Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC DRUG TEST PRSMV DIR OPT OBS

Facility

$106.00

Service Code	HCPCS 80305
Hospital Charge Code	3018030501
Hospital Revenue Code	301
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: MDX Hawaii PPO	$102.82

HC DRUG TEST PRSMV DIR OPT OBS

Facility

$106.00

Service Code	HCPCS 80305
Hospital Charge Code	3018030501
Hospital Revenue Code	301
Min. Negotiated Rate	$8.98
Max. Negotiated Rate	$102.82
Rate for Payer: AlohaCare Medicaid	$12.60
Rate for Payer: AlohaCare Medicare	$12.60
Rate for Payer: Cash Price	$63.60
Rate for Payer: Cash Price	$63.60
Rate for Payer: Devoted Health Medicare	$13.86
Rate for Payer: Hawaii Medical Service Association ABD	$19.03
Rate for Payer: Hawaii Medical Service Association Commercial	$15.75
Rate for Payer: Hawaii Medical Service Association Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.11
Rate for Payer: Hawaii Western Management Group Commercial	$12.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Humana Medicare	$12.60
Rate for Payer: Kaiser Permanente Commercial	$66.78
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: Kaiser Permanente Medicare	$12.60
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: Ohana Health Plan Medicaid	$13.86
Rate for Payer: Ohana Health Plan Medicare	$12.60
Rate for Payer: UnitedHealthcare Medicaid	$8.98
Rate for Payer: UnitedHealthcare Medicare	$12.60
Rate for Payer: University Health Alliance Commercial	$27.68

HC DRUG TEST PRSMV DIR OPT OBS POCT

Facility

$106.00

Service Code	HCPCS 80305 QW
Hospital Charge Code	3018030502
Hospital Revenue Code	301
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: MDX Hawaii PPO	$102.82

HC DRUG TEST PRSMV DIR OPT OBS POCT

Facility

$106.00

Service Code	HCPCS 80305 QW
Hospital Charge Code	3018030502
Hospital Revenue Code	301
Min. Negotiated Rate	$8.98
Max. Negotiated Rate	$102.82
Rate for Payer: AlohaCare Medicaid	$12.60
Rate for Payer: AlohaCare Medicare	$12.60
Rate for Payer: Cash Price	$63.60
Rate for Payer: Cash Price	$63.60
Rate for Payer: Devoted Health Medicare	$13.86
Rate for Payer: Hawaii Medical Service Association ABD	$19.03
Rate for Payer: Hawaii Medical Service Association Commercial	$15.75
Rate for Payer: Hawaii Medical Service Association Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.11
Rate for Payer: Hawaii Western Management Group Commercial	$12.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Humana Medicare	$12.60
Rate for Payer: Kaiser Permanente Commercial	$66.78
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: Kaiser Permanente Medicare	$12.60
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: Ohana Health Plan Medicaid	$13.86
Rate for Payer: Ohana Health Plan Medicare	$12.60
Rate for Payer: UnitedHealthcare Medicaid	$8.98
Rate for Payer: UnitedHealthcare Medicare	$12.60
Rate for Payer: University Health Alliance Commercial	$27.68

HC DUPLEX ABD/PEL VASC STUDY,LIMITD

Facility

$423.00

Service Code	HCPCS 93976
Hospital Charge Code	9219397601
Hospital Revenue Code	921
Min. Negotiated Rate	$106.34
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	$106.34
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	$125.37
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	$106.34
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$308.32

HC DUPLEX ABD/PEL VASC STUDY,LIMITD

Facility

$423.00

Service Code	HCPCS 93976
Hospital Charge Code	9219397601
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 DUPLEX EXTREM VENOUS,UNI OR LTD

Facility

$423.00

Service Code	HCPCS 93971
Hospital Charge Code	9219397101
Hospital Revenue Code	921
Min. Negotiated Rate	$93.10
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	$93.10
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	$109.94
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	$93.10
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$308.32

HC DUPLEX EXTREM VENOUS,UNI OR LTD

Facility

$423.00

Service Code	HCPCS 93971
Hospital Charge Code	9219397101
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 DUPLEX LARGE VESSEL(S),LIMITED

Facility

$423.00

Service Code	HCPCS 93979
Hospital Charge Code	9219397901
Hospital Revenue Code	921
Min. Negotiated Rate	$86.67
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	$86.67
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	$97.82
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	$86.67
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$308.32

HC DUPLEX LARGE VESSEL(S),LIMITED

Facility

$423.00

Service Code	HCPCS 93979
Hospital Charge Code	9219397901
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 DUP-SCAN HEMO COMPL

Facility

$1,924.00

Service Code	HCPCS 93985 50
Hospital Charge Code	9299398501
Hospital Revenue Code	929
Min. Negotiated Rate	$277.08
Max. Negotiated Rate	$1,866.28
Rate for Payer: Cash Price	$1,154.40
Rate for Payer: Cash Price	$1,154.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,827.80
Rate for Payer: Health Management Network Commercial	$1,635.40
Rate for Payer: Kaiser Permanente Commercial	$1,212.12
Rate for Payer: Kaiser Permanente Medicaid	$981.24
Rate for Payer: MDX Hawaii PPO	$1,866.28
Rate for Payer: UnitedHealthcare Medicaid	$277.08
Rate for Payer: University Health Alliance Commercial	$1,402.40

