Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC REPOSITION VENOUS CATHETER

Facility

$6,182.00

Service Code	HCPCS 36597
Hospital Charge Code	3613659701
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 REP,SKIN,SCALP/EXTREM+5 CM/<

Facility

$1,272.00

Service Code	HCPCS 13122
Hospital Charge Code	4501312201
Hospital Revenue Code	450
Min. Negotiated Rate	$1,081.20
Max. Negotiated Rate	$1,233.84
Rate for Payer: Cash Price	$763.20
Rate for Payer: Health Management Network Commercial	$1,081.20
Rate for Payer: MDX Hawaii PPO	$1,233.84

HC REP,SKIN,SCALP/EXTREM+5 CM/<

Facility

$1,272.00

Service Code	HCPCS 13122
Hospital Charge Code	4501312201
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Cash Price	$763.20
Rate for Payer: Cash Price	$763.20
Rate for Payer: Cash Price	$763.20
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	$1,208.40
Rate for Payer: Health Management Network Commercial	$1,081.20
Rate for Payer: Kaiser Permanente Commercial	$801.36
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: MDX Hawaii PPO	$1,233.84
Rate for Payer: University Health Alliance Commercial	$927.16

HC REP,SKIN,TRUNK,CMPLX,+5 CM/<

Facility

$1,811.00

Service Code	HCPCS 13102
Hospital Charge Code	7611310201
Hospital Revenue Code	450
Min. Negotiated Rate	$1,539.35
Max. Negotiated Rate	$1,756.67
Rate for Payer: Cash Price	$1,086.60
Rate for Payer: Health Management Network Commercial	$1,539.35
Rate for Payer: MDX Hawaii PPO	$1,756.67

HC REP,SKIN,TRUNK,CMPLX,+5 CM/<

Facility

$1,811.00

Service Code	HCPCS 13102
Hospital Charge Code	7611310201
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$1,756.67
Rate for Payer: Cash Price	$1,086.60
Rate for Payer: Cash Price	$1,086.60
Rate for Payer: Cash Price	$1,086.60
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	$1,720.45
Rate for Payer: Health Management Network Commercial	$1,539.35
Rate for Payer: Kaiser Permanente Commercial	$1,140.93
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: MDX Hawaii PPO	$1,756.67
Rate for Payer: University Health Alliance Commercial	$1,320.04

HC REPTILASE TEST - REPTILASE TIME

Facility

$83.00

Service Code	HCPCS 85635
Hospital Charge Code	3058563501
Hospital Revenue Code	305
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$49.80
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: MDX Hawaii PPO	$80.51

HC REPTILASE TEST - REPTILASE TIME

Facility

$83.00

Service Code	HCPCS 85635
Hospital Charge Code	3058563501
Hospital Revenue Code	305
Min. Negotiated Rate	$8.26
Max. Negotiated Rate	$80.51
Rate for Payer: AlohaCare Medicaid	$9.85
Rate for Payer: AlohaCare Medicare	$9.85
Rate for Payer: Cash Price	$49.80
Rate for Payer: Cash Price	$49.80
Rate for Payer: Devoted Health Medicare	$10.84
Rate for Payer: Hawaii Medical Service Association ABD	$8.26
Rate for Payer: Hawaii Medical Service Association Commercial	$12.31
Rate for Payer: Hawaii Medical Service Association Medicare	$9.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13.61
Rate for Payer: Hawaii Western Management Group Commercial	$9.85
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Humana Medicare	$9.85
Rate for Payer: Kaiser Permanente Commercial	$52.29
Rate for Payer: Kaiser Permanente Medicaid	$42.33
Rate for Payer: Kaiser Permanente Medicare	$9.85
Rate for Payer: MDX Hawaii PPO	$80.51
Rate for Payer: Ohana Health Plan Medicaid	$10.84
Rate for Payer: Ohana Health Plan Medicare	$9.85
Rate for Payer: UnitedHealthcare Medicaid	$8.26
Rate for Payer: UnitedHealthcare Medicare	$9.85
Rate for Payer: University Health Alliance Commercial	$25.46

