Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC MICROALBUMIN, QUANTITATIVE - MICROALBUMIN 24HR URINE

Facility

$48.00

Service Code	HCPCS 82043
Hospital Charge Code	3018204301
Hospital Revenue Code	301
Min. Negotiated Rate	$5.78
Max. Negotiated Rate	$46.56
Rate for Payer: AlohaCare Medicaid	$5.78
Rate for Payer: AlohaCare Medicare	$5.78
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Devoted Health Medicare	$6.36
Rate for Payer: Hawaii Medical Service Association ABD	$8.00
Rate for Payer: Hawaii Medical Service Association Commercial	$7.22
Rate for Payer: Hawaii Medical Service Association Medicare	$5.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.40
Rate for Payer: Hawaii Western Management Group Commercial	$5.78
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Humana Medicare	$5.78
Rate for Payer: Kaiser Permanente Commercial	$30.24
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: Kaiser Permanente Medicare	$5.78
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: Ohana Health Plan Medicaid	$6.36
Rate for Payer: Ohana Health Plan Medicare	$5.78
Rate for Payer: UnitedHealthcare Medicaid	$8.00
Rate for Payer: UnitedHealthcare Medicare	$5.78
Rate for Payer: University Health Alliance Commercial	$14.97

HC MICROALBUMIN, QUANTITATIVE - MICROALBUMIN 24HR URINE

Facility

$48.00

Service Code	HCPCS 82043
Hospital Charge Code	3018204301
Hospital Revenue Code	301
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$28.80
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: MDX Hawaii PPO	$46.56

HC MICROALBUMIN, QUANTITATIVE - MICROALBUMIN RANDOM URINE

Facility

$48.00

Service Code	HCPCS 82043
Hospital Charge Code	3018204302
Hospital Revenue Code	301
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$28.80
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: MDX Hawaii PPO	$46.56

HC MICROALBUMIN, QUANTITATIVE - MICROALBUMIN RANDOM URINE

Facility

$48.00

Service Code	HCPCS 82043
Hospital Charge Code	3018204302
Hospital Revenue Code	301
Min. Negotiated Rate	$5.78
Max. Negotiated Rate	$46.56
Rate for Payer: AlohaCare Medicaid	$5.78
Rate for Payer: AlohaCare Medicare	$5.78
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Devoted Health Medicare	$6.36
Rate for Payer: Hawaii Medical Service Association ABD	$8.00
Rate for Payer: Hawaii Medical Service Association Commercial	$7.22
Rate for Payer: Hawaii Medical Service Association Medicare	$5.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.40
Rate for Payer: Hawaii Western Management Group Commercial	$5.78
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Humana Medicare	$5.78
Rate for Payer: Kaiser Permanente Commercial	$30.24
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: Kaiser Permanente Medicare	$5.78
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: Ohana Health Plan Medicaid	$6.36
Rate for Payer: Ohana Health Plan Medicare	$5.78
Rate for Payer: UnitedHealthcare Medicaid	$8.00
Rate for Payer: UnitedHealthcare Medicare	$5.78
Rate for Payer: University Health Alliance Commercial	$14.97

HC MICROBIOTA FECAL PREP

Facility

$3,390.00

Service Code	HCPCS G0455
Hospital Charge Code	750G045501
Hospital Revenue Code	750
Min. Negotiated Rate	$32.30
Max. Negotiated Rate	$3,288.30
Rate for Payer: AlohaCare Medicaid	$1,098.60
Rate for Payer: AlohaCare Medicare	$1,098.60
Rate for Payer: Cash Price	$2,034.00
Rate for Payer: Cash Price	$2,034.00
Rate for Payer: Devoted Health Medicare	$1,208.46
Rate for Payer: Hawaii Medical Service Association Commercial	$1,373.25
Rate for Payer: Hawaii Medical Service Association Medicare	$1,098.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,220.50
Rate for Payer: Health Management Network Commercial	$2,881.50
Rate for Payer: Humana Medicare	$1,098.60
Rate for Payer: Kaiser Permanente Commercial	$2,135.70
Rate for Payer: Kaiser Permanente Medicaid	$1,728.90
Rate for Payer: Kaiser Permanente Medicare	$1,098.60
Rate for Payer: MDX Hawaii PPO	$3,288.30
Rate for Payer: Ohana Health Plan Medicaid	$1,208.46
Rate for Payer: Ohana Health Plan Medicare	$1,098.60
Rate for Payer: UnitedHealthcare Medicaid	$32.30
Rate for Payer: UnitedHealthcare Medicare	$1,098.60
Rate for Payer: University Health Alliance Commercial	$2,470.97

