Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC PRQ PLMT BILIARY DRG CATH W/IMG GID RS&I EXTERNL

Facility

$14,044.00

Service Code	HCPCS 47533
Hospital Charge Code	3614753301
Hospital Revenue Code	361
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,622.68
Rate for Payer: AlohaCare Medicaid	$4,229.69
Rate for Payer: AlohaCare Medicare	$4,229.69
Rate for Payer: Cash Price	$8,426.40
Rate for Payer: Cash Price	$8,426.40
Rate for Payer: Cash Price	$8,426.40
Rate for Payer: Devoted Health Medicare	$4,652.66
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	$4,229.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Health Management Network Commercial	$11,937.40
Rate for Payer: Humana Medicare	$4,229.69
Rate for Payer: Kaiser Permanente Commercial	$8,847.72
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,229.69
Rate for Payer: MDX Hawaii PPO	$13,622.68
Rate for Payer: Ohana Health Plan Medicaid	$4,652.66
Rate for Payer: Ohana Health Plan Medicare	$4,229.69
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,229.69
Rate for Payer: University Health Alliance Commercial	$10,236.67

HC PRQ PLMT BILIARY DRG CATH W/IMG GID RS&I EXTERNL

Facility

$14,044.00

Service Code	HCPCS 47533
Hospital Charge Code	3614753301
Hospital Revenue Code	361
Min. Negotiated Rate	$11,937.40
Max. Negotiated Rate	$13,622.68
Rate for Payer: Cash Price	$8,426.40
Rate for Payer: Health Management Network Commercial	$11,937.40
Rate for Payer: MDX Hawaii PPO	$13,622.68

HC PRQ PLMT BILIARY DRG CATH W/IMG GID RS&I INT-EXT

Facility

$14,044.00

Service Code	HCPCS 47534
Hospital Charge Code	3614753401
Hospital Revenue Code	361
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,622.68
Rate for Payer: AlohaCare Medicaid	$4,229.69
Rate for Payer: AlohaCare Medicare	$4,229.69
Rate for Payer: Cash Price	$8,426.40
Rate for Payer: Cash Price	$8,426.40
Rate for Payer: Cash Price	$8,426.40
Rate for Payer: Devoted Health Medicare	$4,652.66
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	$4,229.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Health Management Network Commercial	$11,937.40
Rate for Payer: Humana Medicare	$4,229.69
Rate for Payer: Kaiser Permanente Commercial	$8,847.72
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,229.69
Rate for Payer: MDX Hawaii PPO	$13,622.68
Rate for Payer: Ohana Health Plan Medicaid	$4,652.66
Rate for Payer: Ohana Health Plan Medicare	$4,229.69
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,229.69
Rate for Payer: University Health Alliance Commercial	$10,236.67

HC PRQ PLMT BILIARY DRG CATH W/IMG GID RS&I INT-EXT

Facility

$14,044.00

Service Code	HCPCS 47534
Hospital Charge Code	3614753401
Hospital Revenue Code	361
Min. Negotiated Rate	$11,937.40
Max. Negotiated Rate	$13,622.68
Rate for Payer: Cash Price	$8,426.40
Rate for Payer: Health Management Network Commercial	$11,937.40
Rate for Payer: MDX Hawaii PPO	$13,622.68

HC PRQ TRANSCATHETER RTRVL INTRVAS FB WITH IMAGING

Facility

$12,526.00

Service Code	HCPCS 37197
Hospital Charge Code	3613719701
Hospital Revenue Code	361
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$3,730.07
Rate for Payer: AlohaCare Medicare	$3,730.07
Rate for Payer: Cash Price	$7,515.60
Rate for Payer: Cash Price	$7,515.60
Rate for Payer: Cash Price	$7,515.60
Rate for Payer: Devoted Health Medicare	$4,103.08
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,730.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Health Management Network Commercial	$10,647.10
Rate for Payer: Humana Medicare	$3,730.07
Rate for Payer: Kaiser Permanente Commercial	$7,891.38
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,730.07
Rate for Payer: MDX Hawaii PPO	$12,150.22
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	$9,130.20

