Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC GATED HEART PLANAR SINGLE

Facility

$1,999.00

Service Code	HCPCS 78472
Hospital Charge Code	3417847201
Hospital Revenue Code	341
Min. Negotiated Rate	$1,699.15
Max. Negotiated Rate	$1,939.03
Rate for Payer: Cash Price	$1,199.40
Rate for Payer: Health Management Network Commercial	$1,699.15
Rate for Payer: MDX Hawaii PPO	$1,939.03

HC GATED HEART PLANAR SINGLE - NM HEART BLOOD POOL MUGA WITH RVEF

Facility

$1,999.00

Service Code	HCPCS 78472
Hospital Charge Code	3417847202
Hospital Revenue Code	341
Min. Negotiated Rate	$1,699.15
Max. Negotiated Rate	$1,939.03
Rate for Payer: Cash Price	$1,199.40
Rate for Payer: Health Management Network Commercial	$1,699.15
Rate for Payer: MDX Hawaii PPO	$1,939.03

HC GATED HEART PLANAR SINGLE - NM HEART BLOOD POOL MUGA WITH RVEF

Facility

$1,999.00

Service Code	HCPCS 78472
Hospital Charge Code	3417847202
Hospital Revenue Code	341
Min. Negotiated Rate	$181.81
Max. Negotiated Rate	$1,939.03
Rate for Payer: AlohaCare Medicaid	$472.27
Rate for Payer: AlohaCare Medicare	$472.27
Rate for Payer: Cash Price	$1,199.40
Rate for Payer: Cash Price	$1,199.40
Rate for Payer: Devoted Health Medicare	$519.50
Rate for Payer: Hawaii Medical Service Association ABD	$181.81
Rate for Payer: Hawaii Medical Service Association Commercial	$590.34
Rate for Payer: Hawaii Medical Service Association Medicare	$472.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$197.26
Rate for Payer: Hawaii Western Management Group Commercial	$472.27
Rate for Payer: Health Management Network Commercial	$1,699.15
Rate for Payer: Humana Medicare	$472.27
Rate for Payer: Kaiser Permanente Commercial	$1,259.37
Rate for Payer: Kaiser Permanente Medicaid	$1,019.49
Rate for Payer: Kaiser Permanente Medicare	$472.27
Rate for Payer: MDX Hawaii PPO	$1,939.03
Rate for Payer: Ohana Health Plan Medicaid	$519.50
Rate for Payer: Ohana Health Plan Medicare	$472.27
Rate for Payer: UnitedHealthcare Medicaid	$181.81
Rate for Payer: UnitedHealthcare Medicare	$472.27
Rate for Payer: University Health Alliance Commercial	$553.93

HC GENERAL ANESTHESIA EA ADDL MINUTE

Facility

$42.00

Hospital Charge Code	3700000002
Hospital Revenue Code	370
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$26.46
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: University Health Alliance Commercial	$30.61

HC GENERAL ANESTHESIA EA ADDL MINUTE

Facility

$42.00

Hospital Charge Code	3700000002
Hospital Revenue Code	370
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: MDX Hawaii PPO	$40.74

HC GENERAL ANESTHESIA INITIAL 15 MIN

Facility

$783.00

Hospital Charge Code	3700000001
Hospital Revenue Code	370
Min. Negotiated Rate	$399.33
Max. Negotiated Rate	$759.51
Rate for Payer: Cash Price	$469.80
Rate for Payer: Hawaii Western Management Group Commercial	$743.85
Rate for Payer: Health Management Network Commercial	$665.55
Rate for Payer: Kaiser Permanente Commercial	$493.29
Rate for Payer: Kaiser Permanente Medicaid	$399.33
Rate for Payer: MDX Hawaii PPO	$759.51
Rate for Payer: University Health Alliance Commercial	$570.73

HC GENERAL ANESTHESIA INITIAL 15 MIN

Facility

$783.00

Hospital Charge Code	3700000001
Hospital Revenue Code	370
Min. Negotiated Rate	$665.55
Max. Negotiated Rate	$759.51
Rate for Payer: Cash Price	$469.80
Rate for Payer: Health Management Network Commercial	$665.55
Rate for Payer: MDX Hawaii PPO	$759.51

