Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC PT GAIT TRAINING THERAPY

Facility

$142.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	4209711601
Hospital Revenue Code	420
Min. Negotiated Rate	$16.70
Max. Negotiated Rate	$137.74
Rate for Payer: Cash Price	$85.20
Rate for Payer: Cash Price	$85.20
Rate for Payer: Hawaii Western Management Group Commercial	$134.90
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Kaiser Permanente Commercial	$89.46
Rate for Payer: Kaiser Permanente Medicaid	$72.42
Rate for Payer: MDX Hawaii PPO	$137.74
Rate for Payer: UnitedHealthcare Medicaid	$16.70
Rate for Payer: University Health Alliance Commercial	$103.50

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

Facility

$131.00

Service Code	HCPCS 97140 GP
Hospital Charge Code	4209714001
Hospital Revenue Code	420
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 PT MANUAL THER TECH,1+REGIONS,EA 15 MIN

Facility

$131.00

Service Code	HCPCS 97140 GP
Hospital Charge Code	4209714001
Hospital Revenue Code	420
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 PT NEUROMUSC REEDUCAT,1+ AREAS, EA 15 MIN

Facility

$163.00

Service Code	HCPCS 97112 GP
Hospital Charge Code	4209711201
Hospital Revenue Code	420
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 PT NEUROMUSC REEDUCAT,1+ AREAS, EA 15 MIN

Facility

$163.00

Service Code	HCPCS 97112 GP
Hospital Charge Code	4209711201
Hospital Revenue Code	420
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 PT ORTHOTIC MGMT AND TRAINING, EACH 15 MIN

Facility

$236.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	4209776001
Hospital Revenue Code	420
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 PT ORTHOTIC MGMT AND TRAINING, EACH 15 MIN

Facility

$236.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	4209776001
Hospital Revenue Code	420
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 PT ORTHOTICS/PROSTH MGMT &/TRAINJ SBSQ ENCTR 15 MIN

Facility

$262.00

Service Code	HCPCS 97763 GP
Hospital Charge Code	4209776301
Hospital Revenue Code	420
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

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

Facility

$262.00

Service Code	HCPCS 97763 GP
Hospital Charge Code	4209776301
Hospital Revenue Code	420
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 PT PHYSICAL THERAPY EVALUATION HIGH COMPLEX 45 MINS

Facility

$486.00

Service Code	HCPCS 97163 GP
Hospital Charge Code	4249716301
Hospital Revenue Code	424
Min. Negotiated Rate	$413.10
Max. Negotiated Rate	$471.42
Rate for Payer: Cash Price	$291.60
Rate for Payer: Health Management Network Commercial	$413.10
Rate for Payer: MDX Hawaii PPO	$471.42

HC PT PHYSICAL THERAPY EVALUATION HIGH COMPLEX 45 MINS

Facility

$486.00

Service Code	HCPCS 97163 GP
Hospital Charge Code	4249716301
Hospital Revenue Code	424
Min. Negotiated Rate	$106.70
Max. Negotiated Rate	$471.42
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cash Price	$291.60
Rate for Payer: Hawaii Western Management Group Commercial	$461.70
Rate for Payer: Health Management Network Commercial	$413.10
Rate for Payer: Kaiser Permanente Commercial	$306.18
Rate for Payer: Kaiser Permanente Medicaid	$247.86
Rate for Payer: MDX Hawaii PPO	$471.42
Rate for Payer: UnitedHealthcare Medicaid	$106.70
Rate for Payer: University Health Alliance Commercial	$354.25

HC PT PHYSICAL THERAPY EVALUATION LOW COMPLEX 20 MINS

Facility

$486.00

Service Code	HCPCS 97161 GP
Hospital Charge Code	4249716101
Hospital Revenue Code	424
Min. Negotiated Rate	$106.70
Max. Negotiated Rate	$471.42
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cash Price	$291.60
Rate for Payer: Hawaii Western Management Group Commercial	$461.70
Rate for Payer: Health Management Network Commercial	$413.10
Rate for Payer: Kaiser Permanente Commercial	$306.18
Rate for Payer: Kaiser Permanente Medicaid	$247.86
Rate for Payer: MDX Hawaii PPO	$471.42
Rate for Payer: UnitedHealthcare Medicaid	$106.70
Rate for Payer: University Health Alliance Commercial	$354.25

HC PT PHYSICAL THERAPY EVALUATION LOW COMPLEX 20 MINS

Facility

$486.00

Service Code	HCPCS 97161 GP
Hospital Charge Code	4249716101
Hospital Revenue Code	424
Min. Negotiated Rate	$413.10
Max. Negotiated Rate	$471.42
Rate for Payer: Cash Price	$291.60
Rate for Payer: Health Management Network Commercial	$413.10
Rate for Payer: MDX Hawaii PPO	$471.42

HC PT PHYSICAL THERAPY EVALUATION MOD COMPLEX 30 MINS

Facility

$486.00

Service Code	HCPCS 97162 GP
Hospital Charge Code	4249716201
Hospital Revenue Code	424
Min. Negotiated Rate	$413.10
Max. Negotiated Rate	$471.42
Rate for Payer: Cash Price	$291.60
Rate for Payer: Health Management Network Commercial	$413.10
Rate for Payer: MDX Hawaii PPO	$471.42

HC PT PHYSICAL THERAPY EVALUATION MOD COMPLEX 30 MINS

Facility

$486.00

Service Code	HCPCS 97162 GP
Hospital Charge Code	4249716201
Hospital Revenue Code	424
Min. Negotiated Rate	$106.70
Max. Negotiated Rate	$471.42
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cash Price	$291.60
Rate for Payer: Hawaii Western Management Group Commercial	$461.70
Rate for Payer: Health Management Network Commercial	$413.10
Rate for Payer: Kaiser Permanente Commercial	$306.18
Rate for Payer: Kaiser Permanente Medicaid	$247.86
Rate for Payer: MDX Hawaii PPO	$471.42
Rate for Payer: UnitedHealthcare Medicaid	$106.70
Rate for Payer: University Health Alliance Commercial	$354.25