HC MICROBIOTA FECAL PREP

Facility

$3,390.00

Service Code	HCPCS G0455
Hospital Charge Code	750G045501
Hospital Revenue Code	750
Min. Negotiated Rate	$2,881.50
Max. Negotiated Rate	$3,288.30
Rate for Payer: Cash Price	$2,034.00
Rate for Payer: Health Management Network Commercial	$2,881.50
Rate for Payer: MDX Hawaii PPO	$3,288.30

HC MICROSOMAL ANTIBODY - LIVER-KIDNEY MICROS AB SO

Facility

$122.00

Service Code	HCPCS 86376
Hospital Charge Code	3028637601
Hospital Revenue Code	302
Min. Negotiated Rate	$14.55
Max. Negotiated Rate	$118.34
Rate for Payer: AlohaCare Medicaid	$14.55
Rate for Payer: AlohaCare Medicare	$14.55
Rate for Payer: Cash Price	$73.20
Rate for Payer: Cash Price	$73.20
Rate for Payer: Devoted Health Medicare	$16.00
Rate for Payer: Hawaii Medical Service Association ABD	$20.11
Rate for Payer: Hawaii Medical Service Association Commercial	$18.19
Rate for Payer: Hawaii Medical Service Association Medicare	$14.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.12
Rate for Payer: Hawaii Western Management Group Commercial	$14.55
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: Humana Medicare	$14.55
Rate for Payer: Kaiser Permanente Commercial	$76.86
Rate for Payer: Kaiser Permanente Medicaid	$62.22
Rate for Payer: Kaiser Permanente Medicare	$14.55
Rate for Payer: MDX Hawaii PPO	$118.34
Rate for Payer: Ohana Health Plan Medicaid	$16.00
Rate for Payer: Ohana Health Plan Medicare	$14.55
Rate for Payer: UnitedHealthcare Medicaid	$20.11
Rate for Payer: UnitedHealthcare Medicare	$14.55
Rate for Payer: University Health Alliance Commercial	$37.61

HC MICROSOMAL ANTIBODY - LIVER-KIDNEY MICROS AB SO

Facility

$122.00

Service Code	HCPCS 86376
Hospital Charge Code	3028637601
Hospital Revenue Code	302
Min. Negotiated Rate	$103.70
Max. Negotiated Rate	$118.34
Rate for Payer: Cash Price	$73.20
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: MDX Hawaii PPO	$118.34

HC MICROSOMAL ANTIBODY - MICROSOMAL/THYROID AB

Facility

$122.00

Service Code	HCPCS 86376
Hospital Charge Code	3028637602
Hospital Revenue Code	302
Min. Negotiated Rate	$103.70
Max. Negotiated Rate	$118.34
Rate for Payer: Cash Price	$73.20
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: MDX Hawaii PPO	$118.34

HC MICROSOMAL ANTIBODY - MICROSOMAL/THYROID AB

Facility

$122.00

Service Code	HCPCS 86376
Hospital Charge Code	3028637602
Hospital Revenue Code	302
Min. Negotiated Rate	$14.55
Max. Negotiated Rate	$118.34
Rate for Payer: AlohaCare Medicaid	$14.55
Rate for Payer: AlohaCare Medicare	$14.55
Rate for Payer: Cash Price	$73.20
Rate for Payer: Cash Price	$73.20
Rate for Payer: Devoted Health Medicare	$16.00
Rate for Payer: Hawaii Medical Service Association ABD	$20.11
Rate for Payer: Hawaii Medical Service Association Commercial	$18.19
Rate for Payer: Hawaii Medical Service Association Medicare	$14.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.12
Rate for Payer: Hawaii Western Management Group Commercial	$14.55
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: Humana Medicare	$14.55
Rate for Payer: Kaiser Permanente Commercial	$76.86
Rate for Payer: Kaiser Permanente Medicaid	$62.22
Rate for Payer: Kaiser Permanente Medicare	$14.55
Rate for Payer: MDX Hawaii PPO	$118.34
Rate for Payer: Ohana Health Plan Medicaid	$16.00
Rate for Payer: Ohana Health Plan Medicare	$14.55
Rate for Payer: UnitedHealthcare Medicaid	$20.11
Rate for Payer: UnitedHealthcare Medicare	$14.55
Rate for Payer: University Health Alliance Commercial	$37.61

