Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC RT INHALATION TREATMENT

Facility

$1,092.00

Service Code	HCPCS 94640
Hospital Charge Code	4109464001
Hospital Revenue Code	410
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$2,536.00
Rate for Payer: AlohaCare Medicaid	$258.69
Rate for Payer: AlohaCare Medicare	$258.69
Rate for Payer: Cash Price	$655.20
Rate for Payer: Cash Price	$655.20
Rate for Payer: Cash Price	$655.20
Rate for Payer: Devoted Health Medicare	$284.56
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	$258.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$1,037.40
Rate for Payer: Health Management Network Commercial	$928.20
Rate for Payer: Humana Medicare	$258.69
Rate for Payer: Kaiser Permanente Commercial	$687.96
Rate for Payer: Kaiser Permanente Medicaid	$556.92
Rate for Payer: Kaiser Permanente Medicare	$258.69
Rate for Payer: MDX Hawaii PPO	$1,059.24
Rate for Payer: Ohana Health Plan Medicaid	$284.56
Rate for Payer: Ohana Health Plan Medicare	$258.69
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$258.69
Rate for Payer: University Health Alliance Commercial	$795.96

HC RT INHALATION TREATMENT

Facility

$1,092.00

Service Code	HCPCS 94640
Hospital Charge Code	4109464001
Hospital Revenue Code	410
Min. Negotiated Rate	$928.20
Max. Negotiated Rate	$1,059.24
Rate for Payer: Cash Price	$655.20
Rate for Payer: Health Management Network Commercial	$928.20
Rate for Payer: MDX Hawaii PPO	$1,059.24

HC RT INTRAPULMONARY SURFACTANT ADMINISTJ PHYS/QHP

Facility

$793.00

Service Code	HCPCS 94610
Hospital Charge Code	4109461001
Hospital Revenue Code	410
Min. Negotiated Rate	$43.49
Max. Negotiated Rate	$769.21
Rate for Payer: AlohaCare Medicaid	$258.69
Rate for Payer: AlohaCare Medicare	$258.69
Rate for Payer: Cash Price	$475.80
Rate for Payer: Cash Price	$475.80
Rate for Payer: Devoted Health Medicare	$284.56
Rate for Payer: Hawaii Medical Service Association Commercial	$323.36
Rate for Payer: Hawaii Medical Service Association Medicare	$258.69
Rate for Payer: Hawaii Western Management Group Commercial	$753.35
Rate for Payer: Health Management Network Commercial	$674.05
Rate for Payer: Humana Medicare	$258.69
Rate for Payer: Kaiser Permanente Commercial	$499.59
Rate for Payer: Kaiser Permanente Medicaid	$404.43
Rate for Payer: Kaiser Permanente Medicare	$258.69
Rate for Payer: MDX Hawaii PPO	$769.21
Rate for Payer: Ohana Health Plan Medicaid	$284.56
Rate for Payer: Ohana Health Plan Medicare	$258.69
Rate for Payer: UnitedHealthcare Medicaid	$43.49
Rate for Payer: UnitedHealthcare Medicare	$258.69
Rate for Payer: University Health Alliance Commercial	$578.02

HC RT INTRAPULMONARY SURFACTANT ADMINISTJ PHYS/QHP

Facility

$793.00

Service Code	HCPCS 94610
Hospital Charge Code	4109461001
Hospital Revenue Code	410
Min. Negotiated Rate	$674.05
Max. Negotiated Rate	$769.21
Rate for Payer: Cash Price	$475.80
Rate for Payer: Health Management Network Commercial	$674.05
Rate for Payer: MDX Hawaii PPO	$769.21

HC RT NONINVASV OXYGEN SATUR;SINGLE

Facility

$79.00

Service Code	HCPCS 94760
Hospital Charge Code	4609476001
Hospital Revenue Code	460
Min. Negotiated Rate	$67.15
Max. Negotiated Rate	$76.63
Rate for Payer: Cash Price	$47.40
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: MDX Hawaii PPO	$76.63

