Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC PERICARDIOCENTES INITIAL

Facility

$6,182.00

Service Code	HCPCS 33016
Hospital Charge Code	3613301601
Hospital Revenue Code	361
Min. Negotiated Rate	$5,254.70
Max. Negotiated Rate	$5,996.54
Rate for Payer: Cash Price	$3,709.20
Rate for Payer: Health Management Network Commercial	$5,254.70
Rate for Payer: MDX Hawaii PPO	$5,996.54

HC PERICARDIOCENTES INITIAL

Facility

$6,182.00

Service Code	HCPCS 33016
Hospital Charge Code	3613301601
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$5,996.54
Rate for Payer: AlohaCare Medicaid	$1,859.62
Rate for Payer: AlohaCare Medicare	$1,859.62
Rate for Payer: Cash Price	$3,709.20
Rate for Payer: Cash Price	$3,709.20
Rate for Payer: Cash Price	$3,709.20
Rate for Payer: Devoted Health Medicare	$2,045.58
Rate for Payer: Hawaii Medical Service Association Commercial	$2,324.53
Rate for Payer: Hawaii Medical Service Association Medicare	$1,859.62
Rate for Payer: Health Management Network Commercial	$5,254.70
Rate for Payer: Humana Medicare	$1,859.62
Rate for Payer: Kaiser Permanente Commercial	$3,894.66
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,859.62
Rate for Payer: MDX Hawaii PPO	$5,996.54
Rate for Payer: Ohana Health Plan Medicaid	$2,045.58
Rate for Payer: Ohana Health Plan Medicare	$1,859.62
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,859.62
Rate for Payer: University Health Alliance Commercial	$4,506.06

HC PERI-PX DEV EVAL PM/LDLS PM PHYS/QHP IN PERSON

Facility

$784.00

Service Code	HCPCS 93286
Hospital Charge Code	4809328601
Hospital Revenue Code	480
Min. Negotiated Rate	$8.33
Max. Negotiated Rate	$760.48
Rate for Payer: Cash Price	$470.40
Rate for Payer: Cash Price	$470.40
Rate for Payer: Hawaii Medical Service Association ABD	$8.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.99
Rate for Payer: Hawaii Western Management Group Commercial	$744.80
Rate for Payer: Health Management Network Commercial	$666.40
Rate for Payer: Kaiser Permanente Commercial	$493.92
Rate for Payer: Kaiser Permanente Medicaid	$399.84
Rate for Payer: MDX Hawaii PPO	$760.48
Rate for Payer: UnitedHealthcare Medicaid	$8.33
Rate for Payer: University Health Alliance Commercial	$571.46

HC PERI-PX DEV EVAL PM/LDLS PM PHYS/QHP IN PERSON

Facility

$784.00

Service Code	HCPCS 93286
Hospital Charge Code	4809328601
Hospital Revenue Code	480
Min. Negotiated Rate	$666.40
Max. Negotiated Rate	$760.48
Rate for Payer: Cash Price	$470.40
Rate for Payer: Health Management Network Commercial	$666.40
Rate for Payer: MDX Hawaii PPO	$760.48

HC PERI-PX DEV EVAL & PROG SING/DUAL/MULTI LEAD DFB

Facility

$259.00

Service Code	HCPCS 93287
Hospital Charge Code	4809328701
Hospital Revenue Code	480
Min. Negotiated Rate	$9.37
Max. Negotiated Rate	$251.23
Rate for Payer: Cash Price	$155.40
Rate for Payer: Cash Price	$155.40
Rate for Payer: Hawaii Medical Service Association ABD	$9.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13.49
Rate for Payer: Hawaii Western Management Group Commercial	$246.05
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: Kaiser Permanente Commercial	$163.17
Rate for Payer: Kaiser Permanente Medicaid	$132.09
Rate for Payer: MDX Hawaii PPO	$251.23
Rate for Payer: UnitedHealthcare Medicaid	$9.37
Rate for Payer: University Health Alliance Commercial	$188.79

