Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC DIFFUSING CAPACITY - CARBON MONOXIDE DIFFUSING CAPACITY

Facility

$277.00

Service Code	HCPCS 94729
Hospital Charge Code	4609472901
Hospital Revenue Code	460
Min. Negotiated Rate	$31.25
Max. Negotiated Rate	$268.69
Rate for Payer: Cash Price	$166.20
Rate for Payer: Cash Price	$166.20
Rate for Payer: Hawaii Medical Service Association ABD	$31.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$44.88
Rate for Payer: Hawaii Western Management Group Commercial	$263.15
Rate for Payer: Health Management Network Commercial	$235.45
Rate for Payer: Kaiser Permanente Commercial	$174.51
Rate for Payer: Kaiser Permanente Medicaid	$141.27
Rate for Payer: MDX Hawaii PPO	$268.69
Rate for Payer: UnitedHealthcare Medicaid	$31.25
Rate for Payer: University Health Alliance Commercial	$201.91

HC DIFFUSING CAPACITY - CARBON MONOXIDE DIFFUSING CAPACITY

Facility

$277.00

Service Code	HCPCS 94729
Hospital Charge Code	4609472901
Hospital Revenue Code	460
Min. Negotiated Rate	$235.45
Max. Negotiated Rate	$268.69
Rate for Payer: Cash Price	$166.20
Rate for Payer: Health Management Network Commercial	$235.45
Rate for Payer: MDX Hawaii PPO	$268.69

HC DILATE ESOPHAGUS - ESOPHAGEAL DILATION

Facility

$3,653.00

Service Code	HCPCS 43450
Hospital Charge Code	7504345001
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$3,543.41
Rate for Payer: AlohaCare Medicaid	$1,071.46
Rate for Payer: AlohaCare Medicare	$1,071.46
Rate for Payer: Cash Price	$2,191.80
Rate for Payer: Cash Price	$2,191.80
Rate for Payer: Cash Price	$2,191.80
Rate for Payer: Devoted Health Medicare	$1,178.61
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,071.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$3,470.35
Rate for Payer: Health Management Network Commercial	$3,105.05
Rate for Payer: Humana Medicare	$1,071.46
Rate for Payer: Kaiser Permanente Commercial	$2,301.39
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,071.46
Rate for Payer: MDX Hawaii PPO	$3,543.41
Rate for Payer: Ohana Health Plan Medicaid	$1,178.61
Rate for Payer: Ohana Health Plan Medicare	$1,071.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,071.46
Rate for Payer: University Health Alliance Commercial	$2,662.67

HC DILATE ESOPHAGUS - ESOPHAGEAL DILATION

Facility

$3,653.00

Service Code	HCPCS 43450
Hospital Charge Code	7504345001
Hospital Revenue Code	450
Min. Negotiated Rate	$3,105.05
Max. Negotiated Rate	$3,543.41
Rate for Payer: Cash Price	$2,191.80
Rate for Payer: Health Management Network Commercial	$3,105.05
Rate for Payer: MDX Hawaii PPO	$3,543.41

HC DIRECT ADMIT TO OBSERVATION

Facility

$116.00

Service Code	HCPCS G0379
Hospital Charge Code	762G037901
Hospital Revenue Code	762
Min. Negotiated Rate	$98.60
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: MDX Hawaii PPO	$112.52

HC DIRECT ADMIT TO OBSERVATION

Facility

$116.00

Service Code	HCPCS G0379
Hospital Charge Code	762G037901
Hospital Revenue Code	762
Min. Negotiated Rate	$59.16
Max. Negotiated Rate	$1,200.00
Rate for Payer: AlohaCare Medicaid	$703.53
Rate for Payer: AlohaCare Medicare	$703.53
Rate for Payer: Cash Price	$69.60
Rate for Payer: Cash Price	$69.60
Rate for Payer: Cash Price	$69.60
Rate for Payer: Devoted Health Medicare	$773.88
Rate for Payer: Hawaii Medical Service Association Commercial	$1,200.00
Rate for Payer: Hawaii Medical Service Association Medicare	$703.53
Rate for Payer: Hawaii Western Management Group Commercial	$110.20
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: Humana Medicare	$703.53
Rate for Payer: Kaiser Permanente Commercial	$73.08
Rate for Payer: Kaiser Permanente Medicaid	$59.16
Rate for Payer: Kaiser Permanente Medicare	$703.53
Rate for Payer: MDX Hawaii PPO	$112.52
Rate for Payer: Ohana Health Plan Medicaid	$773.88
Rate for Payer: Ohana Health Plan Medicare	$703.53
Rate for Payer: UnitedHealthcare Medicaid	$459.83
Rate for Payer: UnitedHealthcare Medicare	$703.53
Rate for Payer: University Health Alliance Commercial	$84.55

