Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC OR ACUITY LEVEL 3 BASE 30MIN

Facility

$4,980.00

Hospital Charge Code	3600000003
Hospital Revenue Code	360
Min. Negotiated Rate	$2,837.00
Max. Negotiated Rate	$4,830.60
Rate for Payer: Cash Price	$2,988.00
Rate for Payer: Cash Price	$2,988.00
Rate for Payer: Health Management Network Commercial	$4,233.00
Rate for Payer: Kaiser Permanente Commercial	$3,137.40
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$4,830.60
Rate for Payer: University Health Alliance Commercial	$3,629.92

HC OR ACUITY LEVEL 4 BASE 30 MIN

Facility

$6,745.00

Hospital Charge Code	3600000004
Hospital Revenue Code	360
Min. Negotiated Rate	$2,837.00
Max. Negotiated Rate	$6,542.65
Rate for Payer: Cash Price	$4,047.00
Rate for Payer: Cash Price	$4,047.00
Rate for Payer: Health Management Network Commercial	$5,733.25
Rate for Payer: Kaiser Permanente Commercial	$4,249.35
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$6,542.65
Rate for Payer: University Health Alliance Commercial	$4,916.43

HC OR ACUITY LEVEL 4 BASE 30 MIN

Facility

$6,745.00

Hospital Charge Code	3600000004
Hospital Revenue Code	360
Min. Negotiated Rate	$5,733.25
Max. Negotiated Rate	$6,542.65
Rate for Payer: Cash Price	$4,047.00
Rate for Payer: Health Management Network Commercial	$5,733.25
Rate for Payer: MDX Hawaii PPO	$6,542.65

HC OR ACUITY LEVEL 5 BASE 30 MIN

Facility

$7,211.00

Hospital Charge Code	3600000005
Hospital Revenue Code	360
Min. Negotiated Rate	$2,837.00
Max. Negotiated Rate	$6,994.67
Rate for Payer: Cash Price	$4,326.60
Rate for Payer: Cash Price	$4,326.60
Rate for Payer: Health Management Network Commercial	$6,129.35
Rate for Payer: Kaiser Permanente Commercial	$4,542.93
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$6,994.67
Rate for Payer: University Health Alliance Commercial	$5,256.10

HC OR ACUITY LEVEL 5 BASE 30 MIN

Facility

$7,211.00

Hospital Charge Code	3600000005
Hospital Revenue Code	360
Min. Negotiated Rate	$6,129.35
Max. Negotiated Rate	$6,994.67
Rate for Payer: Cash Price	$4,326.60
Rate for Payer: Health Management Network Commercial	$6,129.35
Rate for Payer: MDX Hawaii PPO	$6,994.67

HC OT ELECTRICAL STIMULATION (ATTENDED)

Facility

$68.00

Service Code	HCPCS 97032 GO
Hospital Charge Code	4309703201
Hospital Revenue Code	430
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$65.96
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cash Price	$40.80
Rate for Payer: Hawaii Western Management Group Commercial	$64.60
Rate for Payer: Health Management Network Commercial	$57.80
Rate for Payer: Kaiser Permanente Commercial	$42.84
Rate for Payer: Kaiser Permanente Medicaid	$34.68
Rate for Payer: MDX Hawaii PPO	$65.96
Rate for Payer: UnitedHealthcare Medicaid	$13.64
Rate for Payer: University Health Alliance Commercial	$49.57

HC OT ELECTRICAL STIMULATION (ATTENDED)

Facility

$68.00

Service Code	HCPCS 97032
Hospital Charge Code	4309701401
Hospital Revenue Code	430
Min. Negotiated Rate	$57.80
Max. Negotiated Rate	$65.96
Rate for Payer: Cash Price	$40.80
Rate for Payer: Health Management Network Commercial	$57.80
Rate for Payer: MDX Hawaii PPO	$65.96

HC OT ELECTRICAL STIMULATION (ATTENDED)

Facility

$68.00

Service Code	HCPCS 97032 GO
Hospital Charge Code	4309703201
Hospital Revenue Code	430
Min. Negotiated Rate	$57.80
Max. Negotiated Rate	$65.96
Rate for Payer: Cash Price	$40.80
Rate for Payer: Health Management Network Commercial	$57.80
Rate for Payer: MDX Hawaii PPO	$65.96

HC OT ELECTRICAL STIMULATION (ATTENDED)

