Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC PT ULTRASOUND THERAPY

Facility

$68.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	4209703501
Hospital Revenue Code	420
Min. Negotiated Rate	$9.52
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	$9.52
Rate for Payer: University Health Alliance Commercial	$49.57

HC PT ULTRASOUND THERAPY

Facility

$68.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	4209703501
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 WHEELCHAIR MNGEMENT TRAINING, EA 15 MIN

Facility

$154.00

Service Code	HCPCS 97542 GP
Hospital Charge Code	4209754201
Hospital Revenue Code	420
Min. Negotiated Rate	$17.54
Max. Negotiated Rate	$149.38
Rate for Payer: Cash Price	$92.40
Rate for Payer: Cash Price	$92.40
Rate for Payer: Hawaii Western Management Group Commercial	$146.30
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: Kaiser Permanente Commercial	$97.02
Rate for Payer: Kaiser Permanente Medicaid	$78.54
Rate for Payer: MDX Hawaii PPO	$149.38
Rate for Payer: UnitedHealthcare Medicaid	$17.54
Rate for Payer: University Health Alliance Commercial	$112.25

HC PT WHEELCHAIR MNGEMENT TRAINING, EA 15 MIN

Facility

$154.00

Service Code	HCPCS 97542 GP
Hospital Charge Code	4209754201
Hospital Revenue Code	420
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 PULM FUNCTION TEST BY GAS - HELIUM DILUTION LUNG VOLUMES

Facility

$623.00

Service Code	HCPCS 94727
Hospital Charge Code	4609472701
Hospital Revenue Code	460
Min. Negotiated Rate	$20.65
Max. Negotiated Rate	$604.31
Rate for Payer: AlohaCare Medicaid	$255.08
Rate for Payer: AlohaCare Medicare	$255.08
Rate for Payer: Cash Price	$373.80
Rate for Payer: Cash Price	$373.80
Rate for Payer: Devoted Health Medicare	$280.59
Rate for Payer: Hawaii Medical Service Association ABD	$20.65
Rate for Payer: Hawaii Medical Service Association Commercial	$318.85
Rate for Payer: Hawaii Medical Service Association Medicare	$255.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29.66
Rate for Payer: Hawaii Western Management Group Commercial	$591.85
Rate for Payer: Health Management Network Commercial	$529.55
Rate for Payer: Humana Medicare	$255.08
Rate for Payer: Kaiser Permanente Commercial	$392.49
Rate for Payer: Kaiser Permanente Medicaid	$317.73
Rate for Payer: Kaiser Permanente Medicare	$255.08
Rate for Payer: MDX Hawaii PPO	$604.31
Rate for Payer: Ohana Health Plan Medicaid	$280.59
Rate for Payer: Ohana Health Plan Medicare	$255.08
Rate for Payer: UnitedHealthcare Medicaid	$20.65
Rate for Payer: UnitedHealthcare Medicare	$255.08
Rate for Payer: University Health Alliance Commercial	$454.10

HC PULM FUNCTION TEST BY GAS - HELIUM DILUTION LUNG VOLUMES

Facility

$623.00

Service Code	HCPCS 94727
Hospital Charge Code	4609472701
Hospital Revenue Code	460
Min. Negotiated Rate	$529.55
Max. Negotiated Rate	$604.31
Rate for Payer: Cash Price	$373.80
Rate for Payer: Health Management Network Commercial	$529.55
Rate for Payer: MDX Hawaii PPO	$604.31