HC DISCOGRAPHY LUMBAR SPINE - FL LUMBAR SPINE DISCOGRAM

Facility

$7,609.00

Service Code	HCPCS 72295
Hospital Charge Code	3207229501
Hospital Revenue Code	320
Min. Negotiated Rate	$6,467.65
Max. Negotiated Rate	$7,380.73
Rate for Payer: Cash Price	$4,565.40
Rate for Payer: Health Management Network Commercial	$6,467.65
Rate for Payer: MDX Hawaii PPO	$7,380.73

HC DISCOGRAPHY LUMBAR SPINE - FL LUMBAR SPINE DISCOGRAM

Facility

$7,609.00

Service Code	HCPCS 72295
Hospital Charge Code	3207229501
Hospital Revenue Code	320
Min. Negotiated Rate	$258.66
Max. Negotiated Rate	$7,380.73
Rate for Payer: AlohaCare Medicaid	$2,306.84
Rate for Payer: AlohaCare Medicare	$2,306.84
Rate for Payer: Cash Price	$4,565.40
Rate for Payer: Cash Price	$4,565.40
Rate for Payer: Devoted Health Medicare	$2,537.52
Rate for Payer: Hawaii Medical Service Association ABD	$258.66
Rate for Payer: Hawaii Medical Service Association Commercial	$2,883.55
Rate for Payer: Hawaii Medical Service Association Medicare	$2,306.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$271.59
Rate for Payer: Hawaii Western Management Group Commercial	$2,306.84
Rate for Payer: Health Management Network Commercial	$6,467.65
Rate for Payer: Humana Medicare	$2,306.84
Rate for Payer: Kaiser Permanente Commercial	$4,793.67
Rate for Payer: Kaiser Permanente Medicaid	$3,880.59
Rate for Payer: Kaiser Permanente Medicare	$2,306.84
Rate for Payer: MDX Hawaii PPO	$7,380.73
Rate for Payer: Ohana Health Plan Medicaid	$2,537.52
Rate for Payer: Ohana Health Plan Medicare	$2,306.84
Rate for Payer: UnitedHealthcare Medicaid	$258.66
Rate for Payer: UnitedHealthcare Medicare	$2,306.84
Rate for Payer: University Health Alliance Commercial	$459.56

HC DNA ANTIBODY, NATV/2 STRAND - ANTI DNA, DOUBLE STRANDED

Facility

$115.00

Service Code	HCPCS 86225
Hospital Charge Code	3028622501
Hospital Revenue Code	302
Min. Negotiated Rate	$13.74
Max. Negotiated Rate	$111.55
Rate for Payer: AlohaCare Medicaid	$13.74
Rate for Payer: AlohaCare Medicare	$13.74
Rate for Payer: Cash Price	$69.00
Rate for Payer: Cash Price	$69.00
Rate for Payer: Devoted Health Medicare	$15.11
Rate for Payer: Hawaii Medical Service Association ABD	$18.99
Rate for Payer: Hawaii Medical Service Association Commercial	$17.18
Rate for Payer: Hawaii Medical Service Association Medicare	$13.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.94
Rate for Payer: Hawaii Western Management Group Commercial	$13.74
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Humana Medicare	$13.74
Rate for Payer: Kaiser Permanente Commercial	$72.45
Rate for Payer: Kaiser Permanente Medicaid	$58.65
Rate for Payer: Kaiser Permanente Medicare	$13.74
Rate for Payer: MDX Hawaii PPO	$111.55
Rate for Payer: Ohana Health Plan Medicaid	$15.11
Rate for Payer: Ohana Health Plan Medicare	$13.74
Rate for Payer: UnitedHealthcare Medicaid	$18.99
Rate for Payer: UnitedHealthcare Medicare	$13.74
Rate for Payer: University Health Alliance Commercial	$35.52

HC DNA ANTIBODY, NATV/2 STRAND - ANTI DNA, DOUBLE STRANDED

Facility

$115.00

Service Code	HCPCS 86225
Hospital Charge Code	3028622501
Hospital Revenue Code	302
Min. Negotiated Rate	$97.75
Max. Negotiated Rate	$111.55
Rate for Payer: Cash Price	$69.00
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: MDX Hawaii PPO	$111.55