HC RT NONINVASV OXYGEN SATUR;SINGLE

Facility

$79.00

Service Code	HCPCS 94760
Hospital Charge Code	4609476001
Hospital Revenue Code	460
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$76.63
Rate for Payer: Cash Price	$47.40
Rate for Payer: Cash Price	$47.40
Rate for Payer: Hawaii Western Management Group Commercial	$75.05
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: Kaiser Permanente Commercial	$49.77
Rate for Payer: Kaiser Permanente Medicaid	$40.29
Rate for Payer: MDX Hawaii PPO	$76.63
Rate for Payer: UnitedHealthcare Medicaid	$2.29
Rate for Payer: University Health Alliance Commercial	$57.58

HC RT NONINVASV OXYGEN SATUT,CONTINUOUS

Facility

$317.00

Service Code	HCPCS 94762
Hospital Charge Code	4109476201
Hospital Revenue Code	410
Min. Negotiated Rate	$19.84
Max. Negotiated Rate	$307.49
Rate for Payer: AlohaCare Medicaid	$152.01
Rate for Payer: AlohaCare Medicare	$152.01
Rate for Payer: Cash Price	$190.20
Rate for Payer: Cash Price	$190.20
Rate for Payer: Devoted Health Medicare	$167.21
Rate for Payer: Hawaii Medical Service Association Commercial	$190.01
Rate for Payer: Hawaii Medical Service Association Medicare	$152.01
Rate for Payer: Hawaii Western Management Group Commercial	$301.15
Rate for Payer: Health Management Network Commercial	$269.45
Rate for Payer: Humana Medicare	$152.01
Rate for Payer: Kaiser Permanente Commercial	$199.71
Rate for Payer: Kaiser Permanente Medicaid	$161.67
Rate for Payer: Kaiser Permanente Medicare	$152.01
Rate for Payer: MDX Hawaii PPO	$307.49
Rate for Payer: Ohana Health Plan Medicaid	$167.21
Rate for Payer: Ohana Health Plan Medicare	$152.01
Rate for Payer: UnitedHealthcare Medicaid	$19.84
Rate for Payer: UnitedHealthcare Medicare	$152.01
Rate for Payer: University Health Alliance Commercial	$231.06

HC RT NONINVASV OXYGEN SATUT,CONTINUOUS

Facility

$317.00

Service Code	HCPCS 94762
Hospital Charge Code	4109476201
Hospital Revenue Code	410
Min. Negotiated Rate	$269.45
Max. Negotiated Rate	$307.49
Rate for Payer: Cash Price	$190.20
Rate for Payer: Health Management Network Commercial	$269.45
Rate for Payer: MDX Hawaii PPO	$307.49

HC RT QUAKING INDUC CONV SO

Facility

$4,539.00

Service Code	HCPCS 0035U
Hospital Charge Code	3090035U01
Hospital Revenue Code	309
Min. Negotiated Rate	$3,858.15
Max. Negotiated Rate	$4,402.83
Rate for Payer: Cash Price	$2,723.40
Rate for Payer: Health Management Network Commercial	$3,858.15
Rate for Payer: MDX Hawaii PPO	$4,402.83

HC RT QUAKING INDUC CONV SO

Facility

$4,539.00

Service Code	HCPCS 0035U
Hospital Charge Code	3090035U01
Hospital Revenue Code	309
Min. Negotiated Rate	$405.74
Max. Negotiated Rate	$4,402.83
Rate for Payer: AlohaCare Medicaid	$540.99
Rate for Payer: AlohaCare Medicare	$540.99
Rate for Payer: Cash Price	$2,723.40
Rate for Payer: Cash Price	$2,723.40
Rate for Payer: Devoted Health Medicare	$595.09
Rate for Payer: Hawaii Medical Service Association Commercial	$676.24
Rate for Payer: Hawaii Medical Service Association Medicare	$540.99
Rate for Payer: Hawaii Western Management Group Commercial	$4,312.05
Rate for Payer: Health Management Network Commercial	$3,858.15
Rate for Payer: Humana Medicare	$540.99
Rate for Payer: Kaiser Permanente Commercial	$2,859.57
Rate for Payer: Kaiser Permanente Medicaid	$2,314.89
Rate for Payer: Kaiser Permanente Medicare	$540.99
Rate for Payer: MDX Hawaii PPO	$4,402.83
Rate for Payer: Ohana Health Plan Medicaid	$595.09
Rate for Payer: Ohana Health Plan Medicare	$540.99
Rate for Payer: UnitedHealthcare Medicaid	$405.74
Rate for Payer: UnitedHealthcare Medicare	$540.99
Rate for Payer: University Health Alliance Commercial	$3,308.48