HC GLIADIN AB QT SO

Facility

$101.00

Service Code	HCPCS 86258
Hospital Charge Code	3018625801
Hospital Revenue Code	301
Min. Negotiated Rate	$6.92
Max. Negotiated Rate	$97.97
Rate for Payer: AlohaCare Medicaid	$12.05
Rate for Payer: AlohaCare Medicare	$12.05
Rate for Payer: Cash Price	$60.60
Rate for Payer: Cash Price	$60.60
Rate for Payer: Devoted Health Medicare	$13.26
Rate for Payer: Hawaii Medical Service Association ABD	$15.95
Rate for Payer: Hawaii Medical Service Association Commercial	$15.06
Rate for Payer: Hawaii Medical Service Association Medicare	$12.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.75
Rate for Payer: Hawaii Western Management Group Commercial	$12.05
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$12.05
Rate for Payer: Kaiser Permanente Commercial	$63.63
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$12.05
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$13.26
Rate for Payer: Ohana Health Plan Medicare	$12.05
Rate for Payer: UnitedHealthcare Medicaid	$6.92
Rate for Payer: UnitedHealthcare Medicare	$12.05
Rate for Payer: University Health Alliance Commercial	$73.62

HC GLIADIN AB QT SO

Facility

$101.00

Service Code	HCPCS 86258
Hospital Charge Code	3018625801
Hospital Revenue Code	301
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$60.60
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: MDX Hawaii PPO	$97.97

HC GLUCOSE BLOOD REAGENT STRIP

Facility

$42.00

Service Code	HCPCS 82948
Hospital Charge Code	3018294801
Hospital Revenue Code	301
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: MDX Hawaii PPO	$40.74

HC GLUCOSE BLOOD REAGENT STRIP

Facility

$42.00

Service Code	HCPCS 82948
Hospital Charge Code	3018294801
Hospital Revenue Code	301
Min. Negotiated Rate	$4.37
Max. Negotiated Rate	$40.74
Rate for Payer: AlohaCare Medicaid	$5.04
Rate for Payer: AlohaCare Medicare	$5.04
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cash Price	$25.20
Rate for Payer: Devoted Health Medicare	$5.54
Rate for Payer: Hawaii Medical Service Association ABD	$4.37
Rate for Payer: Hawaii Medical Service Association Commercial	$6.30
Rate for Payer: Hawaii Medical Service Association Medicare	$5.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.59
Rate for Payer: Hawaii Western Management Group Commercial	$5.04
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Humana Medicare	$5.04
Rate for Payer: Kaiser Permanente Commercial	$26.46
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: Kaiser Permanente Medicare	$5.04
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: Ohana Health Plan Medicaid	$5.54
Rate for Payer: Ohana Health Plan Medicare	$5.04
Rate for Payer: UnitedHealthcare Medicaid	$4.37
Rate for Payer: UnitedHealthcare Medicare	$5.04
Rate for Payer: University Health Alliance Commercial	$8.20

HC GLUCOSE BLOOD TEST WITH DEVICE - POCT GLUCOSE

Facility

$28.00

Service Code	HCPCS 82962 QW
Hospital Charge Code	3018296201
Hospital Revenue Code	301
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: MDX Hawaii PPO	$27.16

HC GLUCOSE BLOOD TEST WITH DEVICE - POCT GLUCOSE

Facility

$28.00

Service Code	HCPCS 82962 QW
Hospital Charge Code	3018296201
Hospital Revenue Code	301
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Hawaii Medical Service Association ABD	$2.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.10
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$17.64
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: UnitedHealthcare Medicaid	$2.50
Rate for Payer: University Health Alliance Commercial	$4.68

HC GLYCOSYLATED HEMOGLOBIN TEST - HEMOGLOBIN A1C

Facility

$81.00

Service Code	HCPCS 83036
Hospital Charge Code	3018303601
Hospital Revenue Code	301
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$78.57
Rate for Payer: Cash Price	$48.60
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: MDX Hawaii PPO	$78.57