Facility

$68.00

Service Code	HCPCS 97032
Hospital Charge Code	4309701401
Hospital Revenue Code	430
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$65.96
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cash Price	$40.80
Rate for Payer: Hawaii Western Management Group Commercial	$64.60
Rate for Payer: Health Management Network Commercial	$57.80
Rate for Payer: Kaiser Permanente Commercial	$42.84
Rate for Payer: Kaiser Permanente Medicaid	$34.68
Rate for Payer: MDX Hawaii PPO	$65.96
Rate for Payer: UnitedHealthcare Medicaid	$13.64
Rate for Payer: University Health Alliance Commercial	$49.57

HC OT MANUAL THER TECH,1+REGIONS,EA 15 MIN

Facility

$131.00

Service Code	HCPCS 97140 GO
Hospital Charge Code	4309714001
Hospital Revenue Code	430
Min. Negotiated Rate	$20.55
Max. Negotiated Rate	$127.07
Rate for Payer: Cash Price	$78.60
Rate for Payer: Cash Price	$78.60
Rate for Payer: Hawaii Western Management Group Commercial	$124.45
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Kaiser Permanente Commercial	$82.53
Rate for Payer: Kaiser Permanente Medicaid	$66.81
Rate for Payer: MDX Hawaii PPO	$127.07
Rate for Payer: UnitedHealthcare Medicaid	$20.55
Rate for Payer: University Health Alliance Commercial	$95.49

HC OT MANUAL THER TECH,1+REGIONS,EA 15 MIN

Facility

$131.00

Service Code	HCPCS 97140 GO
Hospital Charge Code	4309714001
Hospital Revenue Code	430
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 OT NEUROMUSC REEDUCAT,1+ AREAS, EA 15 MIN

Facility

$163.00

Service Code	HCPCS 97112 GO
Hospital Charge Code	4309711201
Hospital Revenue Code	430
Min. Negotiated Rate	$18.58
Max. Negotiated Rate	$158.11
Rate for Payer: Cash Price	$97.80
Rate for Payer: Cash Price	$97.80
Rate for Payer: Hawaii Western Management Group Commercial	$154.85
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Kaiser Permanente Commercial	$102.69
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: UnitedHealthcare Medicaid	$18.58
Rate for Payer: University Health Alliance Commercial	$118.81

HC OT NEUROMUSC REEDUCAT,1+ AREAS, EA 15 MIN

Facility

$163.00

Service Code	HCPCS 97112 GO
Hospital Charge Code	4309711201
Hospital Revenue Code	430
Min. Negotiated Rate	$138.55
Max. Negotiated Rate	$158.11
Rate for Payer: Cash Price	$97.80
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: MDX Hawaii PPO	$158.11

HC OT OCCUPATIONAL THERAPY EVAL HIGH COMPLEX 60 MINS

Facility

$490.00

Service Code	HCPCS 97167 GO
Hospital Charge Code	4349716701
Hospital Revenue Code	434
Min. Negotiated Rate	$416.50
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$294.00
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: MDX Hawaii PPO	$475.30

HC OT OCCUPATIONAL THERAPY EVAL HIGH COMPLEX 60 MINS

Facility

$490.00

Service Code	HCPCS 97167 GO
Hospital Charge Code	4349716701
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$294.00
Rate for Payer: Cash Price	$294.00
Rate for Payer: Hawaii Western Management Group Commercial	$465.50
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Kaiser Permanente Commercial	$308.70
Rate for Payer: Kaiser Permanente Medicaid	$249.90
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: University Health Alliance Commercial	$357.16

HC OT OCCUPATIONAL THERAPY EVAL LOW COMPLEX 30 MINS

Facility

$490.00

Service Code	HCPCS 97165 GO
Hospital Charge Code	4349716501
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$294.00
Rate for Payer: Cash Price	$294.00
Rate for Payer: Hawaii Western Management Group Commercial	$465.50
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Kaiser Permanente Commercial	$308.70
Rate for Payer: Kaiser Permanente Medicaid	$249.90
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: University Health Alliance Commercial	$357.16

HC OT OCCUPATIONAL THERAPY EVAL LOW COMPLEX 30 MINS

Facility

$490.00

Service Code	HCPCS 97165 GO
Hospital Charge Code	4349716501
Hospital Revenue Code	434
Min. Negotiated Rate	$416.50
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$294.00
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: MDX Hawaii PPO	$475.30