HC PULM FUNCT TST PLETHYSMOGRAP - BODY PLETHYSMOGRAPHIC LUNG VOLUMES

Facility

$1,239.00

Service Code	HCPCS 94726
Hospital Charge Code	4609472602
Hospital Revenue Code	460
Min. Negotiated Rate	$28.57
Max. Negotiated Rate	$1,201.83
Rate for Payer: AlohaCare Medicaid	$440.83
Rate for Payer: AlohaCare Medicare	$440.83
Rate for Payer: Cash Price	$743.40
Rate for Payer: Cash Price	$743.40
Rate for Payer: Devoted Health Medicare	$484.91
Rate for Payer: Hawaii Medical Service Association ABD	$28.57
Rate for Payer: Hawaii Medical Service Association Commercial	$551.04
Rate for Payer: Hawaii Medical Service Association Medicare	$440.83
Rate for Payer: Hawaii Medical Service Association Non-ABD	$41.03
Rate for Payer: Hawaii Western Management Group Commercial	$1,177.05
Rate for Payer: Health Management Network Commercial	$1,053.15
Rate for Payer: Humana Medicare	$440.83
Rate for Payer: Kaiser Permanente Commercial	$780.57
Rate for Payer: Kaiser Permanente Medicaid	$631.89
Rate for Payer: Kaiser Permanente Medicare	$440.83
Rate for Payer: MDX Hawaii PPO	$1,201.83
Rate for Payer: Ohana Health Plan Medicaid	$484.91
Rate for Payer: Ohana Health Plan Medicare	$440.83
Rate for Payer: UnitedHealthcare Medicaid	$28.57
Rate for Payer: UnitedHealthcare Medicare	$440.83
Rate for Payer: University Health Alliance Commercial	$903.11

HC PULM FUNCT TST PLETHYSMOGRAP - BODY PLETHYSMOGRAPHIC LUNG VOLUMES

Facility

$1,239.00

Service Code	HCPCS 94726
Hospital Charge Code	4609472602
Hospital Revenue Code	460
Min. Negotiated Rate	$1,053.15
Max. Negotiated Rate	$1,201.83
Rate for Payer: Cash Price	$743.40
Rate for Payer: Health Management Network Commercial	$1,053.15
Rate for Payer: MDX Hawaii PPO	$1,201.83

HC PULMONARY STRESS TESTING

Facility

$513.00

Service Code	HCPCS 94618
Hospital Charge Code	4609461801
Hospital Revenue Code	460
Min. Negotiated Rate	$7.81
Max. Negotiated Rate	$497.61
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cash Price	$307.80
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association ABD	$7.81
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.23
Rate for Payer: Hawaii Western Management Group Commercial	$487.35
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Commercial	$323.19
Rate for Payer: Kaiser Permanente Medicaid	$261.63
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: MDX Hawaii PPO	$497.61
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$36.04
Rate for Payer: UnitedHealthcare Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$373.93

HC PULMONARY STRESS TESTING

Facility

$513.00

Service Code	HCPCS 94618
Hospital Charge Code	4609461801
Hospital Revenue Code	460
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$307.80
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: MDX Hawaii PPO	$497.61

HC PULSE OXIMETRY MULTIPLE

Facility

$201.00

Service Code	HCPCS 94761
Hospital Charge Code	4609476101
Hospital Revenue Code	460
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$194.97
Rate for Payer: Cash Price	$120.60
Rate for Payer: Cash Price	$120.60
Rate for Payer: Hawaii Western Management Group Commercial	$190.95
Rate for Payer: Health Management Network Commercial	$170.85
Rate for Payer: Kaiser Permanente Commercial	$126.63
Rate for Payer: Kaiser Permanente Medicaid	$102.51
Rate for Payer: MDX Hawaii PPO	$194.97
Rate for Payer: UnitedHealthcare Medicaid	$4.77
Rate for Payer: University Health Alliance Commercial	$146.51

HC PULSE OXIMETRY MULTIPLE

Facility

$201.00

Service Code	HCPCS 94761
Hospital Charge Code	4609476101
Hospital Revenue Code	460
Min. Negotiated Rate	$170.85
Max. Negotiated Rate	$194.97
Rate for Payer: Cash Price	$120.60
Rate for Payer: Health Management Network Commercial	$170.85
Rate for Payer: MDX Hawaii PPO	$194.97