HC MITOCHONDRIAL AB EA SO

Facility

$214.00

Service Code	HCPCS 86381
Hospital Charge Code	3018638101
Hospital Revenue Code	301
Min. Negotiated Rate	$15.27
Max. Negotiated Rate	$207.58
Rate for Payer: AlohaCare Medicaid	$25.45
Rate for Payer: AlohaCare Medicare	$25.45
Rate for Payer: Cash Price	$128.40
Rate for Payer: Cash Price	$128.40
Rate for Payer: Devoted Health Medicare	$28.00
Rate for Payer: Hawaii Medical Service Association ABD	$35.54
Rate for Payer: Hawaii Medical Service Association Commercial	$31.81
Rate for Payer: Hawaii Medical Service Association Medicare	$25.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.32
Rate for Payer: Hawaii Western Management Group Commercial	$25.45
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Humana Medicare	$25.45
Rate for Payer: Kaiser Permanente Commercial	$134.82
Rate for Payer: Kaiser Permanente Medicaid	$109.14
Rate for Payer: Kaiser Permanente Medicare	$25.45
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: Ohana Health Plan Medicaid	$28.00
Rate for Payer: Ohana Health Plan Medicare	$25.45
Rate for Payer: UnitedHealthcare Medicaid	$15.27
Rate for Payer: UnitedHealthcare Medicare	$25.45
Rate for Payer: University Health Alliance Commercial	$155.98

HC MITOCHONDRIAL AB EA SO

Facility

$214.00

Service Code	HCPCS 86381
Hospital Charge Code	3018638101
Hospital Revenue Code	301
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$128.40
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: MDX Hawaii PPO	$207.58

HC MLC IMRT TRMT DEVICE

Facility

$1,457.00

Service Code	HCPCS 77338
Hospital Charge Code	3337733801
Hospital Revenue Code	333
Min. Negotiated Rate	$138.15
Max. Negotiated Rate	$1,413.29
Rate for Payer: AlohaCare Medicaid	$442.33
Rate for Payer: AlohaCare Medicare	$442.33
Rate for Payer: Cash Price	$874.20
Rate for Payer: Cash Price	$874.20
Rate for Payer: Devoted Health Medicare	$486.56
Rate for Payer: Hawaii Medical Service Association ABD	$138.15
Rate for Payer: Hawaii Medical Service Association Commercial	$552.91
Rate for Payer: Hawaii Medical Service Association Medicare	$442.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$239.74
Rate for Payer: Hawaii Western Management Group Commercial	$442.33
Rate for Payer: Health Management Network Commercial	$1,238.45
Rate for Payer: Humana Medicare	$442.33
Rate for Payer: Kaiser Permanente Commercial	$917.91
Rate for Payer: Kaiser Permanente Medicaid	$743.07
Rate for Payer: Kaiser Permanente Medicare	$442.33
Rate for Payer: MDX Hawaii PPO	$1,413.29
Rate for Payer: Ohana Health Plan Medicaid	$486.56
Rate for Payer: Ohana Health Plan Medicare	$442.33
Rate for Payer: UnitedHealthcare Medicaid	$138.15
Rate for Payer: UnitedHealthcare Medicare	$442.33
Rate for Payer: University Health Alliance Commercial	$766.09

HC MLC IMRT TRMT DEVICE

Facility

$1,457.00

Service Code	HCPCS 77338
Hospital Charge Code	3337733801
Hospital Revenue Code	333
Min. Negotiated Rate	$1,238.45
Max. Negotiated Rate	$1,413.29
Rate for Payer: Cash Price	$874.20
Rate for Payer: Health Management Network Commercial	$1,238.45
Rate for Payer: MDX Hawaii PPO	$1,413.29

HC MOD SED OTHER PHYS/QHP EACH ADDL 15 MINS

Facility

$158.00

Service Code	HCPCS 99157
Hospital Charge Code	3709915701
Hospital Revenue Code	370
Min. Negotiated Rate	$58.96
Max. Negotiated Rate	$153.26
Rate for Payer: Cash Price	$94.80
Rate for Payer: Cash Price	$94.80
Rate for Payer: Hawaii Western Management Group Commercial	$150.10
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: Kaiser Permanente Commercial	$99.54
Rate for Payer: Kaiser Permanente Medicaid	$80.58
Rate for Payer: MDX Hawaii PPO	$153.26
Rate for Payer: UnitedHealthcare Medicaid	$58.96
Rate for Payer: University Health Alliance Commercial	$115.17

HC MOD SED OTHER PHYS/QHP EACH ADDL 15 MINS

Facility

$158.00

Service Code	HCPCS 99157
Hospital Charge Code	3709915701
Hospital Revenue Code	370
Min. Negotiated Rate	$134.30
Max. Negotiated Rate	$153.26
Rate for Payer: Cash Price	$94.80
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: MDX Hawaii PPO	$153.26