HC PERI-PX DEV EVAL & PROG SING/DUAL/MULTI LEAD DFB

Facility

$259.00

Service Code	HCPCS 93287
Hospital Charge Code	4809328701
Hospital Revenue Code	480
Min. Negotiated Rate	$220.15
Max. Negotiated Rate	$251.23
Rate for Payer: Cash Price	$155.40
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: MDX Hawaii PPO	$251.23

HC PERQ DRAINAGE PLEURA INSERT CATH W/IMAGING

Facility

$6,182.00

Service Code	HCPCS 32557
Hospital Charge Code	3613255701
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$5,996.54
Rate for Payer: AlohaCare Medicaid	$1,859.62
Rate for Payer: AlohaCare Medicare	$1,859.62
Rate for Payer: Cash Price	$3,709.20
Rate for Payer: Cash Price	$3,709.20
Rate for Payer: Cash Price	$3,709.20
Rate for Payer: Devoted Health Medicare	$2,045.58
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	$1,859.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Health Management Network Commercial	$5,254.70
Rate for Payer: Humana Medicare	$1,859.62
Rate for Payer: Kaiser Permanente Commercial	$3,894.66
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,859.62
Rate for Payer: MDX Hawaii PPO	$5,996.54
Rate for Payer: Ohana Health Plan Medicaid	$2,045.58
Rate for Payer: Ohana Health Plan Medicare	$1,859.62
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,859.62
Rate for Payer: University Health Alliance Commercial	$4,506.06

HC PERQ DRAINAGE PLEURA INSERT CATH W/IMAGING

Facility

$6,182.00

Service Code	HCPCS 32557
Hospital Charge Code	3613255701
Hospital Revenue Code	361
Min. Negotiated Rate	$5,254.70
Max. Negotiated Rate	$5,996.54
Rate for Payer: Cash Price	$3,709.20
Rate for Payer: Health Management Network Commercial	$5,254.70
Rate for Payer: MDX Hawaii PPO	$5,996.54

HC PERQ PRCRD DRG 6YR+ W/O CONGENITAL CAR ANOMALY

Facility

$1,110.00

Service Code	HCPCS 33017
Hospital Charge Code	3603301701
Hospital Revenue Code	360
Min. Negotiated Rate	$234.02
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$666.00
Rate for Payer: Cash Price	$666.00
Rate for Payer: Cash Price	$666.00
Rate for Payer: Health Management Network Commercial	$943.50
Rate for Payer: Kaiser Permanente Commercial	$699.30
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$1,076.70
Rate for Payer: UnitedHealthcare Medicaid	$234.02
Rate for Payer: University Health Alliance Commercial	$809.08

HC PERQ PRCRD DRG 6YR+ W/O CONGENITAL CAR ANOMALY

Facility

$1,110.00

Service Code	HCPCS 33017
Hospital Charge Code	3603301701
Hospital Revenue Code	360
Min. Negotiated Rate	$943.50
Max. Negotiated Rate	$1,076.70
Rate for Payer: Cash Price	$666.00
Rate for Payer: Health Management Network Commercial	$943.50
Rate for Payer: MDX Hawaii PPO	$1,076.70

HC PERQ SFT TISS LOC DEVICE PLMT 1ST LES W/GDNCE

Facility

$2,822.00

Service Code	HCPCS 10035
Hospital Charge Code	3611003501
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$836.55
Rate for Payer: AlohaCare Medicare	$836.55
Rate for Payer: Cash Price	$1,693.20
Rate for Payer: Cash Price	$1,693.20
Rate for Payer: Cash Price	$1,693.20
Rate for Payer: Devoted Health Medicare	$920.21
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	$836.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Health Management Network Commercial	$2,398.70
Rate for Payer: Humana Medicare	$836.55
Rate for Payer: Kaiser Permanente Commercial	$1,777.86
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$836.55
Rate for Payer: MDX Hawaii PPO	$2,737.34
Rate for Payer: Ohana Health Plan Medicaid	$920.21
Rate for Payer: Ohana Health Plan Medicare	$836.55
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$836.55
Rate for Payer: University Health Alliance Commercial	$2,056.96

