Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC STRAPPING; ANKLE &/OR FOOT

Facility

$628.00

Service Code	HCPCS 29540
Hospital Charge Code	7612954001
Hospital Revenue Code	761
Min. Negotiated Rate	$20.58
Max. Negotiated Rate	$609.16
Rate for Payer: AlohaCare Medicaid	$191.97
Rate for Payer: AlohaCare Medicare	$191.97
Rate for Payer: Cash Price	$376.80
Rate for Payer: Cash Price	$376.80
Rate for Payer: Devoted Health Medicare	$211.17
Rate for Payer: Hawaii Medical Service Association Commercial	$239.96
Rate for Payer: Hawaii Medical Service Association Medicare	$191.97
Rate for Payer: Hawaii Western Management Group Commercial	$596.60
Rate for Payer: Health Management Network Commercial	$533.80
Rate for Payer: Humana Medicare	$191.97
Rate for Payer: Kaiser Permanente Commercial	$395.64
Rate for Payer: Kaiser Permanente Medicaid	$320.28
Rate for Payer: Kaiser Permanente Medicare	$191.97
Rate for Payer: MDX Hawaii PPO	$609.16
Rate for Payer: Ohana Health Plan Medicaid	$211.17
Rate for Payer: Ohana Health Plan Medicare	$191.97
Rate for Payer: UnitedHealthcare Medicaid	$20.58
Rate for Payer: UnitedHealthcare Medicare	$191.97
Rate for Payer: University Health Alliance Commercial	$457.75

HC STRAPPING; ANKLE &/OR FOOT

Facility

$628.00

Service Code	HCPCS 29540
Hospital Charge Code	7612954001
Hospital Revenue Code	761
Min. Negotiated Rate	$533.80
Max. Negotiated Rate	$609.16
Rate for Payer: Cash Price	$376.80
Rate for Payer: Health Management Network Commercial	$533.80
Rate for Payer: MDX Hawaii PPO	$609.16

HC STRAPPING OF KNEE

Facility

$513.00

Service Code	HCPCS 29530
Hospital Charge Code	4502953001
Hospital Revenue Code	450
Min. Negotiated Rate	$157.18
Max. Negotiated Rate	$1,600.00
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: 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	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
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	$937.50
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 Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$373.93

HC STRAPPING OF KNEE

Facility

$513.00

Service Code	HCPCS 29530
Hospital Charge Code	4502953001
Hospital Revenue Code	450
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 STRAPPING; TOES

Facility

$236.00

Service Code	HCPCS 29550
Hospital Charge Code	4502955001
Hospital Revenue Code	450
Min. Negotiated Rate	$69.69
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$69.69
Rate for Payer: AlohaCare Medicare	$69.69
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Devoted Health Medicare	$76.66
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	$69.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Humana Medicare	$69.69
Rate for Payer: Kaiser Permanente Commercial	$148.68
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$69.69
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: Ohana Health Plan Medicaid	$76.66
Rate for Payer: Ohana Health Plan Medicare	$69.69
Rate for Payer: UnitedHealthcare Medicare	$69.69
Rate for Payer: University Health Alliance Commercial	$172.02

HC STRAPPING; TOES

Facility

$236.00

Service Code	HCPCS 29550
Hospital Charge Code	4502955001
Hospital Revenue Code	450
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 STRAPPING UNNA BOOT

Facility

$628.00

Service Code	HCPCS 29580
Hospital Charge Code	7002958001
Hospital Revenue Code	450
Min. Negotiated Rate	$191.97
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$191.97
Rate for Payer: AlohaCare Medicare	$191.97
Rate for Payer: Cash Price	$376.80
Rate for Payer: Cash Price	$376.80
Rate for Payer: Cash Price	$376.80
Rate for Payer: Cash Price	$376.80
Rate for Payer: Devoted Health Medicare	$211.17
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	$191.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$596.60
Rate for Payer: Health Management Network Commercial	$533.80
Rate for Payer: Humana Medicare	$191.97
Rate for Payer: Kaiser Permanente Commercial	$395.64
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$191.97
Rate for Payer: MDX Hawaii PPO	$609.16
Rate for Payer: Ohana Health Plan Medicaid	$211.17
Rate for Payer: Ohana Health Plan Medicare	$191.97
Rate for Payer: UnitedHealthcare Medicare	$191.97
Rate for Payer: University Health Alliance Commercial	$457.75

HC STRAPPING UNNA BOOT

Facility

$628.00

Service Code	HCPCS 29580
Hospital Charge Code	7002958001
Hospital Revenue Code	450
Min. Negotiated Rate	$533.80
Max. Negotiated Rate	$609.16
Rate for Payer: Cash Price	$376.80
Rate for Payer: Health Management Network Commercial	$533.80
Rate for Payer: MDX Hawaii PPO	$609.16