HC MOD SED OTHER PHYS/QHP INITIAL 15 MINS <5 YRS

Facility

$288.00

Service Code	HCPCS 99155
Hospital Charge Code	3709915501
Hospital Revenue Code	370
Min. Negotiated Rate	$59.68
Max. Negotiated Rate	$279.36
Rate for Payer: Cash Price	$172.80
Rate for Payer: Cash Price	$172.80
Rate for Payer: Hawaii Western Management Group Commercial	$273.60
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: Kaiser Permanente Commercial	$181.44
Rate for Payer: Kaiser Permanente Medicaid	$146.88
Rate for Payer: MDX Hawaii PPO	$279.36
Rate for Payer: UnitedHealthcare Medicaid	$59.68
Rate for Payer: University Health Alliance Commercial	$209.92

HC MOD SED OTHER PHYS/QHP INITIAL 15 MINS <5 YRS

Facility

$288.00

Service Code	HCPCS 99155
Hospital Charge Code	3709915501
Hospital Revenue Code	370
Min. Negotiated Rate	$244.80
Max. Negotiated Rate	$279.36
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: MDX Hawaii PPO	$279.36

HC MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS

Facility

$279.00

Service Code	HCPCS 99156
Hospital Charge Code	3709915601
Hospital Revenue Code	370
Min. Negotiated Rate	$53.37
Max. Negotiated Rate	$270.63
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cash Price	$167.40
Rate for Payer: Hawaii Western Management Group Commercial	$265.05
Rate for Payer: Health Management Network Commercial	$237.15
Rate for Payer: Kaiser Permanente Commercial	$175.77
Rate for Payer: Kaiser Permanente Medicaid	$142.29
Rate for Payer: MDX Hawaii PPO	$270.63
Rate for Payer: UnitedHealthcare Medicaid	$53.37
Rate for Payer: University Health Alliance Commercial	$203.36

HC MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS

Facility

$279.00

Service Code	HCPCS 99156
Hospital Charge Code	3709915601
Hospital Revenue Code	370
Min. Negotiated Rate	$237.15
Max. Negotiated Rate	$270.63
Rate for Payer: Cash Price	$167.40
Rate for Payer: Health Management Network Commercial	$237.15
Rate for Payer: MDX Hawaii PPO	$270.63

HC MOD SED SAME PHYS/QHP EACH ADDL 15 MINS

Facility

$83.00

Service Code	HCPCS 99153
Hospital Charge Code	3719915301
Hospital Revenue Code	371
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$49.80
Rate for Payer: Cash Price	$49.80
Rate for Payer: Hawaii Western Management Group Commercial	$78.85
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Kaiser Permanente Commercial	$52.29
Rate for Payer: Kaiser Permanente Medicaid	$42.33
Rate for Payer: MDX Hawaii PPO	$80.51
Rate for Payer: UnitedHealthcare Medicaid	$13.00
Rate for Payer: University Health Alliance Commercial	$60.50

HC MOD SED SAME PHYS/QHP EACH ADDL 15 MINS

Facility

$83.00

Service Code	HCPCS 99153
Hospital Charge Code	3719915301
Hospital Revenue Code	371
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$49.80
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: MDX Hawaii PPO	$80.51

HC MOD SED SAME PHYS/QHP EACH ADDL 15 MINS

Facility

$83.00

Service Code	HCPCS 99153
Hospital Charge Code	3709915301
Hospital Revenue Code	370
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$49.80
Rate for Payer: Cash Price	$49.80
Rate for Payer: Hawaii Western Management Group Commercial	$78.85
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Kaiser Permanente Commercial	$52.29
Rate for Payer: Kaiser Permanente Medicaid	$42.33
Rate for Payer: MDX Hawaii PPO	$80.51
Rate for Payer: UnitedHealthcare Medicaid	$13.00
Rate for Payer: University Health Alliance Commercial	$60.50

HC MOD SED SAME PHYS/QHP EACH ADDL 15 MINS

Facility

$83.00

Service Code	HCPCS 99153
Hospital Charge Code	3709915301
Hospital Revenue Code	370
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$49.80
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: MDX Hawaii PPO	$80.51

HC MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS

Facility

$510.00

Service Code	HCPCS 99151
Hospital Charge Code	3719915101
Hospital Revenue Code	371
Min. Negotiated Rate	$17.23
Max. Negotiated Rate	$494.70
Rate for Payer: Cash Price	$306.00
Rate for Payer: Cash Price	$306.00
Rate for Payer: Hawaii Western Management Group Commercial	$484.50
Rate for Payer: Health Management Network Commercial	$433.50
Rate for Payer: Kaiser Permanente Commercial	$321.30
Rate for Payer: Kaiser Permanente Medicaid	$260.10
Rate for Payer: MDX Hawaii PPO	$494.70
Rate for Payer: UnitedHealthcare Medicaid	$17.23
Rate for Payer: University Health Alliance Commercial	$371.74

Know your out-of-pocket cost for care.

All Charges