Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC L&D OP VISIT EP LEVEL 1

Facility

$528.00

Service Code	HCPCS 99211
Hospital Charge Code	7619921101
Hospital Revenue Code	761
Min. Negotiated Rate	$448.80
Max. Negotiated Rate	$512.16
Rate for Payer: Cash Price	$316.80
Rate for Payer: Health Management Network Commercial	$448.80
Rate for Payer: MDX Hawaii PPO	$512.16

HC L&D OP VISIT EP LEVEL 2

Facility

$574.00

Service Code	HCPCS 99212
Hospital Charge Code	7619921202
Hospital Revenue Code	761
Min. Negotiated Rate	$24.13
Max. Negotiated Rate	$556.78
Rate for Payer: Cash Price	$344.40
Rate for Payer: Cash Price	$344.40
Rate for Payer: Hawaii Western Management Group Commercial	$545.30
Rate for Payer: Health Management Network Commercial	$487.90
Rate for Payer: Kaiser Permanente Commercial	$361.62
Rate for Payer: Kaiser Permanente Medicaid	$292.74
Rate for Payer: MDX Hawaii PPO	$556.78
Rate for Payer: UnitedHealthcare Medicaid	$24.13
Rate for Payer: University Health Alliance Commercial	$418.39

HC L&D OP VISIT EP LEVEL 2

Facility

$574.00

Service Code	HCPCS 99212
Hospital Charge Code	7619921202
Hospital Revenue Code	761
Min. Negotiated Rate	$487.90
Max. Negotiated Rate	$556.78
Rate for Payer: Cash Price	$344.40
Rate for Payer: Health Management Network Commercial	$487.90
Rate for Payer: MDX Hawaii PPO	$556.78

HC L&D OP VISIT EP LEVEL 3

Facility

$627.00

Service Code	HCPCS 99213
Hospital Charge Code	7619921303
Hospital Revenue Code	761
Min. Negotiated Rate	$36.31
Max. Negotiated Rate	$608.19
Rate for Payer: Cash Price	$376.20
Rate for Payer: Cash Price	$376.20
Rate for Payer: Hawaii Western Management Group Commercial	$595.65
Rate for Payer: Health Management Network Commercial	$532.95
Rate for Payer: Kaiser Permanente Commercial	$395.01
Rate for Payer: Kaiser Permanente Medicaid	$319.77
Rate for Payer: MDX Hawaii PPO	$608.19
Rate for Payer: UnitedHealthcare Medicaid	$36.31
Rate for Payer: University Health Alliance Commercial	$457.02

HC L&D OP VISIT EP LEVEL 3

Facility

$627.00

Service Code	HCPCS 99213
Hospital Charge Code	7619921303
Hospital Revenue Code	761
Min. Negotiated Rate	$532.95
Max. Negotiated Rate	$608.19
Rate for Payer: Cash Price	$376.20
Rate for Payer: Health Management Network Commercial	$532.95
Rate for Payer: MDX Hawaii PPO	$608.19

HC L&D OP VISIT EP LEVEL 4

Facility

$680.00

Service Code	HCPCS 99214
Hospital Charge Code	7619921404
Hospital Revenue Code	761
Min. Negotiated Rate	$56.46
Max. Negotiated Rate	$659.60
Rate for Payer: Cash Price	$408.00
Rate for Payer: Cash Price	$408.00
Rate for Payer: Hawaii Western Management Group Commercial	$646.00
Rate for Payer: Health Management Network Commercial	$578.00
Rate for Payer: Kaiser Permanente Commercial	$428.40
Rate for Payer: Kaiser Permanente Medicaid	$346.80
Rate for Payer: MDX Hawaii PPO	$659.60
Rate for Payer: UnitedHealthcare Medicaid	$56.46
Rate for Payer: University Health Alliance Commercial	$495.65

HC L&D OP VISIT EP LEVEL 4

Facility

$680.00

Service Code	HCPCS 99214
Hospital Charge Code	7619921404
Hospital Revenue Code	761
Min. Negotiated Rate	$578.00
Max. Negotiated Rate	$659.60
Rate for Payer: Cash Price	$408.00
Rate for Payer: Health Management Network Commercial	$578.00
Rate for Payer: MDX Hawaii PPO	$659.60