HC STRAP SHOULDER

Facility

$513.00

Service Code	HCPCS 29240
Hospital Charge Code	4202924001
Hospital Revenue Code	450
Min. Negotiated Rate	$157.18
Max. Negotiated Rate	$1,600.00
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: 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	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
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	$937.50
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 Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$373.93

HC STRAP SHOULDER

Facility

$513.00

Service Code	HCPCS 29240
Hospital Charge Code	4202924001
Hospital Revenue Code	450
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 STREP A ASSAY W/OPTIC - RAPID STREP A SCREEN

Facility

$135.00

Service Code	HCPCS 87880
Hospital Charge Code	3068788001
Hospital Revenue Code	306
Min. Negotiated Rate	$16.53
Max. Negotiated Rate	$130.95
Rate for Payer: AlohaCare Medicaid	$16.53
Rate for Payer: AlohaCare Medicare	$16.53
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Devoted Health Medicare	$18.18
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$20.66
Rate for Payer: Hawaii Medical Service Association Medicare	$16.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$16.53
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Humana Medicare	$16.53
Rate for Payer: Kaiser Permanente Commercial	$85.05
Rate for Payer: Kaiser Permanente Medicaid	$68.85
Rate for Payer: Kaiser Permanente Medicare	$16.53
Rate for Payer: MDX Hawaii PPO	$130.95
Rate for Payer: Ohana Health Plan Medicaid	$18.18
Rate for Payer: Ohana Health Plan Medicare	$16.53
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$16.53
Rate for Payer: University Health Alliance Commercial	$31.01

HC STREP A ASSAY W/OPTIC - RAPID STREP A SCREEN

Facility

$135.00

Service Code	HCPCS 87880
Hospital Charge Code	3068788001
Hospital Revenue Code	306
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$130.95
Rate for Payer: Cash Price	$81.00
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: MDX Hawaii PPO	$130.95

HC STREP A, DNA, AMP PROBE - STREP A DNA PROBE, AMPLIFICATION

Facility

$294.00

Service Code	HCPCS 87651
Hospital Charge Code	3068765101
Hospital Revenue Code	306
Min. Negotiated Rate	$249.90
Max. Negotiated Rate	$285.18
Rate for Payer: Cash Price	$176.40
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: MDX Hawaii PPO	$285.18

HC STREP A, DNA, AMP PROBE - STREP A DNA PROBE, AMPLIFICATION

Facility

$294.00

Service Code	HCPCS 87651
Hospital Charge Code	3068765101
Hospital Revenue Code	306
Min. Negotiated Rate	$29.42
Max. Negotiated Rate	$285.18
Rate for Payer: AlohaCare Medicaid	$35.09
Rate for Payer: AlohaCare Medicare	$35.09
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cash Price	$176.40
Rate for Payer: Devoted Health Medicare	$38.60
Rate for Payer: Hawaii Medical Service Association ABD	$29.42
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$35.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48.48
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: Humana Medicare	$35.09
Rate for Payer: Kaiser Permanente Commercial	$185.22
Rate for Payer: Kaiser Permanente Medicaid	$149.94
Rate for Payer: Kaiser Permanente Medicare	$35.09
Rate for Payer: MDX Hawaii PPO	$285.18
Rate for Payer: Ohana Health Plan Medicaid	$38.60
Rate for Payer: Ohana Health Plan Medicare	$35.09
Rate for Payer: UnitedHealthcare Medicaid	$29.42
Rate for Payer: UnitedHealthcare Medicare	$35.09
Rate for Payer: University Health Alliance Commercial	$90.72

HC STREP B, DNA, AMP PROBE - STREP B DNA PROBE, AMPLIFICATION

Facility

$294.00

Service Code	HCPCS 87653
Hospital Charge Code	3068765301
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$285.18
Rate for Payer: AlohaCare Medicaid	$35.09
Rate for Payer: AlohaCare Medicare	$35.09
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cash Price	$176.40
Rate for Payer: Devoted Health Medicare	$38.60
Rate for Payer: Hawaii Medical Service Association ABD	$49.04
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$35.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.49
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: Humana Medicare	$35.09
Rate for Payer: Kaiser Permanente Commercial	$185.22
Rate for Payer: Kaiser Permanente Medicaid	$149.94
Rate for Payer: Kaiser Permanente Medicare	$35.09
Rate for Payer: MDX Hawaii PPO	$285.18
Rate for Payer: Ohana Health Plan Medicaid	$38.60
Rate for Payer: Ohana Health Plan Medicare	$35.09
Rate for Payer: UnitedHealthcare Medicaid	$49.04
Rate for Payer: UnitedHealthcare Medicare	$35.09
Rate for Payer: University Health Alliance Commercial	$90.72

