Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

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	$38.91
Max. Negotiated Rate	$974.85
Rate for Payer: Cash Price	$603.00
Rate for Payer: Cash Price	$603.00
Rate for Payer: Hawaii Medical Service Association ABD	$102.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$38.91
Rate for Payer: Hawaii Western Management Group Commercial	$954.75
Rate for Payer: Health Management Network Commercial	$854.25
Rate for Payer: Kaiser Permanente Commercial	$633.15
Rate for Payer: Kaiser Permanente Medicaid	$512.55
Rate for Payer: MDX Hawaii PPO	$974.85
Rate for Payer: UnitedHealthcare Medicaid	$102.78
Rate for Payer: University Health Alliance Commercial	$272.82

HC ECHO CONTRAST AGENT USED

Facility

$715.00

Service Code	HCPCS 93352
Hospital Charge Code	4839335201
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 ECHO CONTRAST AGENT USED

Facility

$715.00

Service Code	HCPCS 93352
Hospital Charge Code	4839335201
Hospital Revenue Code	483
Min. Negotiated Rate	$25.79
Max. Negotiated Rate	$693.55
Rate for Payer: Cash Price	$429.00
Rate for Payer: Cash Price	$429.00
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	$25.79
Rate for Payer: University Health Alliance Commercial	$521.16

HC ECHOGRAPHY,TRANSVAGINAL

Facility

$529.00

Service Code	HCPCS 76830
Hospital Charge Code	4027683002
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 ECHOGRAPHY,TRANSVAGINAL

Facility

$529.00

Service Code	HCPCS 76830
Hospital Charge Code	4027683002
Hospital Revenue Code	402
Min. Negotiated Rate	$50.35
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	$50.35
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	$54.65
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	$50.35
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$230.73

HC ECHOGRAPHY,TRANSVAGINAL - US PELVIS TRANSVAGINAL

Facility

$529.00

Service Code	HCPCS 76830
Hospital Charge Code	4027683001
Hospital Revenue Code	402
Min. Negotiated Rate	$50.35
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	$50.35
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	$54.65
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	$50.35
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$230.73

HC ECHOGRAPHY,TRANSVAGINAL - US PELVIS TRANSVAGINAL

Facility

$529.00

Service Code	HCPCS 76830
Hospital Charge Code	4027683001
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 ECHO GUIDE FOR BIOPSY - US GUIDANCE NEEDLE PLACEMENT

Facility

$544.00

Service Code	HCPCS 76942
Hospital Charge Code	4027694232
Hospital Revenue Code	402
Min. Negotiated Rate	$462.40
Max. Negotiated Rate	$527.68
Rate for Payer: Cash Price	$326.40
Rate for Payer: Health Management Network Commercial	$462.40
Rate for Payer: MDX Hawaii PPO	$527.68

HC ECHO GUIDE FOR BIOPSY - US GUIDANCE NEEDLE PLACEMENT

Facility

$544.00

Service Code	HCPCS 76942
Hospital Charge Code	4027694232
Hospital Revenue Code	402
Min. Negotiated Rate	$73.06
Max. Negotiated Rate	$527.68
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cash Price	$326.40
Rate for Payer: Hawaii Medical Service Association ABD	$73.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$104.75
Rate for Payer: Hawaii Western Management Group Commercial	$516.80
Rate for Payer: Health Management Network Commercial	$462.40
Rate for Payer: Kaiser Permanente Commercial	$342.72
Rate for Payer: Kaiser Permanente Medicaid	$277.44
Rate for Payer: MDX Hawaii PPO	$527.68
Rate for Payer: UnitedHealthcare Medicaid	$73.06
Rate for Payer: University Health Alliance Commercial	$361.51

HC ECHO GUIDE FOR BIOPSY - US GUIDED NEEDLE BIOPSY BONE

Facility

$544.00

Service Code	HCPCS 76942
Hospital Charge Code	4027694223
Hospital Revenue Code	402
Min. Negotiated Rate	$73.06
Max. Negotiated Rate	$527.68
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cash Price	$326.40
Rate for Payer: Hawaii Medical Service Association ABD	$73.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$104.75
Rate for Payer: Hawaii Western Management Group Commercial	$516.80
Rate for Payer: Health Management Network Commercial	$462.40
Rate for Payer: Kaiser Permanente Commercial	$342.72
Rate for Payer: Kaiser Permanente Medicaid	$277.44
Rate for Payer: MDX Hawaii PPO	$527.68
Rate for Payer: UnitedHealthcare Medicaid	$73.06
Rate for Payer: University Health Alliance Commercial	$361.51

HC ECHO GUIDE FOR BIOPSY - US GUIDED NEEDLE BIOPSY BONE

Facility

$544.00

Service Code	HCPCS 76942
Hospital Charge Code	4027694223
Hospital Revenue Code	402
Min. Negotiated Rate	$462.40
Max. Negotiated Rate	$527.68
Rate for Payer: Cash Price	$326.40
Rate for Payer: Health Management Network Commercial	$462.40
Rate for Payer: MDX Hawaii PPO	$527.68