HC PRQ TRANSCATHETER RTRVL INTRVAS FB WITH IMAGING

Facility

$12,526.00

Service Code	HCPCS 37197
Hospital Charge Code	3613719701
Hospital Revenue Code	361
Min. Negotiated Rate	$10,647.10
Max. Negotiated Rate	$12,150.22
Rate for Payer: Cash Price	$7,515.60
Rate for Payer: Health Management Network Commercial	$10,647.10
Rate for Payer: MDX Hawaii PPO	$12,150.22

HC PRQ TRLUML CORONARY STENT W/ANGIO ONE ART/BRNCH

Facility

$44,191.00

Service Code	HCPCS 92928
Hospital Charge Code	3219292801
Hospital Revenue Code	321
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$42,865.27
Rate for Payer: AlohaCare Medicaid	$13,637.67
Rate for Payer: AlohaCare Medicare	$13,637.67
Rate for Payer: Cash Price	$26,514.60
Rate for Payer: Cash Price	$26,514.60
Rate for Payer: Cash Price	$26,514.60
Rate for Payer: Devoted Health Medicare	$15,001.44
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$19,192.00
Rate for Payer: Hawaii Medical Service Association Medicare	$13,637.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,561.00
Rate for Payer: Hawaii Western Management Group Commercial	$41,981.45
Rate for Payer: Health Management Network Commercial	$37,562.35
Rate for Payer: Humana Medicare	$13,637.67
Rate for Payer: Kaiser Permanente Commercial	$27,840.33
Rate for Payer: Kaiser Permanente Medicaid	$22,537.41
Rate for Payer: Kaiser Permanente Medicare	$13,637.67
Rate for Payer: MDX Hawaii PPO	$42,865.27
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	$24,500.00

HC PRQ TRLUML CORONARY STENT W/ANGIO ONE ART/BRNCH

Facility

$44,191.00

Service Code	HCPCS 92928
Hospital Charge Code	3219292801
Hospital Revenue Code	321
Min. Negotiated Rate	$37,562.35
Max. Negotiated Rate	$42,865.27
Rate for Payer: Cash Price	$26,514.60
Rate for Payer: Health Management Network Commercial	$37,562.35
Rate for Payer: MDX Hawaii PPO	$42,865.27

HC PRQ TRLUML CORONRY TOT OCCLUS REVASC MI ONE VSL

Facility

$30,196.00

Service Code	HCPCS 92941
Hospital Charge Code	3609294101
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$29,290.12
Rate for Payer: Cash Price	$18,117.60
Rate for Payer: Cash Price	$18,117.60
Rate for Payer: Health Management Network Commercial	$25,666.60
Rate for Payer: Kaiser Permanente Commercial	$19,023.48
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$29,290.12
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: University Health Alliance Commercial	$22,009.86

HC PRQ TRLUML CORONRY TOT OCCLUS REVASC MI ONE VSL

Facility

$30,196.00

Service Code	HCPCS 92941
Hospital Charge Code	3609294101
Hospital Revenue Code	360
Min. Negotiated Rate	$25,666.60
Max. Negotiated Rate	$29,290.12
Rate for Payer: Cash Price	$18,117.60
Rate for Payer: Health Management Network Commercial	$25,666.60
Rate for Payer: MDX Hawaii PPO	$29,290.12

