
Rate for Payer: AlohaCare Medicaid	$8.62
Rate for Payer: AlohaCare Medicare	$8.62
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cash Price	$43.20
Rate for Payer: Devoted Health Medicare	$9.48
Rate for Payer: Hawaii Medical Service Association ABD	$11.90
Rate for Payer: Hawaii Medical Service Association Commercial	$10.78
Rate for Payer: Hawaii Medical Service Association Medicare	$8.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.50
Rate for Payer: Hawaii Western Management Group Commercial	$8.62
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Humana Medicare	$8.62
Rate for Payer: Kaiser Permanente Commercial	$45.36
Rate for Payer: Kaiser Permanente Medicaid	$36.72
Rate for Payer: Kaiser Permanente Medicare	$8.62
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: Ohana Health Plan Medicaid	$9.48
Rate for Payer: Ohana Health Plan Medicare	$8.62
Rate for Payer: UnitedHealthcare Medicaid	$11.90
Rate for Payer: UnitedHealthcare Medicare	$8.62
Rate for Payer: University Health Alliance Commercial	$22.26

HC CULT ALL OTHER ISOL

Facility

$72.00

Service Code	HCPCS 87070
Hospital Charge Code	3068707009
Hospital Revenue Code	306
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$43.20
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: MDX Hawaii PPO	$69.84

Know your out-of-pocket cost for care.

All Charges