HC ECHO HEART XTHORACIC,LIMITED

Facility

$962.00

Service Code	HCPCS 93308
Hospital Charge Code	4839330801
Hospital Revenue Code	450
Min. Negotiated Rate	$817.70
Max. Negotiated Rate	$933.14
Rate for Payer: Cash Price	$577.20
Rate for Payer: Health Management Network Commercial	$817.70
Rate for Payer: MDX Hawaii PPO	$933.14

HC ECHO HEART XTHORACIC,LIMITED

Facility

$962.00

Service Code	HCPCS 93308
Hospital Charge Code	4839330801
Hospital Revenue Code	450
Min. Negotiated Rate	$281.87
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$281.87
Rate for Payer: AlohaCare Medicare	$281.87
Rate for Payer: Cash Price	$577.20
Rate for Payer: Cash Price	$577.20
Rate for Payer: Cash Price	$577.20
Rate for Payer: Cash Price	$577.20
Rate for Payer: Devoted Health Medicare	$310.06
Rate for Payer: Hawaii Medical Service Association ABD	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$281.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$913.90
Rate for Payer: Health Management Network Commercial	$817.70
Rate for Payer: Humana Medicare	$281.87
Rate for Payer: Kaiser Permanente Commercial	$606.06
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$281.87
Rate for Payer: MDX Hawaii PPO	$933.14
Rate for Payer: Ohana Health Plan Medicaid	$310.06
Rate for Payer: Ohana Health Plan Medicare	$281.87
Rate for Payer: UnitedHealthcare Medicare	$281.87
Rate for Payer: University Health Alliance Commercial	$701.20

HC ECHO,PELVIC (NONOBSTETRIC) - US PELVIS

Facility

$529.00

Service Code	HCPCS 76856
Hospital Charge Code	4027685601
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 ECHO,PELVIC (NONOBSTETRIC) - US PELVIS

Facility

$529.00

Service Code	HCPCS 76856
Hospital Charge Code	4027685601
Hospital Revenue Code	402
Min. Negotiated Rate	$50.35
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	$50.35
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	$54.65
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	$50.35
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$231.53

HC ECHO,SCROTUM & CONTENTS - US SCROTUM

Facility

$529.00

Service Code	HCPCS 76870
Hospital Charge Code	4027687001
Hospital Revenue Code	402
Min. Negotiated Rate	$50.35
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	$50.35
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	$54.65
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	$50.35
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$228.81

HC ECHO,SCROTUM & CONTENTS - US SCROTUM

Facility

$529.00

Service Code	HCPCS 76870
Hospital Charge Code	4027687001
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 ECHO STRESS TRANSTHORASIC

Facility

$2,728.00

Service Code	HCPCS 93350
Hospital Charge Code	4839335001
Hospital Revenue Code	483
Min. Negotiated Rate	$2,318.80
Max. Negotiated Rate	$2,646.16
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Health Management Network Commercial	$2,318.80
Rate for Payer: MDX Hawaii PPO	$2,646.16

HC ECHO STRESS TRANSTHORASIC

Facility

$2,728.00

Service Code	HCPCS 93350
Hospital Charge Code	4839335001
Hospital Revenue Code	483
Min. Negotiated Rate	$58.90
Max. Negotiated Rate	$2,646.16
Rate for Payer: AlohaCare Medicaid	$645.50
Rate for Payer: AlohaCare Medicare	$645.50
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Devoted Health Medicare	$710.05
Rate for Payer: Hawaii Medical Service Association ABD	$58.90
Rate for Payer: Hawaii Medical Service Association Commercial	$806.88
Rate for Payer: Hawaii Medical Service Association Medicare	$645.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$61.85
Rate for Payer: Hawaii Western Management Group Commercial	$2,591.60
Rate for Payer: Health Management Network Commercial	$2,318.80
Rate for Payer: Humana Medicare	$645.50
Rate for Payer: Kaiser Permanente Commercial	$1,718.64
Rate for Payer: Kaiser Permanente Medicaid	$1,391.28
Rate for Payer: Kaiser Permanente Medicare	$645.50
Rate for Payer: MDX Hawaii PPO	$2,646.16
Rate for Payer: Ohana Health Plan Medicaid	$710.05
Rate for Payer: Ohana Health Plan Medicare	$645.50
Rate for Payer: UnitedHealthcare Medicaid	$58.90
Rate for Payer: UnitedHealthcare Medicare	$645.50
Rate for Payer: University Health Alliance Commercial	$1,988.44