HC DOPPLER COLOR FLOW ADD-ON

Facility

$715.00

Service Code	HCPCS 93325
Hospital Charge Code	4839332536
Hospital Revenue Code	483
Min. Negotiated Rate	$40.70
Max. Negotiated Rate	$693.55
Rate for Payer: Cash Price	$429.00
Rate for Payer: Cash Price	$429.00
Rate for Payer: Hawaii Medical Service Association ABD	$96.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$40.70
Rate for Payer: Hawaii Western Management Group Commercial	$679.25
Rate for Payer: Health Management Network Commercial	$607.75
Rate for Payer: Kaiser Permanente Commercial	$450.45
Rate for Payer: Kaiser Permanente Medicaid	$364.65
Rate for Payer: MDX Hawaii PPO	$693.55
Rate for Payer: UnitedHealthcare Medicaid	$96.84
Rate for Payer: University Health Alliance Commercial	$521.16

HC DOPPLER COLOR FLOW ADD-ON

Facility

$715.00

Service Code	HCPCS 93325
Hospital Charge Code	4839332536
Hospital Revenue Code	483
Min. Negotiated Rate	$607.75
Max. Negotiated Rate	$693.55
Rate for Payer: Cash Price	$429.00
Rate for Payer: Health Management Network Commercial	$607.75
Rate for Payer: MDX Hawaii PPO	$693.55

HC DOPPLER ECHO EXAM HEART

Facility

$523.00

Service Code	HCPCS 93321
Hospital Charge Code	4839332104
Hospital Revenue Code	483
Min. Negotiated Rate	$444.55
Max. Negotiated Rate	$507.31
Rate for Payer: Cash Price	$313.80
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: MDX Hawaii PPO	$507.31

HC DOPPLER ECHO EXAM HEART

Facility

$715.00

Service Code	HCPCS 93320
Hospital Charge Code	4839332005
Hospital Revenue Code	483
Min. Negotiated Rate	$57.09
Max. Negotiated Rate	$693.55
Rate for Payer: Cash Price	$429.00
Rate for Payer: Cash Price	$429.00
Rate for Payer: Hawaii Medical Service Association ABD	$57.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.94
Rate for Payer: Hawaii Western Management Group Commercial	$679.25
Rate for Payer: Health Management Network Commercial	$607.75
Rate for Payer: Kaiser Permanente Commercial	$450.45
Rate for Payer: Kaiser Permanente Medicaid	$364.65
Rate for Payer: MDX Hawaii PPO	$693.55
Rate for Payer: UnitedHealthcare Medicaid	$57.09
Rate for Payer: University Health Alliance Commercial	$521.16

HC DOPPLER ECHO EXAM HEART

Facility

$523.00

Service Code	HCPCS 93321
Hospital Charge Code	4839332104
Hospital Revenue Code	483
Min. Negotiated Rate	$37.31
Max. Negotiated Rate	$507.31
Rate for Payer: Cash Price	$313.80
Rate for Payer: Cash Price	$313.80
Rate for Payer: Hawaii Medical Service Association ABD	$37.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$39.18
Rate for Payer: Hawaii Western Management Group Commercial	$496.85
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: Kaiser Permanente Commercial	$329.49
Rate for Payer: Kaiser Permanente Medicaid	$266.73
Rate for Payer: MDX Hawaii PPO	$507.31
Rate for Payer: UnitedHealthcare Medicaid	$37.31
Rate for Payer: University Health Alliance Commercial	$381.21

HC DOPPLER ECHO EXAM HEART

Facility

$715.00

Service Code	HCPCS 93320
Hospital Charge Code	4839332005
Hospital Revenue Code	483
Min. Negotiated Rate	$607.75
Max. Negotiated Rate	$693.55
Rate for Payer: Cash Price	$429.00
Rate for Payer: Health Management Network Commercial	$607.75
Rate for Payer: MDX Hawaii PPO	$693.55

HC DOPPLER FETAL UMBILICAL ARTERY - US UMBILICAL ARTERY DOPPLER

Facility

$529.00

Service Code	HCPCS 76820
Hospital Charge Code	4027682001
Hospital Revenue Code	402
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 DOPPLER FETAL UMBILICAL ARTERY - US UMBILICAL ARTERY DOPPLER

Facility

$529.00

Service Code	HCPCS 76820
Hospital Charge Code	4027682001
Hospital Revenue Code	402
Min. Negotiated Rate	$51.43
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	$51.43
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	$57.07
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	$51.43
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$133.24

