Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC INJECTION PROCEDURE MYELOGRAPHY/CT LUMBAR

Facility

$1,398.00

Service Code	HCPCS 62284
Hospital Charge Code	3616228401
Hospital Revenue Code	361
Min. Negotiated Rate	$1,188.30
Max. Negotiated Rate	$1,356.06
Rate for Payer: Cash Price	$838.80
Rate for Payer: Health Management Network Commercial	$1,188.30
Rate for Payer: MDX Hawaii PPO	$1,356.06

HC INJECTION PROC,EXTREMITY,VENOGRAPHY

Facility

$1,586.00

Service Code	HCPCS 36005
Hospital Charge Code	3613600501
Hospital Revenue Code	361
Min. Negotiated Rate	$38.41
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$951.60
Rate for Payer: Cash Price	$951.60
Rate for Payer: Cash Price	$951.60
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 Non-ABD	$496.75
Rate for Payer: Health Management Network Commercial	$1,348.10
Rate for Payer: Kaiser Permanente Commercial	$999.18
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$1,538.42
Rate for Payer: UnitedHealthcare Medicaid	$38.41
Rate for Payer: University Health Alliance Commercial	$1,156.04

HC INJECTION PROC,EXTREMITY,VENOGRAPHY

Facility

$1,586.00

Service Code	HCPCS 36005
Hospital Charge Code	3613600501
Hospital Revenue Code	361
Min. Negotiated Rate	$1,348.10
Max. Negotiated Rate	$1,538.42
Rate for Payer: Cash Price	$951.60
Rate for Payer: Health Management Network Commercial	$1,348.10
Rate for Payer: MDX Hawaii PPO	$1,538.42

HC INJECTION RX EXTREMITY PSEUDOANEURYSM

Facility

$2,460.00

Service Code	HCPCS 36002
Hospital Charge Code	3613600201
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$741.06
Rate for Payer: AlohaCare Medicare	$741.06
Rate for Payer: Cash Price	$1,476.00
Rate for Payer: Cash Price	$1,476.00
Rate for Payer: Cash Price	$1,476.00
Rate for Payer: Devoted Health Medicare	$815.17
Rate for Payer: Hawaii Medical Service Association Commercial	$926.33
Rate for Payer: Hawaii Medical Service Association Medicare	$741.06
Rate for Payer: Health Management Network Commercial	$2,091.00
Rate for Payer: Humana Medicare	$741.06
Rate for Payer: Kaiser Permanente Commercial	$1,549.80
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$741.06
Rate for Payer: MDX Hawaii PPO	$2,386.20
Rate for Payer: Ohana Health Plan Medicaid	$815.17
Rate for Payer: Ohana Health Plan Medicare	$741.06
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$741.06
Rate for Payer: University Health Alliance Commercial	$1,793.09

HC INJECTION RX EXTREMITY PSEUDOANEURYSM

Facility

$2,460.00

Service Code	HCPCS 36002
Hospital Charge Code	3613600201
Hospital Revenue Code	361
Min. Negotiated Rate	$2,091.00
Max. Negotiated Rate	$2,386.20
Rate for Payer: Cash Price	$1,476.00
Rate for Payer: Health Management Network Commercial	$2,091.00
Rate for Payer: MDX Hawaii PPO	$2,386.20

HC INJECTION,SACROILIAC JOINT

Facility

$1,826.00

Service Code	HCPCS 27096
Hospital Charge Code	3502709601
Hospital Revenue Code	350
Min. Negotiated Rate	$42.43
Max. Negotiated Rate	$4,035.20
Rate for Payer: Cash Price	$1,095.60
Rate for Payer: Cash Price	$1,095.60
Rate for Payer: Cash Price	$1,095.60
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 Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$1,734.70
Rate for Payer: Health Management Network Commercial	$1,552.10
Rate for Payer: Kaiser Permanente Commercial	$1,150.38
Rate for Payer: Kaiser Permanente Medicaid	$931.26
Rate for Payer: MDX Hawaii PPO	$1,771.22
Rate for Payer: UnitedHealthcare Medicaid	$42.43
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC INJECTION,SACROILIAC JOINT

Facility

$1,826.00

Service Code	HCPCS 27096
Hospital Charge Code	3502709601
Hospital Revenue Code	350
Min. Negotiated Rate	$1,552.10
Max. Negotiated Rate	$1,771.22
Rate for Payer: Cash Price	$1,095.60
Rate for Payer: Health Management Network Commercial	$1,552.10
Rate for Payer: MDX Hawaii PPO	$1,771.22

HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; VAGUS NERVE

Facility

$1,150.00

Service Code	HCPCS 64408
Hospital Charge Code	4506440801
Hospital Revenue Code	450
Min. Negotiated Rate	$362.62
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$362.62
Rate for Payer: AlohaCare Medicare	$362.62
Rate for Payer: Cash Price	$690.00
Rate for Payer: Cash Price	$690.00
Rate for Payer: Cash Price	$690.00
Rate for Payer: Cash Price	$690.00
Rate for Payer: Devoted Health Medicare	$398.88
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	$362.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,092.50
Rate for Payer: Health Management Network Commercial	$977.50
Rate for Payer: Humana Medicare	$362.62
Rate for Payer: Kaiser Permanente Commercial	$724.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$362.62
Rate for Payer: MDX Hawaii PPO	$1,115.50
Rate for Payer: Ohana Health Plan Medicaid	$398.88
Rate for Payer: Ohana Health Plan Medicare	$362.62
Rate for Payer: UnitedHealthcare Medicare	$362.62
Rate for Payer: University Health Alliance Commercial	$838.24

HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; VAGUS NERVE

Facility

$1,150.00

Service Code	HCPCS 64408
Hospital Charge Code	4506440801
Hospital Revenue Code	450
Min. Negotiated Rate	$977.50
Max. Negotiated Rate	$1,115.50
Rate for Payer: Cash Price	$690.00
Rate for Payer: Health Management Network Commercial	$977.50
Rate for Payer: MDX Hawaii PPO	$1,115.50

HC INJECTION,THERAP/PROPH/DIAGNOST, IM OR SUBCUT

Facility

$368.00

Service Code	HCPCS 96372
Hospital Charge Code	9409637201
Hospital Revenue Code	940
Min. Negotiated Rate	$13.87
Max. Negotiated Rate	$356.96
Rate for Payer: AlohaCare Medicaid	$85.06
Rate for Payer: AlohaCare Medicare	$85.06
Rate for Payer: Cash Price	$220.80
Rate for Payer: Cash Price	$220.80
Rate for Payer: Devoted Health Medicare	$93.57
Rate for Payer: Hawaii Medical Service Association Commercial	$106.33
Rate for Payer: Hawaii Medical Service Association Medicare	$85.06
Rate for Payer: Hawaii Western Management Group Commercial	$349.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Humana Medicare	$85.06
Rate for Payer: Kaiser Permanente Commercial	$231.84
Rate for Payer: Kaiser Permanente Medicaid	$187.68
Rate for Payer: Kaiser Permanente Medicare	$85.06
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: Ohana Health Plan Medicaid	$93.57
Rate for Payer: Ohana Health Plan Medicare	$85.06
Rate for Payer: UnitedHealthcare Medicaid	$13.87
Rate for Payer: UnitedHealthcare Medicare	$85.06
Rate for Payer: University Health Alliance Commercial	$268.24

HC INJECTION,THERAP/PROPH/DIAGNOST, IM OR SUBCUT

Facility

$368.00

Service Code	HCPCS 96372
Hospital Charge Code	9409637201
Hospital Revenue Code	940
Min. Negotiated Rate	$312.80
Max. Negotiated Rate	$356.96
Rate for Payer: Cash Price	$220.80
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: MDX Hawaii PPO	$356.96

HC INJECTION,THERAP/PROPH/DIAGNOST, IM OR SUBCUT

Facility

$283.00

Service Code	HCPCS 96372
Hospital Charge Code	4509637201
Hospital Revenue Code	450
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$85.06
Rate for Payer: AlohaCare Medicare	$85.06
Rate for Payer: Cash Price	$169.80
Rate for Payer: Cash Price	$169.80
Rate for Payer: Cash Price	$169.80
Rate for Payer: Cash Price	$169.80
Rate for Payer: Devoted Health Medicare	$93.57
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	$85.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$268.85
Rate for Payer: Health Management Network Commercial	$240.55
Rate for Payer: Humana Medicare	$85.06
Rate for Payer: Kaiser Permanente Commercial	$178.29
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$85.06
Rate for Payer: MDX Hawaii PPO	$274.51
Rate for Payer: Ohana Health Plan Medicaid	$93.57
Rate for Payer: Ohana Health Plan Medicare	$85.06
Rate for Payer: UnitedHealthcare Medicare	$85.06
Rate for Payer: University Health Alliance Commercial	$206.28