HC PERQ SFT TISS LOC DEVICE PLMT 1ST LES W/GDNCE

Facility

$2,822.00

Service Code	HCPCS 10035
Hospital Charge Code	3611003501
Hospital Revenue Code	361
Min. Negotiated Rate	$2,398.70
Max. Negotiated Rate	$2,737.34
Rate for Payer: Cash Price	$1,693.20
Rate for Payer: Health Management Network Commercial	$2,398.70
Rate for Payer: MDX Hawaii PPO	$2,737.34

HC PERQ TCAT PLMT NTRAC ST 2+LES 2+ST 2+C SEGMENTS

Facility

$63,116.00

Service Code	HCPCS 92930
Hospital Charge Code	4819293001
Hospital Revenue Code	481
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$61,222.52
Rate for Payer: AlohaCare Medicaid	$21,655.98
Rate for Payer: AlohaCare Medicare	$21,655.98
Rate for Payer: Cash Price	$37,869.60
Rate for Payer: Cash Price	$37,869.60
Rate for Payer: Cash Price	$37,869.60
Rate for Payer: Devoted Health Medicare	$23,821.58
Rate for Payer: Hawaii Medical Service Association Commercial	$27,069.97
Rate for Payer: Hawaii Medical Service Association Medicare	$21,655.98
Rate for Payer: Hawaii Western Management Group Commercial	$59,960.20
Rate for Payer: Health Management Network Commercial	$53,648.60
Rate for Payer: Humana Medicare	$21,655.98
Rate for Payer: Kaiser Permanente Commercial	$39,763.08
Rate for Payer: Kaiser Permanente Medicaid	$32,189.16
Rate for Payer: Kaiser Permanente Medicare	$21,655.98
Rate for Payer: MDX Hawaii PPO	$61,222.52
Rate for Payer: Ohana Health Plan Medicaid	$23,821.58
Rate for Payer: Ohana Health Plan Medicare	$21,655.98
Rate for Payer: UnitedHealthcare Medicaid	$644.55
Rate for Payer: UnitedHealthcare Medicare	$21,655.98
Rate for Payer: University Health Alliance Commercial	$46,005.25

HC PERQ TCAT PLMT NTRAC ST 2+LES 2+ST 2+C SEGMENTS

Facility

$63,116.00

Service Code	HCPCS 92930
Hospital Charge Code	4819293001
Hospital Revenue Code	481
Min. Negotiated Rate	$53,648.60
Max. Negotiated Rate	$61,222.52
Rate for Payer: Cash Price	$37,869.60
Rate for Payer: Health Management Network Commercial	$53,648.60
Rate for Payer: MDX Hawaii PPO	$61,222.52

HC PERQ TCAT THER RX DLVR NTRAC RX BALO 1 MAJ C ART

Facility

$28,363.00

Service Code	HCPCS 0913T
Hospital Charge Code	3210913T01
Hospital Revenue Code	321
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$27,512.11
Rate for Payer: AlohaCare Medicaid	$13,637.67
Rate for Payer: AlohaCare Medicare	$13,637.67
Rate for Payer: Cash Price	$17,017.80
Rate for Payer: Cash Price	$17,017.80
Rate for Payer: Cash Price	$17,017.80
Rate for Payer: Devoted Health Medicare	$15,001.44
Rate for Payer: Hawaii Medical Service Association Commercial	$17,047.09
Rate for Payer: Hawaii Medical Service Association Medicare	$13,637.67
Rate for Payer: Hawaii Western Management Group Commercial	$26,944.85
Rate for Payer: Health Management Network Commercial	$24,108.55
Rate for Payer: Humana Medicare	$13,637.67
Rate for Payer: Kaiser Permanente Commercial	$17,868.69
Rate for Payer: Kaiser Permanente Medicaid	$14,465.13
Rate for Payer: Kaiser Permanente Medicare	$13,637.67
Rate for Payer: MDX Hawaii PPO	$27,512.11
Rate for Payer: Ohana Health Plan Medicaid	$15,001.44
Rate for Payer: Ohana Health Plan Medicare	$13,637.67
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$13,637.67
Rate for Payer: University Health Alliance Commercial	$20,673.79