HC OT OCCUPATIONAL THERAPY EVAL MOD COMPLEX 45 MINS

Facility

$490.00

Service Code	HCPCS 97166 GO
Hospital Charge Code	4349716601
Hospital Revenue Code	434
Min. Negotiated Rate	$416.50
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$294.00
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: MDX Hawaii PPO	$475.30

HC OT OCCUPATIONAL THERAPY EVAL MOD COMPLEX 45 MINS

Facility

$490.00

Service Code	HCPCS 97166 GO
Hospital Charge Code	4349716601
Hospital Revenue Code	434
Min. Negotiated Rate	$107.85
Max. Negotiated Rate	$475.30
Rate for Payer: Cash Price	$294.00
Rate for Payer: Cash Price	$294.00
Rate for Payer: Hawaii Western Management Group Commercial	$465.50
Rate for Payer: Health Management Network Commercial	$416.50
Rate for Payer: Kaiser Permanente Commercial	$308.70
Rate for Payer: Kaiser Permanente Medicaid	$249.90
Rate for Payer: MDX Hawaii PPO	$475.30
Rate for Payer: UnitedHealthcare Medicaid	$107.85
Rate for Payer: University Health Alliance Commercial	$357.16

HC OT OCCUPATIONAL THER RE-EVAL EST PLAN CARE 30 MINS

Facility

$342.00

Service Code	HCPCS 97168 GO
Hospital Charge Code	4349716801
Hospital Revenue Code	434
Min. Negotiated Rate	$74.97
Max. Negotiated Rate	$331.74
Rate for Payer: Cash Price	$205.20
Rate for Payer: Cash Price	$205.20
Rate for Payer: Hawaii Western Management Group Commercial	$324.90
Rate for Payer: Health Management Network Commercial	$290.70
Rate for Payer: Kaiser Permanente Commercial	$215.46
Rate for Payer: Kaiser Permanente Medicaid	$174.42
Rate for Payer: MDX Hawaii PPO	$331.74
Rate for Payer: UnitedHealthcare Medicaid	$74.97
Rate for Payer: University Health Alliance Commercial	$249.28

HC OT OCCUPATIONAL THER RE-EVAL EST PLAN CARE 30 MINS

Facility

$342.00

Service Code	HCPCS 97168 GO
Hospital Charge Code	4349716801
Hospital Revenue Code	434
Min. Negotiated Rate	$290.70
Max. Negotiated Rate	$331.74
Rate for Payer: Cash Price	$205.20
Rate for Payer: Health Management Network Commercial	$290.70
Rate for Payer: MDX Hawaii PPO	$331.74

HC OT ORTHOTIC MGMT AND TRAINING, EACH 15 MIN

Facility

$236.00

Service Code	HCPCS 97760 GO
Hospital Charge Code	4309776001
Hospital Revenue Code	430
Min. Negotiated Rate	$17.21
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$148.68
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: UnitedHealthcare Medicaid	$17.21
Rate for Payer: University Health Alliance Commercial	$172.02

HC OT ORTHOTIC MGMT AND TRAINING, EACH 15 MIN

Facility

$236.00

Service Code	HCPCS 97760 GO
Hospital Charge Code	4309776001
Hospital Revenue Code	430
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: MDX Hawaii PPO	$228.92

HC OT ORTHOTICS/PROSTH MGMT &/TRAINJ SBSQ ENCTR 15 MIN

Facility

$262.00

Service Code	HCPCS 97763 GO
Hospital Charge Code	4309776301
Hospital Revenue Code	430
Min. Negotiated Rate	$222.70
Max. Negotiated Rate	$254.14
Rate for Payer: Cash Price	$157.20
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: MDX Hawaii PPO	$254.14

HC OT ORTHOTICS/PROSTH MGMT &/TRAINJ SBSQ ENCTR 15 MIN

Facility

$262.00

Service Code	HCPCS 97763 GO
Hospital Charge Code	4309776301
Hospital Revenue Code	430
Min. Negotiated Rate	$57.47
Max. Negotiated Rate	$254.14
Rate for Payer: Cash Price	$157.20
Rate for Payer: Cash Price	$157.20
Rate for Payer: Hawaii Western Management Group Commercial	$248.90
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: Kaiser Permanente Commercial	$165.06
Rate for Payer: Kaiser Permanente Medicaid	$133.62
Rate for Payer: MDX Hawaii PPO	$254.14
Rate for Payer: UnitedHealthcare Medicaid	$57.47
Rate for Payer: University Health Alliance Commercial	$190.97

Know your out-of-pocket cost for care.

All Charges