HC DUP-SCAN HEMO COMPL

Facility

$423.00

Service Code	HCPCS 93986
Hospital Charge Code	9299398601
Hospital Revenue Code	929
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 DUP-SCAN HEMO COMPL

Facility

$423.00

Service Code	HCPCS 93986
Hospital Charge Code	9299398601
Hospital Revenue Code	929
Min. Negotiated Rate	$123.50
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 Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
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	$162.70
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$308.32

HC DUP-SCAN HEMO COMPL

Facility

$1,924.00

Service Code	HCPCS 93985 50
Hospital Charge Code	9299398501
Hospital Revenue Code	929
Min. Negotiated Rate	$1,635.40
Max. Negotiated Rate	$1,866.28
Rate for Payer: Cash Price	$1,154.40
Rate for Payer: Health Management Network Commercial	$1,635.40
Rate for Payer: MDX Hawaii PPO	$1,866.28

HC DX LMBR SPI PNXR W/FLUOR/CT

Facility

$2,756.00

Service Code	HCPCS 62328
Hospital Charge Code	3206232801
Hospital Revenue Code	320
Min. Negotiated Rate	$2,342.60
Max. Negotiated Rate	$2,673.32
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Health Management Network Commercial	$2,342.60
Rate for Payer: MDX Hawaii PPO	$2,673.32

HC DX LMBR SPI PNXR W/FLUOR/CT

Facility

$2,756.00

Service Code	HCPCS 62328
Hospital Charge Code	3206232801
Hospital Revenue Code	320
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,673.32
Rate for Payer: AlohaCare Medicaid	$833.89
Rate for Payer: AlohaCare Medicare	$833.89
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Devoted Health Medicare	$917.28
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	$833.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$2,618.20
Rate for Payer: Health Management Network Commercial	$2,342.60
Rate for Payer: Humana Medicare	$833.89
Rate for Payer: Kaiser Permanente Commercial	$1,736.28
Rate for Payer: Kaiser Permanente Medicaid	$1,405.56
Rate for Payer: Kaiser Permanente Medicare	$833.89
Rate for Payer: MDX Hawaii PPO	$2,673.32
Rate for Payer: Ohana Health Plan Medicaid	$917.28
Rate for Payer: Ohana Health Plan Medicare	$833.89
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$833.89
Rate for Payer: University Health Alliance Commercial	$2,008.85

HC ECD ICF ROOM DAILY

Facility

$1,250.00

Hospital Charge Code	1310000001
Hospital Revenue Code	131
Min. Negotiated Rate	$694.28
Max. Negotiated Rate	$7,250.00
Rate for Payer: AlohaCare Medicaid	$694.28
Rate for Payer: Cash Price	$750.00
Rate for Payer: Cash Price	$750.00
Rate for Payer: Hawaii Medical Service Association ABD	$694.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$694.28
Rate for Payer: Hawaii Western Management Group Commercial	$7,250.00
Rate for Payer: Health Management Network Commercial	$1,062.50
Rate for Payer: Kaiser Permanente Commercial	$837.00
Rate for Payer: Kaiser Permanente Medicaid	$694.28
Rate for Payer: MDX Hawaii PPO	$1,212.50
Rate for Payer: Ohana Health Plan Medicaid	$694.28
Rate for Payer: UnitedHealthcare Medicaid	$694.28
Rate for Payer: University Health Alliance Commercial	$5,923.00

HC ECD SNF ROOM DAILY

Facility

$2,500.00

Hospital Charge Code	1310000002
Hospital Revenue Code	131
Min. Negotiated Rate	$694.28
Max. Negotiated Rate	$2,425.00
Rate for Payer: AlohaCare Medicaid	$694.28
Rate for Payer: Cash Price	$1,500.00
Rate for Payer: Cash Price	$1,500.00
Rate for Payer: Hawaii Medical Service Association ABD	$694.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$694.28
Rate for Payer: Hawaii Western Management Group Commercial	$2,350.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: Kaiser Permanente Commercial	$837.00
Rate for Payer: Kaiser Permanente Medicaid	$694.28
Rate for Payer: MDX Hawaii PPO	$2,425.00
Rate for Payer: Ohana Health Plan Medicaid	$694.28
Rate for Payer: UnitedHealthcare Medicaid	$694.28
Rate for Payer: University Health Alliance Commercial	$2,320.00