HC PSA FREE SO

Facility

$154.00

Service Code	HCPCS 84154
Hospital Charge Code	3018415401
Hospital Revenue Code	301
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$149.38
Rate for Payer: AlohaCare Medicaid	$18.39
Rate for Payer: AlohaCare Medicare	$18.39
Rate for Payer: Cash Price	$92.40
Rate for Payer: Cash Price	$92.40
Rate for Payer: Devoted Health Medicare	$20.23
Rate for Payer: Hawaii Medical Service Association ABD	$25.42
Rate for Payer: Hawaii Medical Service Association Commercial	$22.99
Rate for Payer: Hawaii Medical Service Association Medicare	$18.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.69
Rate for Payer: Hawaii Western Management Group Commercial	$18.39
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: Humana Medicare	$18.39
Rate for Payer: Kaiser Permanente Commercial	$97.02
Rate for Payer: Kaiser Permanente Medicaid	$78.54
Rate for Payer: Kaiser Permanente Medicare	$18.39
Rate for Payer: MDX Hawaii PPO	$149.38
Rate for Payer: Ohana Health Plan Medicaid	$20.23
Rate for Payer: Ohana Health Plan Medicare	$18.39
Rate for Payer: UnitedHealthcare Medicaid	$25.42
Rate for Payer: UnitedHealthcare Medicare	$18.39
Rate for Payer: University Health Alliance Commercial	$47.55

HC PSA FREE SO

Facility

$154.00

Service Code	HCPCS 84154
Hospital Charge Code	3018415401
Hospital Revenue Code	301
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$149.38
Rate for Payer: Cash Price	$92.40
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: MDX Hawaii PPO	$149.38

HC PSA TOTAL CA MCR SCREEN

Facility

$162.00

Service Code	HCPCS G0103
Hospital Charge Code	300G010301
Hospital Revenue Code	300
Min. Negotiated Rate	$19.31
Max. Negotiated Rate	$157.14
Rate for Payer: AlohaCare Medicaid	$19.31
Rate for Payer: AlohaCare Medicare	$19.31
Rate for Payer: Cash Price	$97.20
Rate for Payer: Cash Price	$97.20
Rate for Payer: Devoted Health Medicare	$21.24
Rate for Payer: Hawaii Medical Service Association Commercial	$24.14
Rate for Payer: Hawaii Medical Service Association Medicare	$19.31
Rate for Payer: Hawaii Western Management Group Commercial	$153.90
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Humana Medicare	$19.31
Rate for Payer: Kaiser Permanente Commercial	$102.06
Rate for Payer: Kaiser Permanente Medicaid	$82.62
Rate for Payer: Kaiser Permanente Medicare	$19.31
Rate for Payer: MDX Hawaii PPO	$157.14
Rate for Payer: Ohana Health Plan Medicaid	$21.24
Rate for Payer: Ohana Health Plan Medicare	$19.31
Rate for Payer: UnitedHealthcare Medicaid	$25.42
Rate for Payer: UnitedHealthcare Medicare	$19.31
Rate for Payer: University Health Alliance Commercial	$118.08

HC PSA TOTAL CA MCR SCREEN

Facility

$162.00

Service Code	HCPCS G0103
Hospital Charge Code	300G010301
Hospital Revenue Code	300
Min. Negotiated Rate	$137.70
Max. Negotiated Rate	$157.14
Rate for Payer: Cash Price	$97.20
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: MDX Hawaii PPO	$157.14

HC PSYCH ROOM DAILY

Facility

$4,375.00

Hospital Charge Code	1240000001
Hospital Revenue Code	124
Min. Negotiated Rate	$3,150.00
Max. Negotiated Rate	$4,243.75
Rate for Payer: Cash Price	$2,625.00
Rate for Payer: Cash Price	$2,625.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,200.00
Rate for Payer: Health Management Network Commercial	$3,718.75
Rate for Payer: MDX Hawaii PPO	$4,243.75
Rate for Payer: University Health Alliance Commercial	$3,150.00

HC PSYCH ROOM DAILY PRIVATE

Facility

$4,375.00

Hospital Charge Code	1140000001
Hospital Revenue Code	114
Min. Negotiated Rate	$3,150.00
Max. Negotiated Rate	$4,243.75
Rate for Payer: Cash Price	$2,625.00
Rate for Payer: Cash Price	$2,625.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,200.00
Rate for Payer: Health Management Network Commercial	$3,718.75
Rate for Payer: MDX Hawaii PPO	$4,243.75
Rate for Payer: University Health Alliance Commercial	$3,150.00