HC PT PHYSICAL THERAPY RE-EVAL EST PLAN CARE 20 MINS

Facility

$339.00

Service Code	HCPCS 97164 GP
Hospital Charge Code	4249716401
Hospital Revenue Code	424
Min. Negotiated Rate	$288.15
Max. Negotiated Rate	$328.83
Rate for Payer: Cash Price	$203.40
Rate for Payer: Health Management Network Commercial	$288.15
Rate for Payer: MDX Hawaii PPO	$328.83

HC PT PHYSICAL THERAPY RE-EVAL EST PLAN CARE 20 MINS

Facility

$339.00

Service Code	HCPCS 97164 GP
Hospital Charge Code	4249716401
Hospital Revenue Code	424
Min. Negotiated Rate	$74.59
Max. Negotiated Rate	$328.83
Rate for Payer: Cash Price	$203.40
Rate for Payer: Cash Price	$203.40
Rate for Payer: Hawaii Western Management Group Commercial	$322.05
Rate for Payer: Health Management Network Commercial	$288.15
Rate for Payer: Kaiser Permanente Commercial	$213.57
Rate for Payer: Kaiser Permanente Medicaid	$172.89
Rate for Payer: MDX Hawaii PPO	$328.83
Rate for Payer: UnitedHealthcare Medicaid	$74.59
Rate for Payer: University Health Alliance Commercial	$247.10

HC PT PROSTHETIC TRAINING, EACH 15 MIN

Facility

$205.00

Service Code	HCPCS 97761 GP
Hospital Charge Code	4209776101
Hospital Revenue Code	420
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$123.00
Rate for Payer: Cash Price	$123.00
Rate for Payer: Hawaii Western Management Group Commercial	$194.75
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$129.15
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: UnitedHealthcare Medicaid	$17.70
Rate for Payer: University Health Alliance Commercial	$149.42

HC PT PROSTHETIC TRAINING, EACH 15 MIN

Facility

$205.00

Service Code	HCPCS 97761 GP
Hospital Charge Code	4209776101
Hospital Revenue Code	420
Min. Negotiated Rate	$174.25
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$123.00
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: MDX Hawaii PPO	$198.85

HC P-TRANSCATH BX IC

Facility

$21,513.00

Service Code	HCPCS 37200
Hospital Charge Code	3613720001
Hospital Revenue Code	361
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$20,867.61
Rate for Payer: AlohaCare Medicaid	$6,573.58
Rate for Payer: AlohaCare Medicare	$6,573.58
Rate for Payer: Cash Price	$12,907.80
Rate for Payer: Cash Price	$12,907.80
Rate for Payer: Cash Price	$12,907.80
Rate for Payer: Devoted Health Medicare	$7,230.94
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	$6,573.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Health Management Network Commercial	$18,286.05
Rate for Payer: Humana Medicare	$6,573.58
Rate for Payer: Kaiser Permanente Commercial	$13,553.19
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,573.58
Rate for Payer: MDX Hawaii PPO	$20,867.61
Rate for Payer: Ohana Health Plan Medicaid	$7,230.94
Rate for Payer: Ohana Health Plan Medicare	$6,573.58
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,573.58
Rate for Payer: University Health Alliance Commercial	$13,923.44

HC P-TRANSCATH BX IC

Facility

$21,513.00

Service Code	HCPCS 37200
Hospital Charge Code	3613720001
Hospital Revenue Code	361
Min. Negotiated Rate	$18,286.05
Max. Negotiated Rate	$20,867.61
Rate for Payer: Cash Price	$12,907.80
Rate for Payer: Health Management Network Commercial	$18,286.05
Rate for Payer: MDX Hawaii PPO	$20,867.61

HC PT THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN

Facility

$181.00

Service Code	HCPCS 97530 GP
Hospital Charge Code	4209753001
Hospital Revenue Code	420
Min. Negotiated Rate	$153.85
Max. Negotiated Rate	$175.57
Rate for Payer: Cash Price	$108.60
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: MDX Hawaii PPO	$175.57

HC PT THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN

Facility

$181.00

Service Code	HCPCS 97530 GP
Hospital Charge Code	4209753001
Hospital Revenue Code	420
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$175.57
Rate for Payer: Cash Price	$108.60
Rate for Payer: Cash Price	$108.60
Rate for Payer: Hawaii Western Management Group Commercial	$171.95
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: Kaiser Permanente Commercial	$114.03
Rate for Payer: Kaiser Permanente Medicaid	$92.31
Rate for Payer: MDX Hawaii PPO	$175.57
Rate for Payer: UnitedHealthcare Medicaid	$18.32
Rate for Payer: University Health Alliance Commercial	$131.93

HC PT THERAPEUTIC EXERCISES

Facility

$140.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	4209711001
Hospital Revenue Code	420
Min. Negotiated Rate	$17.65
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Cash Price	$84.00
Rate for Payer: Hawaii Western Management Group Commercial	$133.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: Kaiser Permanente Medicaid	$71.40
Rate for Payer: MDX Hawaii PPO	$135.80
Rate for Payer: UnitedHealthcare Medicaid	$17.65
Rate for Payer: University Health Alliance Commercial	$102.05

HC PT THERAPEUTIC EXERCISES

Facility

$140.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	4209711001
Hospital Revenue Code	420
Min. Negotiated Rate	$119.00
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: MDX Hawaii PPO	$135.80

Know your out-of-pocket cost for care.

All Charges