HC ECHO TRANSESOPHAGEAL - TEE COMPLETE

Facility

$2,728.00

Service Code	HCPCS 93312
Hospital Charge Code	4839331204
Hospital Revenue Code	483
Min. Negotiated Rate	$126.66
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$645.50
Rate for Payer: AlohaCare Medicare	$645.50
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Devoted Health Medicare	$710.05
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	$645.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Hawaii Western Management Group Commercial	$2,591.60
Rate for Payer: Health Management Network Commercial	$2,318.80
Rate for Payer: Humana Medicare	$645.50
Rate for Payer: Kaiser Permanente Commercial	$1,718.64
Rate for Payer: Kaiser Permanente Medicaid	$1,391.28
Rate for Payer: Kaiser Permanente Medicare	$645.50
Rate for Payer: MDX Hawaii PPO	$2,646.16
Rate for Payer: Ohana Health Plan Medicaid	$710.05
Rate for Payer: Ohana Health Plan Medicare	$645.50
Rate for Payer: UnitedHealthcare Medicaid	$126.66
Rate for Payer: UnitedHealthcare Medicare	$645.50
Rate for Payer: University Health Alliance Commercial	$1,988.44

HC ECHO TRANSESOPHAGEAL - TEE COMPLETE

Facility

$2,728.00

Service Code	HCPCS 93312
Hospital Charge Code	4839331204
Hospital Revenue Code	483
Min. Negotiated Rate	$2,318.80
Max. Negotiated Rate	$2,646.16
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Health Management Network Commercial	$2,318.80
Rate for Payer: MDX Hawaii PPO	$2,646.16

HC ECHO TRANSTHORACIC - CONGENITAL TTE COMPLETE

Facility

$2,728.00

Service Code	HCPCS 93303
Hospital Charge Code	4839330302
Hospital Revenue Code	483
Min. Negotiated Rate	$127.90
Max. Negotiated Rate	$2,646.16
Rate for Payer: AlohaCare Medicaid	$645.50
Rate for Payer: AlohaCare Medicare	$645.50
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Devoted Health Medicare	$710.05
Rate for Payer: Hawaii Medical Service Association ABD	$127.90
Rate for Payer: Hawaii Medical Service Association Commercial	$806.88
Rate for Payer: Hawaii Medical Service Association Medicare	$645.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$134.30
Rate for Payer: Hawaii Western Management Group Commercial	$2,591.60
Rate for Payer: Health Management Network Commercial	$2,318.80
Rate for Payer: Humana Medicare	$645.50
Rate for Payer: Kaiser Permanente Commercial	$1,718.64
Rate for Payer: Kaiser Permanente Medicaid	$1,391.28
Rate for Payer: Kaiser Permanente Medicare	$645.50
Rate for Payer: MDX Hawaii PPO	$2,646.16
Rate for Payer: Ohana Health Plan Medicaid	$710.05
Rate for Payer: Ohana Health Plan Medicare	$645.50
Rate for Payer: UnitedHealthcare Medicaid	$127.90
Rate for Payer: UnitedHealthcare Medicare	$645.50
Rate for Payer: University Health Alliance Commercial	$1,988.44

HC ECHO TRANSTHORACIC - CONGENITAL TTE COMPLETE

Facility

$2,728.00

Service Code	HCPCS 93303
Hospital Charge Code	4839330302
Hospital Revenue Code	483
Min. Negotiated Rate	$2,318.80
Max. Negotiated Rate	$2,646.16
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Health Management Network Commercial	$2,318.80
Rate for Payer: MDX Hawaii PPO	$2,646.16

HC ECHO TRANSTHORACIC - CONGENITAL TTE LIMITED

Facility

$2,728.00

Service Code	HCPCS 93304
Hospital Charge Code	4839330402
Hospital Revenue Code	483
Min. Negotiated Rate	$2,318.80
Max. Negotiated Rate	$2,646.16
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Health Management Network Commercial	$2,318.80
Rate for Payer: MDX Hawaii PPO	$2,646.16

HC ECHO TRANSTHORACIC - CONGENITAL TTE LIMITED

Facility

$2,728.00

Service Code	HCPCS 93304
Hospital Charge Code	4839330402
Hospital Revenue Code	483
Min. Negotiated Rate	$64.51
Max. Negotiated Rate	$2,646.16
Rate for Payer: AlohaCare Medicaid	$645.50
Rate for Payer: AlohaCare Medicare	$645.50
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Devoted Health Medicare	$710.05
Rate for Payer: Hawaii Medical Service Association ABD	$64.51
Rate for Payer: Hawaii Medical Service Association Commercial	$806.88
Rate for Payer: Hawaii Medical Service Association Medicare	$645.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$67.74
Rate for Payer: Hawaii Western Management Group Commercial	$2,591.60
Rate for Payer: Health Management Network Commercial	$2,318.80
Rate for Payer: Humana Medicare	$645.50
Rate for Payer: Kaiser Permanente Commercial	$1,718.64
Rate for Payer: Kaiser Permanente Medicaid	$1,391.28
Rate for Payer: Kaiser Permanente Medicare	$645.50
Rate for Payer: MDX Hawaii PPO	$2,646.16
Rate for Payer: Ohana Health Plan Medicaid	$710.05
Rate for Payer: Ohana Health Plan Medicare	$645.50
Rate for Payer: UnitedHealthcare Medicaid	$64.51
Rate for Payer: UnitedHealthcare Medicare	$645.50
Rate for Payer: University Health Alliance Commercial	$1,988.44

Know your out-of-pocket cost for care.

All Charges