HC RESPIRATORY FLOW VOLUME LOOP - FLOW VOLUME LOOP

Facility

$1,213.00

Service Code	HCPCS 94375
Hospital Charge Code	4609437501
Hospital Revenue Code	460
Min. Negotiated Rate	$15.25
Max. Negotiated Rate	$1,176.61
Rate for Payer: AlohaCare Medicaid	$255.08
Rate for Payer: AlohaCare Medicare	$255.08
Rate for Payer: Cash Price	$727.80
Rate for Payer: Cash Price	$727.80
Rate for Payer: Devoted Health Medicare	$280.59
Rate for Payer: Hawaii Medical Service Association ABD	$15.25
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	$16.07
Rate for Payer: Hawaii Western Management Group Commercial	$1,152.35
Rate for Payer: Health Management Network Commercial	$1,031.05
Rate for Payer: Humana Medicare	$255.08
Rate for Payer: Kaiser Permanente Commercial	$764.19
Rate for Payer: Kaiser Permanente Medicaid	$618.63
Rate for Payer: Kaiser Permanente Medicare	$255.08
Rate for Payer: MDX Hawaii PPO	$1,176.61
Rate for Payer: Ohana Health Plan Medicaid	$280.59
Rate for Payer: Ohana Health Plan Medicare	$255.08
Rate for Payer: UnitedHealthcare Medicaid	$15.25
Rate for Payer: UnitedHealthcare Medicare	$255.08
Rate for Payer: University Health Alliance Commercial	$884.16

HC RESPIRATORY FLOW VOLUME LOOP - FLOW VOLUME LOOP

Facility

$1,213.00

Service Code	HCPCS 94375
Hospital Charge Code	4609437501
Hospital Revenue Code	460
Min. Negotiated Rate	$1,031.05
Max. Negotiated Rate	$1,176.61
Rate for Payer: Cash Price	$727.80
Rate for Payer: Health Management Network Commercial	$1,031.05
Rate for Payer: MDX Hawaii PPO	$1,176.61

HC RESPIRATORY PATH PNL 2.1

Facility

$3,497.00

Service Code	HCPCS 0202U
Hospital Charge Code	3000202U01
Hospital Revenue Code	300
Min. Negotiated Rate	$416.78
Max. Negotiated Rate	$3,392.09
Rate for Payer: AlohaCare Medicaid	$416.78
Rate for Payer: AlohaCare Medicare	$416.78
Rate for Payer: Cash Price	$2,098.20
Rate for Payer: Cash Price	$2,098.20
Rate for Payer: Devoted Health Medicare	$458.46
Rate for Payer: Hawaii Medical Service Association Commercial	$520.98
Rate for Payer: Hawaii Medical Service Association Medicare	$416.78
Rate for Payer: Hawaii Western Management Group Commercial	$3,322.15
Rate for Payer: Health Management Network Commercial	$2,972.45
Rate for Payer: Humana Medicare	$416.78
Rate for Payer: Kaiser Permanente Commercial	$2,203.11
Rate for Payer: Kaiser Permanente Medicaid	$1,783.47
Rate for Payer: Kaiser Permanente Medicare	$416.78
Rate for Payer: MDX Hawaii PPO	$3,392.09
Rate for Payer: Ohana Health Plan Medicaid	$458.46
Rate for Payer: Ohana Health Plan Medicare	$416.78
Rate for Payer: UnitedHealthcare Medicaid	$416.78
Rate for Payer: UnitedHealthcare Medicare	$416.78
Rate for Payer: University Health Alliance Commercial	$2,548.96

HC RESPIRATORY PATH PNL 2.1

Facility

$3,497.00

Service Code	HCPCS 0202U
Hospital Charge Code	3000202U01
Hospital Revenue Code	300
Min. Negotiated Rate	$2,972.45
Max. Negotiated Rate	$3,392.09
Rate for Payer: Cash Price	$2,098.20
Rate for Payer: Health Management Network Commercial	$2,972.45
Rate for Payer: MDX Hawaii PPO	$3,392.09

HC RESP MOTION MGMT W SIMUL

Facility

$1,301.00

Service Code	HCPCS 77293
Hospital Charge Code	3337729301
Hospital Revenue Code	333
Min. Negotiated Rate	$273.87
Max. Negotiated Rate	$1,261.97
Rate for Payer: Cash Price	$780.60
Rate for Payer: Cash Price	$780.60
Rate for Payer: Hawaii Medical Service Association ABD	$510.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$301.97
Rate for Payer: Hawaii Western Management Group Commercial	$1,235.95
Rate for Payer: Health Management Network Commercial	$1,105.85
Rate for Payer: Kaiser Permanente Commercial	$819.63
Rate for Payer: Kaiser Permanente Medicaid	$663.51
Rate for Payer: MDX Hawaii PPO	$1,261.97
Rate for Payer: UnitedHealthcare Medicaid	$273.87
Rate for Payer: University Health Alliance Commercial	$941.04