HC GLYCOSYLATED HEMOGLOBIN TEST - HEMOGLOBIN A1C

Facility

$81.00

Service Code	HCPCS 83036
Hospital Charge Code	3018303601
Hospital Revenue Code	301
Min. Negotiated Rate	$9.71
Max. Negotiated Rate	$78.57
Rate for Payer: AlohaCare Medicaid	$9.71
Rate for Payer: AlohaCare Medicare	$9.71
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cash Price	$48.60
Rate for Payer: Devoted Health Medicare	$10.68
Rate for Payer: Hawaii Medical Service Association ABD	$13.42
Rate for Payer: Hawaii Medical Service Association Commercial	$12.14
Rate for Payer: Hawaii Medical Service Association Medicare	$9.71
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.09
Rate for Payer: Hawaii Western Management Group Commercial	$9.71
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Humana Medicare	$9.71
Rate for Payer: Kaiser Permanente Commercial	$51.03
Rate for Payer: Kaiser Permanente Medicaid	$41.31
Rate for Payer: Kaiser Permanente Medicare	$9.71
Rate for Payer: MDX Hawaii PPO	$78.57
Rate for Payer: Ohana Health Plan Medicaid	$10.68
Rate for Payer: Ohana Health Plan Medicare	$9.71
Rate for Payer: UnitedHealthcare Medicaid	$13.42
Rate for Payer: UnitedHealthcare Medicare	$9.71
Rate for Payer: University Health Alliance Commercial	$25.09

HC GONADOTROPIN (FSH) - FSH

Facility

$156.00

Service Code	HCPCS 83001
Hospital Charge Code	3018300101
Hospital Revenue Code	301
Min. Negotiated Rate	$18.58
Max. Negotiated Rate	$151.32
Rate for Payer: AlohaCare Medicaid	$18.58
Rate for Payer: AlohaCare Medicare	$18.58
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Devoted Health Medicare	$20.44
Rate for Payer: Hawaii Medical Service Association ABD	$25.69
Rate for Payer: Hawaii Medical Service Association Commercial	$23.23
Rate for Payer: Hawaii Medical Service Association Medicare	$18.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.97
Rate for Payer: Hawaii Western Management Group Commercial	$18.58
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: Humana Medicare	$18.58
Rate for Payer: Kaiser Permanente Commercial	$98.28
Rate for Payer: Kaiser Permanente Medicaid	$79.56
Rate for Payer: Kaiser Permanente Medicare	$18.58
Rate for Payer: MDX Hawaii PPO	$151.32
Rate for Payer: Ohana Health Plan Medicaid	$20.44
Rate for Payer: Ohana Health Plan Medicare	$18.58
Rate for Payer: UnitedHealthcare Medicaid	$25.69
Rate for Payer: UnitedHealthcare Medicare	$18.58
Rate for Payer: University Health Alliance Commercial	$48.04

HC GONADOTROPIN (FSH) - FSH

Facility

$156.00

Service Code	HCPCS 83001
Hospital Charge Code	3018300101
Hospital Revenue Code	301
Min. Negotiated Rate	$132.60
Max. Negotiated Rate	$151.32
Rate for Payer: Cash Price	$93.60
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: MDX Hawaii PPO	$151.32

HC GONADOTROPIN (LH) - LUTEINIZING HORMONE

Facility

$155.00

Service Code	HCPCS 83002
Hospital Charge Code	3018300201
Hospital Revenue Code	301
Min. Negotiated Rate	$18.52
Max. Negotiated Rate	$150.35
Rate for Payer: AlohaCare Medicaid	$18.52
Rate for Payer: AlohaCare Medicare	$18.52
Rate for Payer: Cash Price	$93.00
Rate for Payer: Cash Price	$93.00
Rate for Payer: Devoted Health Medicare	$20.37
Rate for Payer: Hawaii Medical Service Association ABD	$25.60
Rate for Payer: Hawaii Medical Service Association Commercial	$23.15
Rate for Payer: Hawaii Medical Service Association Medicare	$18.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.88
Rate for Payer: Hawaii Western Management Group Commercial	$18.52
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Humana Medicare	$18.52
Rate for Payer: Kaiser Permanente Commercial	$97.65
Rate for Payer: Kaiser Permanente Medicaid	$79.05
Rate for Payer: Kaiser Permanente Medicare	$18.52
Rate for Payer: MDX Hawaii PPO	$150.35
Rate for Payer: Ohana Health Plan Medicaid	$20.37
Rate for Payer: Ohana Health Plan Medicare	$18.52
Rate for Payer: UnitedHealthcare Medicaid	$25.60
Rate for Payer: UnitedHealthcare Medicare	$18.52
Rate for Payer: University Health Alliance Commercial	$47.88

HC GONADOTROPIN (LH) - LUTEINIZING HORMONE

Facility

$155.00

Service Code	HCPCS 83002
Hospital Charge Code	3018300201
Hospital Revenue Code	301
Min. Negotiated Rate	$131.75
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$93.00
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: MDX Hawaii PPO	$150.35