HC PERQ TCAT THER RX DLVR NTRAC RX BALO 1 MAJ C ART

Facility

$28,363.00

Service Code	HCPCS 0913T
Hospital Charge Code	3210913T01
Hospital Revenue Code	321
Min. Negotiated Rate	$24,108.55
Max. Negotiated Rate	$27,512.11
Rate for Payer: Cash Price	$17,017.80
Rate for Payer: Health Management Network Commercial	$24,108.55
Rate for Payer: MDX Hawaii PPO	$27,512.11

HC PERQ TCAT THER RX DLVR NTRAC RX BALO SEPARATE

Facility

$4,023.00

Service Code	HCPCS 0914T
Hospital Charge Code	3210914T01
Hospital Revenue Code	321
Min. Negotiated Rate	$2,051.73
Max. Negotiated Rate	$3,902.31
Rate for Payer: Cash Price	$2,413.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,821.85
Rate for Payer: Health Management Network Commercial	$3,419.55
Rate for Payer: Kaiser Permanente Commercial	$2,534.49
Rate for Payer: Kaiser Permanente Medicaid	$2,051.73
Rate for Payer: MDX Hawaii PPO	$3,902.31
Rate for Payer: University Health Alliance Commercial	$2,932.36

HC PERQ TCAT THER RX DLVR NTRAC RX BALO SEPARATE

Facility

$4,023.00

Service Code	HCPCS 0914T
Hospital Charge Code	3210914T01
Hospital Revenue Code	321
Min. Negotiated Rate	$3,419.55
Max. Negotiated Rate	$3,902.31
Rate for Payer: Cash Price	$2,413.80
Rate for Payer: Health Management Network Commercial	$3,419.55
Rate for Payer: MDX Hawaii PPO	$3,902.31

HC PERQ THRMBC/NFS DIAL CIRCUIT TCAT PLMT IV STENT

Facility

$71,461.00

Service Code	HCPCS 36906
Hospital Charge Code	3613690601
Hospital Revenue Code	361
Min. Negotiated Rate	$487.12
Max. Negotiated Rate	$69,317.17
Rate for Payer: AlohaCare Medicaid	$21,655.98
Rate for Payer: AlohaCare Medicare	$21,655.98
Rate for Payer: Cash Price	$42,876.60
Rate for Payer: Cash Price	$42,876.60
Rate for Payer: Cash Price	$42,876.60
Rate for Payer: Devoted Health Medicare	$23,821.58
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$21,655.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Health Management Network Commercial	$60,741.85
Rate for Payer: Humana Medicare	$21,655.98
Rate for Payer: Kaiser Permanente Commercial	$45,020.43
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$21,655.98
Rate for Payer: MDX Hawaii PPO	$69,317.17
Rate for Payer: Ohana Health Plan Medicaid	$23,821.58
Rate for Payer: Ohana Health Plan Medicare	$21,655.98
Rate for Payer: UnitedHealthcare Medicaid	$487.12
Rate for Payer: UnitedHealthcare Medicare	$21,655.98
Rate for Payer: University Health Alliance Commercial	$6,743.44

HC PERQ THRMBC/NFS DIAL CIRCUIT TCAT PLMT IV STENT

Facility

$71,461.00

Service Code	HCPCS 36906
Hospital Charge Code	3613690601
Hospital Revenue Code	361
Min. Negotiated Rate	$60,741.85
Max. Negotiated Rate	$69,317.17
Rate for Payer: Cash Price	$42,876.60
Rate for Payer: Health Management Network Commercial	$60,741.85
Rate for Payer: MDX Hawaii PPO	$69,317.17