HC PT CAREGIVER TRAINING STRATEGIES&TQ EA ADDL 15 MIN

Facility

$108.00

Service Code	HCPCS 97551
Hospital Charge Code	9429755101
Hospital Revenue Code	942
Min. Negotiated Rate	$25.05
Max. Negotiated Rate	$104.76
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cash Price	$64.80
Rate for Payer: Hawaii Western Management Group Commercial	$102.60
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Kaiser Permanente Commercial	$68.04
Rate for Payer: Kaiser Permanente Medicaid	$55.08
Rate for Payer: MDX Hawaii PPO	$104.76
Rate for Payer: UnitedHealthcare Medicaid	$25.05
Rate for Payer: University Health Alliance Commercial	$78.72

HC PT CAREGIVER TRAINING STRATEGIES&TQ EA ADDL 15 MIN

Facility

$108.00

Service Code	HCPCS 97551
Hospital Charge Code	9429755101
Hospital Revenue Code	942
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$104.76
Rate for Payer: Cash Price	$64.80
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: MDX Hawaii PPO	$104.76

HC PT DEBRIDEMENT OPEN WOUND EA ADDL 20 SQ CM

Facility

$288.00

Service Code	HCPCS 97598
Hospital Charge Code	4209759801
Hospital Revenue Code	450
Min. Negotiated Rate	$181.44
Max. Negotiated Rate	$1,600.00
Rate for Payer: Cash Price	$172.80
Rate for Payer: Cash Price	$172.80
Rate for Payer: Cash Price	$172.80
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 Non-ABD	$520.00
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	$937.50
Rate for Payer: MDX Hawaii PPO	$279.36
Rate for Payer: University Health Alliance Commercial	$209.92

HC PT DEBRIDEMENT OPEN WOUND EA ADDL 20 SQ CM

Facility

$288.00

Service Code	HCPCS 97598
Hospital Charge Code	4209759801
Hospital Revenue Code	450
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 PT ELECTRICAL STIMULATION

Facility

$68.00

Service Code	HCPCS 97032 GP
Hospital Charge Code	4209703201
Hospital Revenue Code	420
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 PT ELECTRICAL STIMULATION

Facility

$68.00

Service Code	HCPCS 97032 GP
Hospital Charge Code	4209703201
Hospital Revenue Code	420
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 PT-FOCUSED HLTH RISK ASSMT

Facility

$119.00

Service Code	HCPCS 96160
Hospital Charge Code	9189616001
Hospital Revenue Code	918
Min. Negotiated Rate	$3.44
Max. Negotiated Rate	$115.43
Rate for Payer: AlohaCare Medicaid	$44.26
Rate for Payer: AlohaCare Medicare	$44.26
Rate for Payer: Cash Price	$71.40
Rate for Payer: Cash Price	$71.40
Rate for Payer: Devoted Health Medicare	$48.69
Rate for Payer: Hawaii Medical Service Association Commercial	$55.33
Rate for Payer: Hawaii Medical Service Association Medicare	$44.26
Rate for Payer: Hawaii Western Management Group Commercial	$113.05
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Humana Medicare	$44.26
Rate for Payer: Kaiser Permanente Commercial	$74.97
Rate for Payer: Kaiser Permanente Medicaid	$60.69
Rate for Payer: Kaiser Permanente Medicare	$44.26
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: Ohana Health Plan Medicaid	$48.69
Rate for Payer: Ohana Health Plan Medicare	$44.26
Rate for Payer: UnitedHealthcare Medicaid	$3.44
Rate for Payer: UnitedHealthcare Medicare	$44.26
Rate for Payer: University Health Alliance Commercial	$86.74

HC PT-FOCUSED HLTH RISK ASSMT

Facility

$119.00

Service Code	HCPCS 96160
Hospital Charge Code	9189616001
Hospital Revenue Code	918
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: MDX Hawaii PPO	$115.43

HC PT GAIT TRAINING THERAPY

Facility

$142.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	4209711601
Hospital Revenue Code	420
Min. Negotiated Rate	$120.70
Max. Negotiated Rate	$137.74
Rate for Payer: Cash Price	$85.20
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: MDX Hawaii PPO	$137.74

Know your out-of-pocket cost for care.

All Charges