HC GRAM STAIN

Facility

$36.00

Service Code	HCPCS 87205
Hospital Charge Code	3068720503
Hospital Revenue Code	306
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$4.27
Rate for Payer: AlohaCare Medicare	$4.27
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Devoted Health Medicare	$4.70
Rate for Payer: Hawaii Medical Service Association ABD	$5.90
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$4.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.20
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$4.27
Rate for Payer: Kaiser Permanente Commercial	$22.68
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$4.27
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$4.70
Rate for Payer: Ohana Health Plan Medicare	$4.27
Rate for Payer: UnitedHealthcare Medicaid	$5.90
Rate for Payer: UnitedHealthcare Medicare	$4.27
Rate for Payer: University Health Alliance Commercial	$11.03

HC GRAM STAIN

Facility

$36.00

Service Code	HCPCS 87205
Hospital Charge Code	3068720503
Hospital Revenue Code	306
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$34.92

HC GUIDANCE FOR RADIAJ TX DLVR - US GUIDANCE RADIATION THERAPY FIELDS

Facility

$290.00

Service Code	HCPCS 77387
Hospital Charge Code	3337738701
Hospital Revenue Code	333
Min. Negotiated Rate	$246.50
Max. Negotiated Rate	$281.30
Rate for Payer: Cash Price	$174.00
Rate for Payer: Health Management Network Commercial	$246.50
Rate for Payer: MDX Hawaii PPO	$281.30

HC GUIDANCE FOR RADIAJ TX DLVR - US GUIDANCE RADIATION THERAPY FIELDS

Facility

$290.00

Service Code	HCPCS 77387
Hospital Charge Code	3337738701
Hospital Revenue Code	333
Min. Negotiated Rate	$96.56
Max. Negotiated Rate	$281.30
Rate for Payer: Cash Price	$174.00
Rate for Payer: Cash Price	$174.00
Rate for Payer: Hawaii Medical Service Association ABD	$96.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$116.13
Rate for Payer: Hawaii Western Management Group Commercial	$275.50
Rate for Payer: Health Management Network Commercial	$246.50
Rate for Payer: Kaiser Permanente Commercial	$182.70
Rate for Payer: Kaiser Permanente Medicaid	$147.90
Rate for Payer: MDX Hawaii PPO	$281.30
Rate for Payer: University Health Alliance Commercial	$211.38

HC HBA1/HBA2 GENE - GENE TEST BETA-THALASSEMIA

Facility

$858.00

Service Code	HCPCS 81257
Hospital Charge Code	3008125701
Hospital Revenue Code	300
Min. Negotiated Rate	$729.30
Max. Negotiated Rate	$832.26
Rate for Payer: Cash Price	$514.80
Rate for Payer: Health Management Network Commercial	$729.30
Rate for Payer: MDX Hawaii PPO	$832.26

HC HBA1/HBA2 GENE - GENE TEST BETA-THALASSEMIA

Facility

$858.00

Service Code	HCPCS 81257
Hospital Charge Code	3008125701
Hospital Revenue Code	300
Min. Negotiated Rate	$76.70
Max. Negotiated Rate	$832.26
Rate for Payer: AlohaCare Medicaid	$102.26
Rate for Payer: AlohaCare Medicare	$102.26
Rate for Payer: Cash Price	$514.80
Rate for Payer: Cash Price	$514.80
Rate for Payer: Devoted Health Medicare	$112.49
Rate for Payer: Hawaii Medical Service Association ABD	$178.42
Rate for Payer: Hawaii Medical Service Association Commercial	$127.83
Rate for Payer: Hawaii Medical Service Association Medicare	$102.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$178.42
Rate for Payer: Hawaii Western Management Group Commercial	$102.26
Rate for Payer: Health Management Network Commercial	$729.30
Rate for Payer: Humana Medicare	$102.26
Rate for Payer: Kaiser Permanente Commercial	$540.54
Rate for Payer: Kaiser Permanente Medicaid	$437.58
Rate for Payer: Kaiser Permanente Medicare	$102.26
Rate for Payer: MDX Hawaii PPO	$832.26
Rate for Payer: Ohana Health Plan Medicaid	$112.49
Rate for Payer: Ohana Health Plan Medicare	$102.26
Rate for Payer: UnitedHealthcare Medicaid	$76.70
Rate for Payer: UnitedHealthcare Medicare	$102.26
Rate for Payer: University Health Alliance Commercial	$338.96

Know your out-of-pocket cost for care.

All Charges