HC L&D OP VISIT EP LEVEL 5

Facility

$761.00

Service Code	HCPCS 99215
Hospital Charge Code	7619921505
Hospital Revenue Code	761
Min. Negotiated Rate	$83.57
Max. Negotiated Rate	$738.17
Rate for Payer: Cash Price	$456.60
Rate for Payer: Cash Price	$456.60
Rate for Payer: Hawaii Western Management Group Commercial	$722.95
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Kaiser Permanente Commercial	$479.43
Rate for Payer: Kaiser Permanente Medicaid	$388.11
Rate for Payer: MDX Hawaii PPO	$738.17
Rate for Payer: UnitedHealthcare Medicaid	$83.57
Rate for Payer: University Health Alliance Commercial	$554.69

HC L&D OP VISIT EP LEVEL 5

Facility

$761.00

Service Code	HCPCS 99215
Hospital Charge Code	7619921505
Hospital Revenue Code	761
Min. Negotiated Rate	$646.85
Max. Negotiated Rate	$738.17
Rate for Payer: Cash Price	$456.60
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: MDX Hawaii PPO	$738.17

HC LEGION PNEUMO AG, DFA - LEGIONELLA PNEUMOPHILIA ANTIGEN

Facility

$131.00

Service Code	HCPCS 87278
Hospital Charge Code	3068727801
Hospital Revenue Code	306
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$127.07
Rate for Payer: AlohaCare Medicaid	$15.60
Rate for Payer: AlohaCare Medicare	$15.60
Rate for Payer: Cash Price	$78.60
Rate for Payer: Cash Price	$78.60
Rate for Payer: Devoted Health Medicare	$17.16
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$19.50
Rate for Payer: Hawaii Medical Service Association Medicare	$15.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$15.60
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Humana Medicare	$15.60
Rate for Payer: Kaiser Permanente Commercial	$82.53
Rate for Payer: Kaiser Permanente Medicaid	$66.81
Rate for Payer: Kaiser Permanente Medicare	$15.60
Rate for Payer: MDX Hawaii PPO	$127.07
Rate for Payer: Ohana Health Plan Medicaid	$17.16
Rate for Payer: Ohana Health Plan Medicare	$15.60
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$15.60
Rate for Payer: University Health Alliance Commercial	$31.01

HC LEGION PNEUMO AG, DFA - LEGIONELLA PNEUMOPHILIA ANTIGEN

Facility

$131.00

Service Code	HCPCS 87278
Hospital Charge Code	3068727801
Hospital Revenue Code	306
Min. Negotiated Rate	$111.35
Max. Negotiated Rate	$127.07
Rate for Payer: Cash Price	$78.60
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: MDX Hawaii PPO	$127.07

HC L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I

Facility

$16,000.00

Service Code	HCPCS 93452
Hospital Charge Code	4819345201
Hospital Revenue Code	418
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$15,520.00
Rate for Payer: AlohaCare Medicaid	$3,829.84
Rate for Payer: AlohaCare Medicare	$3,829.84
Rate for Payer: Cash Price	$9,600.00
Rate for Payer: Cash Price	$9,600.00
Rate for Payer: Cash Price	$9,600.00
Rate for Payer: Devoted Health Medicare	$4,212.82
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,395.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,829.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Hawaii Western Management Group Commercial	$15,200.00
Rate for Payer: Health Management Network Commercial	$13,600.00
Rate for Payer: Humana Medicare	$3,829.84
Rate for Payer: Kaiser Permanente Commercial	$10,080.00
Rate for Payer: Kaiser Permanente Medicaid	$8,160.00
Rate for Payer: Kaiser Permanente Medicare	$3,829.84
Rate for Payer: MDX Hawaii PPO	$15,520.00
Rate for Payer: Ohana Health Plan Medicaid	$4,212.82
Rate for Payer: Ohana Health Plan Medicare	$3,829.84
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$3,829.84
Rate for Payer: University Health Alliance Commercial	$11,662.40

HC L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I

Facility

$16,000.00

Service Code	HCPCS 93452
Hospital Charge Code	4819345201
Hospital Revenue Code	418
Min. Negotiated Rate	$13,600.00
Max. Negotiated Rate	$15,520.00
Rate for Payer: Cash Price	$9,600.00
Rate for Payer: Health Management Network Commercial	$13,600.00
Rate for Payer: MDX Hawaii PPO	$15,520.00