HC PUNCTURE ASPIRATION CYST BREAST EACH ADDL CYST

Facility

$1,073.00

Service Code	HCPCS 19001
Hospital Charge Code	3611900101
Hospital Revenue Code	361
Min. Negotiated Rate	$15.86
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$643.80
Rate for Payer: Cash Price	$643.80
Rate for Payer: Cash Price	$643.80
Rate for Payer: Health Management Network Commercial	$912.05
Rate for Payer: Kaiser Permanente Commercial	$675.99
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$1,040.81
Rate for Payer: UnitedHealthcare Medicaid	$15.86
Rate for Payer: University Health Alliance Commercial	$782.11

HC PUNCTURE ASPIRATION CYST BREAST EACH ADDL CYST

Facility

$1,073.00

Service Code	HCPCS 19001
Hospital Charge Code	3611900101
Hospital Revenue Code	361
Min. Negotiated Rate	$912.05
Max. Negotiated Rate	$1,040.81
Rate for Payer: Cash Price	$643.80
Rate for Payer: Health Management Network Commercial	$912.05
Rate for Payer: MDX Hawaii PPO	$1,040.81

HC PUNCTURE DRAINAGE OF LESION

Facility

$1,590.00

Service Code	HCPCS 10160
Hospital Charge Code	3611016001
Hospital Revenue Code	361
Min. Negotiated Rate	$57.25
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$528.25
Rate for Payer: Hawaii Medical Service Association Commercial	$600.29
Rate for Payer: Hawaii Medical Service Association Medicare	$480.23
Rate for Payer: Health Management Network Commercial	$1,351.50
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Commercial	$1,001.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: MDX Hawaii PPO	$1,542.30
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicaid	$57.25
Rate for Payer: UnitedHealthcare Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC PUNCTURE DRAINAGE OF LESION

Facility

$1,590.00

Service Code	HCPCS 10160
Hospital Charge Code	3611016001
Hospital Revenue Code	361
Min. Negotiated Rate	$1,351.50
Max. Negotiated Rate	$1,542.30
Rate for Payer: Cash Price	$954.00
Rate for Payer: Health Management Network Commercial	$1,351.50
Rate for Payer: MDX Hawaii PPO	$1,542.30

HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - OLANZAPINE LEVEL SO

Facility

$156.00

Service Code	HCPCS 80299
Hospital Charge Code	3018029901
Hospital Revenue Code	301
Min. Negotiated Rate	$18.64
Max. Negotiated Rate	$151.32
Rate for Payer: AlohaCare Medicaid	$18.64
Rate for Payer: AlohaCare Medicare	$18.64
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Devoted Health Medicare	$20.50
Rate for Payer: Hawaii Medical Service Association ABD	$18.92
Rate for Payer: Hawaii Medical Service Association Commercial	$23.30
Rate for Payer: Hawaii Medical Service Association Medicare	$18.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.87
Rate for Payer: Hawaii Western Management Group Commercial	$18.64
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: Humana Medicare	$18.64
Rate for Payer: Kaiser Permanente Commercial	$98.28
Rate for Payer: Kaiser Permanente Medicaid	$79.56
Rate for Payer: Kaiser Permanente Medicare	$18.64
Rate for Payer: MDX Hawaii PPO	$151.32
Rate for Payer: Ohana Health Plan Medicaid	$20.50
Rate for Payer: Ohana Health Plan Medicare	$18.64
Rate for Payer: UnitedHealthcare Medicaid	$18.92
Rate for Payer: UnitedHealthcare Medicare	$18.64
Rate for Payer: University Health Alliance Commercial	$35.39

HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - OLANZAPINE LEVEL SO

Facility

$156.00

Service Code	HCPCS 80299
Hospital Charge Code	3018029901
Hospital Revenue Code	301
Min. Negotiated Rate	$132.60
Max. Negotiated Rate	$151.32
Rate for Payer: Cash Price	$93.60
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: MDX Hawaii PPO	$151.32