HC RTRVL INTRVAS VC FILTR W/WO ACS VSL SELXN RS&I

Facility

$12,526.00

Service Code	HCPCS 37193
Hospital Charge Code	3613719301
Hospital Revenue Code	361
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$12,150.22
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	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,730.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
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 RTRVL INTRVAS VC FILTR W/WO ACS VSL SELXN RS&I

Facility

$12,526.00

Service Code	HCPCS 37193
Hospital Charge Code	3613719301
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 RT VENT MGMT, INPATIENT, INITIAL DAY

Facility

$3,552.00

Service Code	HCPCS 94002
Hospital Charge Code	4109400201
Hospital Revenue Code	410
Min. Negotiated Rate	$59.64
Max. Negotiated Rate	$3,445.44
Rate for Payer: AlohaCare Medicaid	$729.82
Rate for Payer: AlohaCare Medicare	$729.82
Rate for Payer: Cash Price	$2,131.20
Rate for Payer: Cash Price	$2,131.20
Rate for Payer: Devoted Health Medicare	$802.80
Rate for Payer: Hawaii Medical Service Association Commercial	$912.27
Rate for Payer: Hawaii Medical Service Association Medicare	$729.82
Rate for Payer: Hawaii Western Management Group Commercial	$3,374.40
Rate for Payer: Health Management Network Commercial	$3,019.20
Rate for Payer: Humana Medicare	$729.82
Rate for Payer: Kaiser Permanente Commercial	$2,237.76
Rate for Payer: Kaiser Permanente Medicaid	$1,811.52
Rate for Payer: Kaiser Permanente Medicare	$729.82
Rate for Payer: MDX Hawaii PPO	$3,445.44
Rate for Payer: Ohana Health Plan Medicaid	$802.80
Rate for Payer: Ohana Health Plan Medicare	$729.82
Rate for Payer: UnitedHealthcare Medicaid	$59.64
Rate for Payer: UnitedHealthcare Medicare	$729.82
Rate for Payer: University Health Alliance Commercial	$2,589.05

HC RT VENT MGMT, INPATIENT, INITIAL DAY

Facility

$3,552.00

Service Code	HCPCS 94002
Hospital Charge Code	4109400201
Hospital Revenue Code	410
Min. Negotiated Rate	$3,019.20
Max. Negotiated Rate	$3,445.44
Rate for Payer: Cash Price	$2,131.20
Rate for Payer: Health Management Network Commercial	$3,019.20
Rate for Payer: MDX Hawaii PPO	$3,445.44

HC RT VENT MGMT, INPATIENT, SUBQ DAY

Facility

$3,552.00

Service Code	HCPCS 94003
Hospital Charge Code	4109400301
Hospital Revenue Code	410
Min. Negotiated Rate	$43.79
Max. Negotiated Rate	$3,445.44
Rate for Payer: AlohaCare Medicaid	$729.82
Rate for Payer: AlohaCare Medicare	$729.82
Rate for Payer: Cash Price	$2,131.20
Rate for Payer: Cash Price	$2,131.20
Rate for Payer: Devoted Health Medicare	$802.80
Rate for Payer: Hawaii Medical Service Association Commercial	$912.27
Rate for Payer: Hawaii Medical Service Association Medicare	$729.82
Rate for Payer: Hawaii Western Management Group Commercial	$3,374.40
Rate for Payer: Health Management Network Commercial	$3,019.20
Rate for Payer: Humana Medicare	$729.82
Rate for Payer: Kaiser Permanente Commercial	$2,237.76
Rate for Payer: Kaiser Permanente Medicaid	$1,811.52
Rate for Payer: Kaiser Permanente Medicare	$729.82
Rate for Payer: MDX Hawaii PPO	$3,445.44
Rate for Payer: Ohana Health Plan Medicaid	$802.80
Rate for Payer: Ohana Health Plan Medicare	$729.82
Rate for Payer: UnitedHealthcare Medicaid	$43.79
Rate for Payer: UnitedHealthcare Medicare	$729.82
Rate for Payer: University Health Alliance Commercial	$2,589.05