HC RESP MOTION MGMT W SIMUL

Facility

$1,301.00

Service Code	HCPCS 77293
Hospital Charge Code	3337729301
Hospital Revenue Code	333
Min. Negotiated Rate	$1,105.85
Max. Negotiated Rate	$1,261.97
Rate for Payer: Cash Price	$780.60
Rate for Payer: Health Management Network Commercial	$1,105.85
Rate for Payer: MDX Hawaii PPO	$1,261.97

HC RESUPERF WND BODY 12.6-20 CM

Facility

$1,590.00

Service Code	HCPCS 12005
Hospital Charge Code	4501200501
Hospital Revenue Code	450
Min. Negotiated Rate	$480.23
Max. Negotiated Rate	$1,600.00
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: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$528.25
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 Medicare	$480.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,510.50
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	$937.50
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 Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$1,158.95

HC RESUPERF WND BODY 12.6-20 CM

Facility

$1,590.00

Service Code	HCPCS 12005
Hospital Charge Code	4501200501
Hospital Revenue Code	450
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 RESUPERF WND BODY 20.1-30 CM

Facility

$1,590.00

Service Code	HCPCS 12006
Hospital Charge Code	4501200601
Hospital Revenue Code	450
Min. Negotiated Rate	$480.23
Max. Negotiated Rate	$1,600.00
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: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$528.25
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 Medicare	$480.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,510.50
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	$937.50
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 Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$1,158.95

HC RESUPERF WND BODY 20.1-30 CM

Facility

$1,590.00

Service Code	HCPCS 12006
Hospital Charge Code	4501200601
Hospital Revenue Code	450
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 RESUPERF WND BODY <2.5CM

Facility

$791.00

Service Code	HCPCS 12001
Hospital Charge Code	4501200101
Hospital Revenue Code	450
Min. Negotiated Rate	$237.02
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Devoted Health Medicare	$260.72
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 Medicare	$237.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$751.45
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Commercial	$498.33
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicare	$237.02
Rate for Payer: University Health Alliance Commercial	$576.56

HC RESUPERF WND BODY <2.5CM

Facility

$791.00

Service Code	HCPCS 12001
Hospital Charge Code	4501200101
Hospital Revenue Code	450
Min. Negotiated Rate	$672.35
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: MDX Hawaii PPO	$767.27

HC RESUPERF WND BODY >30 CM

Facility

$791.00

Service Code	HCPCS 12007
Hospital Charge Code	7611200701
Hospital Revenue Code	450
Min. Negotiated Rate	$237.02
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Devoted Health Medicare	$260.72
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 Medicare	$237.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$751.45
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Commercial	$498.33
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicare	$237.02
Rate for Payer: University Health Alliance Commercial	$576.56

HC RESUPERF WND BODY >30 CM

Facility

$791.00

Service Code	HCPCS 12007
Hospital Charge Code	7611200701
Hospital Revenue Code	450
Min. Negotiated Rate	$672.35
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: MDX Hawaii PPO	$767.27

HC RESUPERF WND BODY 7.6-12.5 CM

Facility

$791.00

Service Code	HCPCS 12004
Hospital Charge Code	4501200401
Hospital Revenue Code	450
Min. Negotiated Rate	$237.02
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Devoted Health Medicare	$260.72
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 Medicare	$237.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$751.45
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Commercial	$498.33
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicare	$237.02
Rate for Payer: University Health Alliance Commercial	$576.56

HC RESUPERF WND BODY 7.6-12.5 CM

Facility

$791.00

Service Code	HCPCS 12004
Hospital Charge Code	4501200401
Hospital Revenue Code	450
Min. Negotiated Rate	$672.35
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: MDX Hawaii PPO	$767.27

HC RESUPERF WND FACE 12.6-20 CM

Facility

$1,590.00

Service Code	HCPCS 12016
Hospital Charge Code	4501201601
Hospital Revenue Code	450
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 RESUPERF WND FACE 12.6-20 CM

Facility

$1,590.00

Service Code	HCPCS 12016
Hospital Charge Code	4501201601
Hospital Revenue Code	450
Min. Negotiated Rate	$480.23
Max. Negotiated Rate	$1,600.00
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: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$528.25
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 Medicare	$480.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,510.50
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	$937.50
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 Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$1,158.95

Know your out-of-pocket cost for care.

All Charges