HC QUANT THERA DRUG NOS SO

Facility

$156.00

Service Code	HCPCS 80299
Hospital Charge Code	3018029919
Hospital Revenue Code	301
Min. Negotiated Rate	$18.64
Max. Negotiated Rate	$151.32
Rate for Payer: AlohaCare Medicaid	$18.64
Rate for Payer: AlohaCare Medicare	$18.64
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Devoted Health Medicare	$20.50
Rate for Payer: Hawaii Medical Service Association ABD	$18.92
Rate for Payer: Hawaii Medical Service Association Commercial	$23.30
Rate for Payer: Hawaii Medical Service Association Medicare	$18.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.87
Rate for Payer: Hawaii Western Management Group Commercial	$18.64
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: Humana Medicare	$18.64
Rate for Payer: Kaiser Permanente Commercial	$98.28
Rate for Payer: Kaiser Permanente Medicaid	$79.56
Rate for Payer: Kaiser Permanente Medicare	$18.64
Rate for Payer: MDX Hawaii PPO	$151.32
Rate for Payer: Ohana Health Plan Medicaid	$20.50
Rate for Payer: Ohana Health Plan Medicare	$18.64
Rate for Payer: UnitedHealthcare Medicaid	$18.92
Rate for Payer: UnitedHealthcare Medicare	$18.64
Rate for Payer: University Health Alliance Commercial	$35.39

HC QUANT THERA DRUG NOS SO

Facility

$156.00

Service Code	HCPCS 80299
Hospital Charge Code	3018029919
Hospital Revenue Code	301
Min. Negotiated Rate	$132.60
Max. Negotiated Rate	$151.32
Rate for Payer: Cash Price	$93.60
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: MDX Hawaii PPO	$151.32

HC RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 1 VW - XR ENTIRE SPINE 1 V

Facility

$438.00

Service Code	HCPCS 72081
Hospital Charge Code	3207208102
Hospital Revenue Code	320
Min. Negotiated Rate	$372.30
Max. Negotiated Rate	$424.86
Rate for Payer: Cash Price	$262.80
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: MDX Hawaii PPO	$424.86

HC RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 1 VW - XR ENTIRE SPINE 1 V

Facility

$438.00

Service Code	HCPCS 72081
Hospital Charge Code	3207208102
Hospital Revenue Code	320
Min. Negotiated Rate	$17.62
Max. Negotiated Rate	$424.86
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$262.80
Rate for Payer: Cash Price	$262.80
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association ABD	$17.62
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.05
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$275.94
Rate for Payer: Kaiser Permanente Medicaid	$223.38
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$424.86
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$28.37
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$80.07

HC RADEX SPINE CERVICAL 2 OR 3 VIEWS - XR CERVICAL SPINE 2-3 VIEWS

Facility

$438.00

Service Code	HCPCS 72040
Hospital Charge Code	3207204002
Hospital Revenue Code	320
Min. Negotiated Rate	$19.78
Max. Negotiated Rate	$424.86
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$262.80
Rate for Payer: Cash Price	$262.80
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association ABD	$19.78
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.66
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$275.94
Rate for Payer: Kaiser Permanente Medicaid	$223.38
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$424.86
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$19.78
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$73.65

HC RADEX SPINE CERVICAL 2 OR 3 VIEWS - XR CERVICAL SPINE 2-3 VIEWS

Facility

$438.00

Service Code	HCPCS 72040
Hospital Charge Code	3207204002
Hospital Revenue Code	320
Min. Negotiated Rate	$372.30
Max. Negotiated Rate	$424.86
Rate for Payer: Cash Price	$262.80
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: MDX Hawaii PPO	$424.86

HC RADEX SPINE CERVICAL 4 OR 5 VIEWS - XR CERVICAL SPINE COMP 4-5 VIEWS

Facility

$529.00

Service Code	HCPCS 72050
Hospital Charge Code	3207205001
Hospital Revenue Code	320
Min. Negotiated Rate	$29.64
Max. Negotiated Rate	$513.13
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$317.40
Rate for Payer: Cash Price	$317.40
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$29.64
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$32.30
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$333.27
Rate for Payer: Kaiser Permanente Medicaid	$269.79
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$513.13
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$29.64
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$105.14

Know your out-of-pocket cost for care.

All Charges