HC INJECTION,THERAP/PROPH/DIAGNOST, IM OR SUBCUT

Facility

$283.00

Service Code	HCPCS 96372
Hospital Charge Code	4509637201
Hospital Revenue Code	450
Min. Negotiated Rate	$240.55
Max. Negotiated Rate	$274.51
Rate for Payer: Cash Price	$169.80
Rate for Payer: Health Management Network Commercial	$240.55
Rate for Payer: MDX Hawaii PPO	$274.51

HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, EA ADD, NEW DRUG

Facility

$239.00

Service Code	HCPCS 96375
Hospital Charge Code	9409637501
Hospital Revenue Code	940
Min. Negotiated Rate	$15.80
Max. Negotiated Rate	$231.83
Rate for Payer: AlohaCare Medicaid	$55.32
Rate for Payer: AlohaCare Medicare	$55.32
Rate for Payer: Cash Price	$143.40
Rate for Payer: Cash Price	$143.40
Rate for Payer: Devoted Health Medicare	$60.85
Rate for Payer: Hawaii Medical Service Association Commercial	$69.15
Rate for Payer: Hawaii Medical Service Association Medicare	$55.32
Rate for Payer: Hawaii Western Management Group Commercial	$227.05
Rate for Payer: Health Management Network Commercial	$203.15
Rate for Payer: Humana Medicare	$55.32
Rate for Payer: Kaiser Permanente Commercial	$150.57
Rate for Payer: Kaiser Permanente Medicaid	$121.89
Rate for Payer: Kaiser Permanente Medicare	$55.32
Rate for Payer: MDX Hawaii PPO	$231.83
Rate for Payer: Ohana Health Plan Medicaid	$60.85
Rate for Payer: Ohana Health Plan Medicare	$55.32
Rate for Payer: UnitedHealthcare Medicaid	$15.80
Rate for Payer: UnitedHealthcare Medicare	$55.32
Rate for Payer: University Health Alliance Commercial	$174.21

HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, EA ADD, NEW DRUG

Facility

$239.00

Service Code	HCPCS 96375
Hospital Charge Code	9409637501
Hospital Revenue Code	940
Min. Negotiated Rate	$203.15
Max. Negotiated Rate	$231.83
Rate for Payer: Cash Price	$143.40
Rate for Payer: Health Management Network Commercial	$203.15
Rate for Payer: MDX Hawaii PPO	$231.83

HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, EA ADD, NEW DRUG

Facility

$184.00

Service Code	HCPCS 96375
Hospital Charge Code	4509637501
Hospital Revenue Code	450
Min. Negotiated Rate	$55.32
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$55.32
Rate for Payer: AlohaCare Medicare	$55.32
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cash Price	$110.40
Rate for Payer: Devoted Health Medicare	$60.85
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	$55.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$174.80
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Humana Medicare	$55.32
Rate for Payer: Kaiser Permanente Commercial	$115.92
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$55.32
Rate for Payer: MDX Hawaii PPO	$178.48
Rate for Payer: Ohana Health Plan Medicaid	$60.85
Rate for Payer: Ohana Health Plan Medicare	$55.32
Rate for Payer: UnitedHealthcare Medicare	$55.32
Rate for Payer: University Health Alliance Commercial	$134.12

HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, EA ADD, NEW DRUG

Facility

$184.00

Service Code	HCPCS 96375
Hospital Charge Code	4509637501
Hospital Revenue Code	450
Min. Negotiated Rate	$156.40
Max. Negotiated Rate	$178.48
Rate for Payer: Cash Price	$110.40
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: MDX Hawaii PPO	$178.48

HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, INITIAL DRUG

Facility

$1,089.00

Service Code	HCPCS 96374
Hospital Charge Code	9409637401
Hospital Revenue Code	940
Min. Negotiated Rate	$36.88
Max. Negotiated Rate	$1,056.33
Rate for Payer: AlohaCare Medicaid	$251.28
Rate for Payer: AlohaCare Medicare	$251.28
Rate for Payer: Cash Price	$653.40
Rate for Payer: Cash Price	$653.40
Rate for Payer: Devoted Health Medicare	$276.41
Rate for Payer: Hawaii Medical Service Association Commercial	$314.10
Rate for Payer: Hawaii Medical Service Association Medicare	$251.28
Rate for Payer: Hawaii Western Management Group Commercial	$1,034.55
Rate for Payer: Health Management Network Commercial	$925.65
Rate for Payer: Humana Medicare	$251.28
Rate for Payer: Kaiser Permanente Commercial	$686.07
Rate for Payer: Kaiser Permanente Medicaid	$555.39
Rate for Payer: Kaiser Permanente Medicare	$251.28
Rate for Payer: MDX Hawaii PPO	$1,056.33
Rate for Payer: Ohana Health Plan Medicaid	$276.41
Rate for Payer: Ohana Health Plan Medicare	$251.28
Rate for Payer: UnitedHealthcare Medicaid	$36.88
Rate for Payer: UnitedHealthcare Medicare	$251.28
Rate for Payer: University Health Alliance Commercial	$793.77

HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, INITIAL DRUG

Facility

$1,089.00

Service Code	HCPCS 96374
Hospital Charge Code	9409637401
Hospital Revenue Code	940
Min. Negotiated Rate	$925.65
Max. Negotiated Rate	$1,056.33
Rate for Payer: Cash Price	$653.40
Rate for Payer: Health Management Network Commercial	$925.65
Rate for Payer: MDX Hawaii PPO	$1,056.33

HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, INITIAL DRUG

Facility

$838.00

Service Code	HCPCS 96374
Hospital Charge Code	4509637401
Hospital Revenue Code	450
Min. Negotiated Rate	$251.28
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$251.28
Rate for Payer: AlohaCare Medicare	$251.28
Rate for Payer: Cash Price	$502.80
Rate for Payer: Cash Price	$502.80
Rate for Payer: Cash Price	$502.80
Rate for Payer: Cash Price	$502.80
Rate for Payer: Devoted Health Medicare	$276.41
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	$251.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$796.10
Rate for Payer: Health Management Network Commercial	$712.30
Rate for Payer: Humana Medicare	$251.28
Rate for Payer: Kaiser Permanente Commercial	$527.94
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$251.28
Rate for Payer: MDX Hawaii PPO	$812.86
Rate for Payer: Ohana Health Plan Medicaid	$276.41
Rate for Payer: Ohana Health Plan Medicare	$251.28
Rate for Payer: UnitedHealthcare Medicare	$251.28
Rate for Payer: University Health Alliance Commercial	$610.82

HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, INITIAL DRUG

Facility

$838.00

Service Code	HCPCS 96374
Hospital Charge Code	4509637401
Hospital Revenue Code	450
Min. Negotiated Rate	$712.30
Max. Negotiated Rate	$812.86
Rate for Payer: Cash Price	$502.80
Rate for Payer: Health Management Network Commercial	$712.30
Rate for Payer: MDX Hawaii PPO	$812.86

HC INJECTION THERAPY VEIN,MULT VEINS

Facility

$1,590.00

Service Code	HCPCS 36471
Hospital Charge Code	3613647101
Hospital Revenue Code	361
Min. Negotiated Rate	$63.59
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$528.25
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	$480.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Health Management Network Commercial	$1,351.50
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Commercial	$1,001.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: MDX Hawaii PPO	$1,542.30
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicaid	$63.59
Rate for Payer: UnitedHealthcare Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$1,158.95

HC INJECTION THERAPY VEIN,MULT VEINS

Facility

$1,590.00

Service Code	HCPCS 36471
Hospital Charge Code	3613647101
Hospital Revenue Code	361
Min. Negotiated Rate	$1,351.50
Max. Negotiated Rate	$1,542.30
Rate for Payer: Cash Price	$954.00
Rate for Payer: Health Management Network Commercial	$1,351.50
Rate for Payer: MDX Hawaii PPO	$1,542.30

HC INJECTION THERAPY VEIN,ONE VEIN

Facility

$1,590.00

Service Code	HCPCS 36470
Hospital Charge Code	3613647001
Hospital Revenue Code	361
Min. Negotiated Rate	$1,351.50
Max. Negotiated Rate	$1,542.30
Rate for Payer: Cash Price	$954.00
Rate for Payer: Health Management Network Commercial	$1,351.50
Rate for Payer: MDX Hawaii PPO	$1,542.30

HC INJECTION THERAPY VEIN,ONE VEIN

Facility

$1,590.00

Service Code	HCPCS 36470
Hospital Charge Code	3613647001
Hospital Revenue Code	361
Min. Negotiated Rate	$45.53
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$528.25
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	$480.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Health Management Network Commercial	$1,351.50
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Commercial	$1,001.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: MDX Hawaii PPO	$1,542.30
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicaid	$45.53
Rate for Payer: UnitedHealthcare Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$1,158.95

Know your out-of-pocket cost for care.

All Charges