HC RT VENT MGMT, INPATIENT, SUBQ DAY

Facility

$3,552.00

Service Code	HCPCS 94003
Hospital Charge Code	4109400301
Hospital Revenue Code	410
Min. Negotiated Rate	$3,019.20
Max. Negotiated Rate	$3,445.44
Rate for Payer: Cash Price	$2,131.20
Rate for Payer: Health Management Network Commercial	$3,019.20
Rate for Payer: MDX Hawaii PPO	$3,445.44

HC RUBELLA - RUBELLA ANTIBODY, IGM

Facility

$121.00

Service Code	HCPCS 86762
Hospital Charge Code	3028676201
Hospital Revenue Code	302
Min. Negotiated Rate	$14.39
Max. Negotiated Rate	$117.37
Rate for Payer: AlohaCare Medicaid	$14.39
Rate for Payer: AlohaCare Medicare	$14.39
Rate for Payer: Cash Price	$72.60
Rate for Payer: Cash Price	$72.60
Rate for Payer: Devoted Health Medicare	$15.83
Rate for Payer: Hawaii Medical Service Association ABD	$19.89
Rate for Payer: Hawaii Medical Service Association Commercial	$17.99
Rate for Payer: Hawaii Medical Service Association Medicare	$14.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.88
Rate for Payer: Hawaii Western Management Group Commercial	$14.39
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Humana Medicare	$14.39
Rate for Payer: Kaiser Permanente Commercial	$76.23
Rate for Payer: Kaiser Permanente Medicaid	$61.71
Rate for Payer: Kaiser Permanente Medicare	$14.39
Rate for Payer: MDX Hawaii PPO	$117.37
Rate for Payer: Ohana Health Plan Medicaid	$15.83
Rate for Payer: Ohana Health Plan Medicare	$14.39
Rate for Payer: UnitedHealthcare Medicaid	$19.89
Rate for Payer: UnitedHealthcare Medicare	$14.39
Rate for Payer: University Health Alliance Commercial	$37.20

HC RUBELLA - RUBELLA ANTIBODY, IGM

Facility

$121.00

Service Code	HCPCS 86762
Hospital Charge Code	3028676201
Hospital Revenue Code	302
Min. Negotiated Rate	$102.85
Max. Negotiated Rate	$117.37
Rate for Payer: Cash Price	$72.60
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: MDX Hawaii PPO	$117.37

HC RUBEOLA - RUBEOLA ANTIBODY IGG

Facility

$108.00

Service Code	HCPCS 86765
Hospital Charge Code	3028676501
Hospital Revenue Code	302
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$104.76
Rate for Payer: AlohaCare Medicaid	$12.88
Rate for Payer: AlohaCare Medicare	$12.88
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cash Price	$64.80
Rate for Payer: Devoted Health Medicare	$14.17
Rate for Payer: Hawaii Medical Service Association ABD	$17.81
Rate for Payer: Hawaii Medical Service Association Commercial	$16.10
Rate for Payer: Hawaii Medical Service Association Medicare	$12.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.70
Rate for Payer: Hawaii Western Management Group Commercial	$12.88
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Humana Medicare	$12.88
Rate for Payer: Kaiser Permanente Commercial	$68.04
Rate for Payer: Kaiser Permanente Medicaid	$55.08
Rate for Payer: Kaiser Permanente Medicare	$12.88
Rate for Payer: MDX Hawaii PPO	$104.76
Rate for Payer: Ohana Health Plan Medicaid	$14.17
Rate for Payer: Ohana Health Plan Medicare	$12.88
Rate for Payer: UnitedHealthcare Medicaid	$17.81
Rate for Payer: UnitedHealthcare Medicare	$12.88
Rate for Payer: University Health Alliance Commercial	$33.30