HC DOPPLER FLOW TESTING

Facility

$423.00

Service Code	HCPCS 93990
Hospital Charge Code	9219399002
Hospital Revenue Code	921
Min. Negotiated Rate	$102.96
Max. Negotiated Rate	$410.31
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$253.80
Rate for Payer: Cash Price	$253.80
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$102.96
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	$122.94
Rate for Payer: Hawaii Western Management Group Commercial	$401.85
Rate for Payer: Health Management Network Commercial	$359.55
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$266.49
Rate for Payer: Kaiser Permanente Medicaid	$215.73
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$410.31
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$102.96
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$308.32

HC DOPPLER FLOW TESTING

Facility

$423.00

Service Code	HCPCS 93990
Hospital Charge Code	9219399002
Hospital Revenue Code	921
Min. Negotiated Rate	$359.55
Max. Negotiated Rate	$410.31
Rate for Payer: Cash Price	$253.80
Rate for Payer: Health Management Network Commercial	$359.55
Rate for Payer: MDX Hawaii PPO	$410.31

HC DRAINAGE ABSCESS PALATE UVULA

Facility

$924.00

Service Code	HCPCS 42000
Hospital Charge Code	4504200001
Hospital Revenue Code	450
Min. Negotiated Rate	$785.40
Max. Negotiated Rate	$896.28
Rate for Payer: Cash Price	$554.40
Rate for Payer: Health Management Network Commercial	$785.40
Rate for Payer: MDX Hawaii PPO	$896.28

HC DRAINAGE ABSCESS PALATE UVULA

Facility

$924.00

Service Code	HCPCS 42000
Hospital Charge Code	4504200001
Hospital Revenue Code	450
Min. Negotiated Rate	$279.80
Max. Negotiated Rate	$2,536.00
Rate for Payer: AlohaCare Medicaid	$279.80
Rate for Payer: AlohaCare Medicare	$279.80
Rate for Payer: Cash Price	$554.40
Rate for Payer: Cash Price	$554.40
Rate for Payer: Cash Price	$554.40
Rate for Payer: Devoted Health Medicare	$307.78
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$279.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$877.80
Rate for Payer: Health Management Network Commercial	$785.40
Rate for Payer: Humana Medicare	$279.80
Rate for Payer: Kaiser Permanente Commercial	$582.12
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$279.80
Rate for Payer: MDX Hawaii PPO	$896.28
Rate for Payer: Ohana Health Plan Medicaid	$307.78
Rate for Payer: Ohana Health Plan Medicare	$279.80
Rate for Payer: UnitedHealthcare Medicare	$279.80
Rate for Payer: University Health Alliance Commercial	$673.50

HC DRAINAGE CATHETER EXCHANGE

Facility

$7,549.00

Service Code	HCPCS 49423
Hospital Charge Code	3614942301
Hospital Revenue Code	361
Min. Negotiated Rate	$6,416.65
Max. Negotiated Rate	$7,322.53
Rate for Payer: Cash Price	$4,529.40
Rate for Payer: Health Management Network Commercial	$6,416.65
Rate for Payer: MDX Hawaii PPO	$7,322.53

HC DRAINAGE CATHETER EXCHANGE

Facility

$7,549.00

Service Code	HCPCS 49423
Hospital Charge Code	3614942301
Hospital Revenue Code	361
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,322.53
Rate for Payer: AlohaCare Medicaid	$2,266.89
Rate for Payer: AlohaCare Medicare	$2,266.89
Rate for Payer: Cash Price	$4,529.40
Rate for Payer: Cash Price	$4,529.40
Rate for Payer: Cash Price	$4,529.40
Rate for Payer: Devoted Health Medicare	$2,493.58
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,266.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Health Management Network Commercial	$6,416.65
Rate for Payer: Humana Medicare	$2,266.89
Rate for Payer: Kaiser Permanente Commercial	$4,755.87
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,266.89
Rate for Payer: MDX Hawaii PPO	$7,322.53
Rate for Payer: Ohana Health Plan Medicaid	$2,493.58
Rate for Payer: Ohana Health Plan Medicare	$2,266.89
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,266.89
Rate for Payer: University Health Alliance Commercial	$5,502.47

HC DRAINAGE EXTERNAL AUDITORY CANAL, ABSCESS

Facility

$2,800.00

Service Code	HCPCS 69020
Hospital Charge Code	4506902001
Hospital Revenue Code	450
Min. Negotiated Rate	$2,380.00
Max. Negotiated Rate	$2,716.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,380.00
Rate for Payer: MDX Hawaii PPO	$2,716.00

Know your out-of-pocket cost for care.

All Charges