HC LIDOCAINE/XYLOCAINE SO

Facility

$123.00

Service Code	HCPCS 80176
Hospital Charge Code	3018017602
Hospital Revenue Code	301
Min. Negotiated Rate	$14.69
Max. Negotiated Rate	$119.31
Rate for Payer: AlohaCare Medicaid	$14.69
Rate for Payer: AlohaCare Medicare	$14.69
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cash Price	$73.80
Rate for Payer: Devoted Health Medicare	$16.16
Rate for Payer: Hawaii Medical Service Association ABD	$20.30
Rate for Payer: Hawaii Medical Service Association Commercial	$18.36
Rate for Payer: Hawaii Medical Service Association Medicare	$14.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.32
Rate for Payer: Hawaii Western Management Group Commercial	$14.69
Rate for Payer: Health Management Network Commercial	$104.55
Rate for Payer: Humana Medicare	$14.69
Rate for Payer: Kaiser Permanente Commercial	$77.49
Rate for Payer: Kaiser Permanente Medicaid	$62.73
Rate for Payer: Kaiser Permanente Medicare	$14.69
Rate for Payer: MDX Hawaii PPO	$119.31
Rate for Payer: Ohana Health Plan Medicaid	$16.16
Rate for Payer: Ohana Health Plan Medicare	$14.69
Rate for Payer: UnitedHealthcare Medicaid	$20.30
Rate for Payer: UnitedHealthcare Medicare	$14.69
Rate for Payer: University Health Alliance Commercial	$37.96

HC LIDOCAINE/XYLOCAINE SO

Facility

$123.00

Service Code	HCPCS 80176
Hospital Charge Code	3018017602
Hospital Revenue Code	301
Min. Negotiated Rate	$104.55
Max. Negotiated Rate	$119.31
Rate for Payer: Cash Price	$73.80
Rate for Payer: Health Management Network Commercial	$104.55
Rate for Payer: MDX Hawaii PPO	$119.31

HC LIG/BANDING ANGIOACCESS ARTERIOVENOUS FISTULA

Facility

$12,265.00

Service Code	HCPCS 37607
Hospital Charge Code	3613760701
Hospital Revenue Code	361
Min. Negotiated Rate	$10,425.25
Max. Negotiated Rate	$11,897.05
Rate for Payer: Cash Price	$7,359.00
Rate for Payer: Health Management Network Commercial	$10,425.25
Rate for Payer: MDX Hawaii PPO	$11,897.05

HC LIG/BANDING ANGIOACCESS ARTERIOVENOUS FISTULA

Facility

$12,265.00

Service Code	HCPCS 37607
Hospital Charge Code	3613760701
Hospital Revenue Code	361
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$11,897.05
Rate for Payer: AlohaCare Medicaid	$3,730.07
Rate for Payer: AlohaCare Medicare	$3,730.07
Rate for Payer: Cash Price	$7,359.00
Rate for Payer: Cash Price	$7,359.00
Rate for Payer: Cash Price	$7,359.00
Rate for Payer: Devoted Health Medicare	$4,103.08
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	$3,730.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Health Management Network Commercial	$10,425.25
Rate for Payer: Humana Medicare	$3,730.07
Rate for Payer: Kaiser Permanente Commercial	$7,726.95
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,730.07
Rate for Payer: MDX Hawaii PPO	$11,897.05
Rate for Payer: Ohana Health Plan Medicaid	$4,103.08
Rate for Payer: Ohana Health Plan Medicare	$3,730.07
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,730.07
Rate for Payer: University Health Alliance Commercial	$6,743.44

HC LIPID PANEL - BUNDLED CHARGE

Facility

$112.00

Service Code	HCPCS 80061
Hospital Charge Code	3018006101
Hospital Revenue Code	301
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$108.64
Rate for Payer: Cash Price	$67.20
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: MDX Hawaii PPO	$108.64

HC LIPID PANEL - BUNDLED CHARGE

Facility

$112.00

Service Code	HCPCS 80061
Hospital Charge Code	3018006101
Hospital Revenue Code	301
Min. Negotiated Rate	$13.39
Max. Negotiated Rate	$108.64
Rate for Payer: AlohaCare Medicaid	$13.39
Rate for Payer: AlohaCare Medicare	$13.39
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cash Price	$67.20
Rate for Payer: Devoted Health Medicare	$14.73
Rate for Payer: Hawaii Medical Service Association ABD	$18.51
Rate for Payer: Hawaii Medical Service Association Commercial	$16.74
Rate for Payer: Hawaii Medical Service Association Medicare	$13.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.44
Rate for Payer: Hawaii Western Management Group Commercial	$13.39
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Humana Medicare	$13.39
Rate for Payer: Kaiser Permanente Commercial	$70.56
Rate for Payer: Kaiser Permanente Medicaid	$57.12
Rate for Payer: Kaiser Permanente Medicare	$13.39
Rate for Payer: MDX Hawaii PPO	$108.64
Rate for Payer: Ohana Health Plan Medicaid	$14.73
Rate for Payer: Ohana Health Plan Medicare	$13.39
Rate for Payer: UnitedHealthcare Medicaid	$18.51
Rate for Payer: UnitedHealthcare Medicare	$13.39
Rate for Payer: University Health Alliance Commercial	$34.63