HC RUBEOLA - RUBEOLA ANTIBODY IGG

Facility

$108.00

Service Code	HCPCS 86765
Hospital Charge Code	3028676501
Hospital Revenue Code	302
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 RUBEOLA - RUBEOLA ANTIBODY, IGM

Facility

$108.00

Service Code	HCPCS 86765
Hospital Charge Code	3028676502
Hospital Revenue Code	302
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 RUBEOLA - RUBEOLA ANTIBODY, IGM

Facility

$108.00

Service Code	HCPCS 86765
Hospital Charge Code	3028676502
Hospital Revenue Code	302
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$104.76
Rate for Payer: AlohaCare Medicaid	$12.88
Rate for Payer: AlohaCare Medicare	$12.88
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cash Price	$64.80
Rate for Payer: Devoted Health Medicare	$14.17
Rate for Payer: Hawaii Medical Service Association ABD	$17.81
Rate for Payer: Hawaii Medical Service Association Commercial	$16.10
Rate for Payer: Hawaii Medical Service Association Medicare	$12.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.70
Rate for Payer: Hawaii Western Management Group Commercial	$12.88
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Humana Medicare	$12.88
Rate for Payer: Kaiser Permanente Commercial	$68.04
Rate for Payer: Kaiser Permanente Medicaid	$55.08
Rate for Payer: Kaiser Permanente Medicare	$12.88
Rate for Payer: MDX Hawaii PPO	$104.76
Rate for Payer: Ohana Health Plan Medicaid	$14.17
Rate for Payer: Ohana Health Plan Medicare	$12.88
Rate for Payer: UnitedHealthcare Medicaid	$17.81
Rate for Payer: UnitedHealthcare Medicare	$12.88
Rate for Payer: University Health Alliance Commercial	$33.30

HC RUSSELL VIPER VENOM, DILUTED - DRVVT (DILUTE RUSSEL VV TIME)

Facility

$80.00

Service Code	HCPCS 85613
Hospital Charge Code	3058561301
Hospital Revenue Code	305
Min. Negotiated Rate	$68.00
Max. Negotiated Rate	$77.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Health Management Network Commercial	$68.00
Rate for Payer: MDX Hawaii PPO	$77.60

HC RUSSELL VIPER VENOM, DILUTED - DRVVT (DILUTE RUSSEL VV TIME)

Facility

$80.00

Service Code	HCPCS 85613
Hospital Charge Code	3058561301
Hospital Revenue Code	305
Min. Negotiated Rate	$9.58
Max. Negotiated Rate	$77.60
Rate for Payer: UnitedHealthcare Medicaid	$13.22
Rate for Payer: AlohaCare Medicaid	$9.58
Rate for Payer: AlohaCare Medicare	$9.58
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cash Price	$48.00
Rate for Payer: Devoted Health Medicare	$10.54
Rate for Payer: Hawaii Medical Service Association ABD	$13.22
Rate for Payer: Hawaii Medical Service Association Commercial	$11.97
Rate for Payer: Hawaii Medical Service Association Medicare	$9.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13.88
Rate for Payer: Hawaii Western Management Group Commercial	$9.58
Rate for Payer: Health Management Network Commercial	$68.00
Rate for Payer: Humana Medicare	$9.58
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$40.80
Rate for Payer: Kaiser Permanente Medicare	$9.58
Rate for Payer: MDX Hawaii PPO	$77.60
Rate for Payer: Ohana Health Plan Medicaid	$10.54
Rate for Payer: Ohana Health Plan Medicare	$9.58
Rate for Payer: UnitedHealthcare Medicare	$9.58
Rate for Payer: University Health Alliance Commercial	$24.73

HC SALIVARY GLAND FUNCTION EXAM - NM SALIVARY GLAND FUNCTION

Facility

$1,999.00

Service Code	HCPCS 78232
Hospital Charge Code	3417823201
Hospital Revenue Code	341
Min. Negotiated Rate	$1,699.15
Max. Negotiated Rate	$1,939.03
Rate for Payer: Cash Price	$1,199.40
Rate for Payer: Health Management Network Commercial	$1,699.15
Rate for Payer: MDX Hawaii PPO	$1,939.03

Know your out-of-pocket cost for care.

All Charges