HC PERQ THRMBC/NFS DIAL CIRCUIT TRLUML BALO ANGIOP

Facility

$56,414.00

Service Code	HCPCS 36905
Hospital Charge Code	3613690501
Hospital Revenue Code	361
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$54,721.58
Rate for Payer: AlohaCare Medicaid	$13,637.67
Rate for Payer: AlohaCare Medicare	$13,637.67
Rate for Payer: Cash Price	$33,848.40
Rate for Payer: Cash Price	$33,848.40
Rate for Payer: Cash Price	$33,848.40
Rate for Payer: Devoted Health Medicare	$15,001.44
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$13,637.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Health Management Network Commercial	$47,951.90
Rate for Payer: Humana Medicare	$13,637.67
Rate for Payer: Kaiser Permanente Commercial	$35,540.82
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$13,637.67
Rate for Payer: MDX Hawaii PPO	$54,721.58
Rate for Payer: Ohana Health Plan Medicaid	$15,001.44
Rate for Payer: Ohana Health Plan Medicare	$13,637.67
Rate for Payer: UnitedHealthcare Medicaid	$644.55
Rate for Payer: UnitedHealthcare Medicare	$13,637.67
Rate for Payer: University Health Alliance Commercial	$41,120.16

HC PERQ THRMBC/NFS DIAL CIRCUIT TRLUML BALO ANGIOP

Facility

$56,414.00

Service Code	HCPCS 36905
Hospital Charge Code	3613690501
Hospital Revenue Code	361
Min. Negotiated Rate	$47,951.90
Max. Negotiated Rate	$54,721.58
Rate for Payer: Cash Price	$33,848.40
Rate for Payer: Health Management Network Commercial	$47,951.90
Rate for Payer: MDX Hawaii PPO	$54,721.58

HC PERQ THRMBC/NFS DIALYSIS CIRCUIT IMG DX ANGRPH

Facility

$28,363.00

Service Code	HCPCS 36904
Hospital Charge Code	3613690401
Hospital Revenue Code	361
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$27,512.11
Rate for Payer: AlohaCare Medicaid	$6,723.70
Rate for Payer: AlohaCare Medicare	$6,723.70
Rate for Payer: Cash Price	$17,017.80
Rate for Payer: Cash Price	$17,017.80
Rate for Payer: Cash Price	$17,017.80
Rate for Payer: Devoted Health Medicare	$7,396.07
Rate for Payer: Hawaii Medical Service Association Commercial	$8,404.62
Rate for Payer: Hawaii Medical Service Association Medicare	$6,723.70
Rate for Payer: Health Management Network Commercial	$24,108.55
Rate for Payer: Humana Medicare	$6,723.70
Rate for Payer: Kaiser Permanente Commercial	$17,868.69
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,723.70
Rate for Payer: MDX Hawaii PPO	$27,512.11
Rate for Payer: Ohana Health Plan Medicaid	$7,396.07
Rate for Payer: Ohana Health Plan Medicare	$6,723.70
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,723.70
Rate for Payer: University Health Alliance Commercial	$20,673.79

HC PERQ THRMBC/NFS DIALYSIS CIRCUIT IMG DX ANGRPH

Facility

$28,363.00

Service Code	HCPCS 36904
Hospital Charge Code	3613690401
Hospital Revenue Code	361
Min. Negotiated Rate	$24,108.55
Max. Negotiated Rate	$27,512.11
Rate for Payer: Cash Price	$17,017.80
Rate for Payer: Health Management Network Commercial	$24,108.55
Rate for Payer: MDX Hawaii PPO	$27,512.11

HC PERQ TRANSLUMINAL CORONARY MECHANICL THROMBECTOMY

Facility

$13,214.00

Service Code	HCPCS 92973
Hospital Charge Code	4819297301
Hospital Revenue Code	481
Min. Negotiated Rate	$129.06
Max. Negotiated Rate	$12,817.58
Rate for Payer: Cash Price	$7,928.40
Rate for Payer: Cash Price	$7,928.40
Rate for Payer: Hawaii Western Management Group Commercial	$12,553.30
Rate for Payer: Health Management Network Commercial	$11,231.90
Rate for Payer: Kaiser Permanente Commercial	$8,324.82
Rate for Payer: Kaiser Permanente Medicaid	$6,739.14
Rate for Payer: MDX Hawaii PPO	$12,817.58
Rate for Payer: UnitedHealthcare Medicaid	$129.06
Rate for Payer: University Health Alliance Commercial	$9,631.68

Know your out-of-pocket cost for care.

All Charges