HC LIPOPROTEIN A SO

Facility

$120.00

Service Code	HCPCS 83695
Hospital Charge Code	3018369501
Hospital Revenue Code	301
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: MDX Hawaii PPO	$116.40

HC LIPOPROTEIN A SO

Facility

$120.00

Service Code	HCPCS 83695
Hospital Charge Code	3018369501
Hospital Revenue Code	301
Min. Negotiated Rate	$12.66
Max. Negotiated Rate	$116.40
Rate for Payer: AlohaCare Medicaid	$14.32
Rate for Payer: AlohaCare Medicare	$14.32
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Devoted Health Medicare	$15.75
Rate for Payer: Hawaii Medical Service Association ABD	$12.66
Rate for Payer: Hawaii Medical Service Association Commercial	$17.90
Rate for Payer: Hawaii Medical Service Association Medicare	$14.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.88
Rate for Payer: Hawaii Western Management Group Commercial	$14.32
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Humana Medicare	$14.32
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: Kaiser Permanente Medicare	$14.32
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: Ohana Health Plan Medicaid	$15.75
Rate for Payer: Ohana Health Plan Medicare	$14.32
Rate for Payer: UnitedHealthcare Medicaid	$12.66
Rate for Payer: UnitedHealthcare Medicare	$14.32
Rate for Payer: University Health Alliance Commercial	$33.47

HC LIPOPROTEIN, BLOOD, BY NMR SPECT - LIPOPROTEIN NMR

Facility

$287.00

Service Code	HCPCS 83704
Hospital Charge Code	3018370401
Hospital Revenue Code	301
Min. Negotiated Rate	$30.86
Max. Negotiated Rate	$278.39
Rate for Payer: AlohaCare Medicaid	$34.19
Rate for Payer: AlohaCare Medicare	$34.19
Rate for Payer: Cash Price	$172.20
Rate for Payer: Cash Price	$172.20
Rate for Payer: Devoted Health Medicare	$37.61
Rate for Payer: Hawaii Medical Service Association ABD	$30.86
Rate for Payer: Hawaii Medical Service Association Commercial	$42.74
Rate for Payer: Hawaii Medical Service Association Medicare	$34.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$43.57
Rate for Payer: Hawaii Western Management Group Commercial	$34.19
Rate for Payer: Health Management Network Commercial	$243.95
Rate for Payer: Humana Medicare	$34.19
Rate for Payer: Kaiser Permanente Commercial	$180.81
Rate for Payer: Kaiser Permanente Medicaid	$146.37
Rate for Payer: Kaiser Permanente Medicare	$34.19
Rate for Payer: MDX Hawaii PPO	$278.39
Rate for Payer: Ohana Health Plan Medicaid	$37.61
Rate for Payer: Ohana Health Plan Medicare	$34.19
Rate for Payer: UnitedHealthcare Medicaid	$30.86
Rate for Payer: UnitedHealthcare Medicare	$34.19
Rate for Payer: University Health Alliance Commercial	$81.55

HC LIPOPROTEIN, BLOOD, BY NMR SPECT - LIPOPROTEIN NMR

Facility

$287.00

Service Code	HCPCS 83704
Hospital Charge Code	3018370401
Hospital Revenue Code	301
Min. Negotiated Rate	$243.95
Max. Negotiated Rate	$278.39
Rate for Payer: Cash Price	$172.20
Rate for Payer: Health Management Network Commercial	$243.95
Rate for Payer: MDX Hawaii PPO	$278.39

HC LIVER AND SPLEEN IMAGING - NM LIVER SPLEEN

Facility

$1,999.00

Service Code	HCPCS 78215
Hospital Charge Code	3417821501
Hospital Revenue Code	341
Min. Negotiated Rate	$96.57
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	$96.57
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	$105.09
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	$96.57
Rate for Payer: UnitedHealthcare Medicare	$472.27
Rate for Payer: University Health Alliance Commercial	$356.57

HC LIVER AND SPLEEN IMAGING - NM LIVER SPLEEN

Facility

$1,999.00

Service Code	HCPCS 78215
Hospital Charge Code	3417821501
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

Know your out-of-pocket cost for care.

All Charges