HC EC GABAPENTIN NON BLOOD SO

Facility

$960.00

Service Code	HCPCS 80355
Hospital Charge Code	3008035501
Hospital Revenue Code	300
Min. Negotiated Rate	$18.31
Max. Negotiated Rate	$931.20
Rate for Payer: Cash Price	$576.00
Rate for Payer: Cash Price	$576.00
Rate for Payer: Hawaii Medical Service Association ABD	$18.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.23
Rate for Payer: Hawaii Western Management Group Commercial	$912.00
Rate for Payer: Health Management Network Commercial	$816.00
Rate for Payer: Kaiser Permanente Commercial	$604.80
Rate for Payer: Kaiser Permanente Medicaid	$489.60
Rate for Payer: MDX Hawaii PPO	$931.20
Rate for Payer: University Health Alliance Commercial	$699.74

HC EC GABAPENTIN NON BLOOD SO

Facility

$960.00

Service Code	HCPCS 80355
Hospital Charge Code	3008035501
Hospital Revenue Code	300
Min. Negotiated Rate	$816.00
Max. Negotiated Rate	$931.20
Rate for Payer: Cash Price	$576.00
Rate for Payer: Health Management Network Commercial	$816.00
Rate for Payer: MDX Hawaii PPO	$931.20

HC ECHO 2D PROBE PLACEMENT ONLY

Facility

$2,137.00

Service Code	HCPCS 93313
Hospital Charge Code	4839331301
Hospital Revenue Code	483
Min. Negotiated Rate	$1,816.45
Max. Negotiated Rate	$2,072.89
Rate for Payer: Cash Price	$1,282.20
Rate for Payer: Health Management Network Commercial	$1,816.45
Rate for Payer: MDX Hawaii PPO	$2,072.89

HC ECHO 2D PROBE PLACEMENT ONLY

Facility

$2,137.00

Service Code	HCPCS 93313
Hospital Charge Code	4839331301
Hospital Revenue Code	483
Min. Negotiated Rate	$46.11
Max. Negotiated Rate	$2,072.89
Rate for Payer: AlohaCare Medicaid	$645.50
Rate for Payer: AlohaCare Medicare	$645.50
Rate for Payer: Cash Price	$1,282.20
Rate for Payer: Cash Price	$1,282.20
Rate for Payer: Devoted Health Medicare	$710.05
Rate for Payer: Hawaii Medical Service Association Commercial	$806.88
Rate for Payer: Hawaii Medical Service Association Medicare	$645.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,030.15
Rate for Payer: Health Management Network Commercial	$1,816.45
Rate for Payer: Humana Medicare	$645.50
Rate for Payer: Kaiser Permanente Commercial	$1,346.31
Rate for Payer: Kaiser Permanente Medicaid	$1,089.87
Rate for Payer: Kaiser Permanente Medicare	$645.50
Rate for Payer: MDX Hawaii PPO	$2,072.89
Rate for Payer: Ohana Health Plan Medicaid	$710.05
Rate for Payer: Ohana Health Plan Medicare	$645.50
Rate for Payer: UnitedHealthcare Medicaid	$46.11
Rate for Payer: UnitedHealthcare Medicare	$645.50
Rate for Payer: University Health Alliance Commercial	$1,557.66

HC ECHO 3D RENDER W/INTRP POSTPROCESS - 3D RENDERING NOT ON AN INDEP WORKSTATION

Facility

$714.00

Service Code	HCPCS 76376
Hospital Charge Code	4027637601
Hospital Revenue Code	402
Min. Negotiated Rate	$606.90
Max. Negotiated Rate	$692.58
Rate for Payer: Cash Price	$428.40
Rate for Payer: Health Management Network Commercial	$606.90
Rate for Payer: MDX Hawaii PPO	$692.58

HC ECHO 3D RENDER W/INTRP POSTPROCESS - 3D RENDERING NOT ON AN INDEP WORKSTATION

Facility

$714.00

Service Code	HCPCS 76376
Hospital Charge Code	4027637601
Hospital Revenue Code	402
Min. Negotiated Rate	$40.37
Max. Negotiated Rate	$692.58
Rate for Payer: Cash Price	$428.40
Rate for Payer: Cash Price	$428.40
Rate for Payer: Hawaii Medical Service Association ABD	$98.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$40.37
Rate for Payer: Hawaii Western Management Group Commercial	$678.30
Rate for Payer: Health Management Network Commercial	$606.90
Rate for Payer: Kaiser Permanente Commercial	$449.82
Rate for Payer: Kaiser Permanente Medicaid	$364.14
Rate for Payer: MDX Hawaii PPO	$692.58
Rate for Payer: UnitedHealthcare Medicaid	$98.13
Rate for Payer: University Health Alliance Commercial	$214.08

HC ECHO 3D RENDER W/INTRP POSTPROCESS - 3D RENDERING ON AN INDEP WORKSTATION

Facility

$1,005.00

Service Code	HCPCS 76377
Hospital Charge Code	4027637701
Hospital Revenue Code	402
Min. Negotiated Rate	$854.25
Max. Negotiated Rate	$974.85
Rate for Payer: Cash Price	$603.00
Rate for Payer: Health Management Network Commercial	$854.25
Rate for Payer: MDX Hawaii PPO	$974.85

Know your out-of-pocket cost for care.

All Charges