HC STREP B, DNA, AMP PROBE - STREP B DNA PROBE, AMPLIFICATION

Facility

$294.00

Service Code	HCPCS 87653
Hospital Charge Code	3068765301
Hospital Revenue Code	306
Min. Negotiated Rate	$249.90
Max. Negotiated Rate	$285.18
Rate for Payer: Cash Price	$176.40
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: MDX Hawaii PPO	$285.18

HC STRESS TTE COMPLETE

Facility

$2,728.00

Service Code	HCPCS 93351
Hospital Charge Code	4839335101
Hospital Revenue Code	483
Min. Negotiated Rate	$183.31
Max. Negotiated Rate	$2,646.16
Rate for Payer: AlohaCare Medicaid	$645.50
Rate for Payer: AlohaCare Medicare	$645.50
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Devoted Health Medicare	$710.05
Rate for Payer: Hawaii Medical Service Association Commercial	$806.88
Rate for Payer: Hawaii Medical Service Association Medicare	$645.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,591.60
Rate for Payer: Health Management Network Commercial	$2,318.80
Rate for Payer: Humana Medicare	$645.50
Rate for Payer: Kaiser Permanente Commercial	$1,718.64
Rate for Payer: Kaiser Permanente Medicaid	$1,391.28
Rate for Payer: Kaiser Permanente Medicare	$645.50
Rate for Payer: MDX Hawaii PPO	$2,646.16
Rate for Payer: Ohana Health Plan Medicaid	$710.05
Rate for Payer: Ohana Health Plan Medicare	$645.50
Rate for Payer: UnitedHealthcare Medicaid	$183.31
Rate for Payer: UnitedHealthcare Medicare	$645.50
Rate for Payer: University Health Alliance Commercial	$1,988.44

HC STRESS TTE COMPLETE

Facility

$2,728.00

Service Code	HCPCS 93351
Hospital Charge Code	4839335101
Hospital Revenue Code	483
Min. Negotiated Rate	$2,318.80
Max. Negotiated Rate	$2,646.16
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Health Management Network Commercial	$2,318.80
Rate for Payer: MDX Hawaii PPO	$2,646.16

HC STRESS TTE W/ECG W/CONT

Facility

$3,930.00

Service Code	HCPCS C8930
Hospital Charge Code	483C893001
Hospital Revenue Code	483
Min. Negotiated Rate	$592.55
Max. Negotiated Rate	$3,812.10
Rate for Payer: AlohaCare Medicaid	$926.08
Rate for Payer: AlohaCare Medicare	$926.08
Rate for Payer: Cash Price	$2,358.00
Rate for Payer: Cash Price	$2,358.00
Rate for Payer: Devoted Health Medicare	$1,018.69
Rate for Payer: Hawaii Medical Service Association Commercial	$1,157.60
Rate for Payer: Hawaii Medical Service Association Medicare	$926.08
Rate for Payer: Hawaii Western Management Group Commercial	$3,733.50
Rate for Payer: Health Management Network Commercial	$3,340.50
Rate for Payer: Humana Medicare	$926.08
Rate for Payer: Kaiser Permanente Commercial	$2,475.90
Rate for Payer: Kaiser Permanente Medicaid	$2,004.30
Rate for Payer: Kaiser Permanente Medicare	$926.08
Rate for Payer: MDX Hawaii PPO	$3,812.10
Rate for Payer: Ohana Health Plan Medicaid	$1,018.69
Rate for Payer: Ohana Health Plan Medicare	$926.08
Rate for Payer: UnitedHealthcare Medicaid	$592.55
Rate for Payer: UnitedHealthcare Medicare	$926.08
Rate for Payer: University Health Alliance Commercial	$2,864.58

HC STRESS TTE W/ECG W/CONT

Facility

$3,930.00

Service Code	HCPCS C8930
Hospital Charge Code	483C893001
Hospital Revenue Code	483
Min. Negotiated Rate	$3,340.50
Max. Negotiated Rate	$3,812.10
Rate for Payer: Cash Price	$2,358.00
Rate for Payer: Health Management Network Commercial	$3,340.50
Rate for Payer: MDX Hawaii PPO	$3,812.10

HC SUBQ DEFIB EVAL ADJUST - IN PERSON

Facility

$185.00

Service Code	HCPCS 93260
Hospital Charge Code	4809326001
Hospital Revenue Code	480
Min. Negotiated Rate	$157.25
Max. Negotiated Rate	$179.45
Rate for Payer: Cash Price	$111.00
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: MDX Hawaii PPO	$179.45

HC SUBQ DEFIB EVAL ADJUST - IN PERSON

Facility

$185.00

Service Code	HCPCS 93260
Hospital Charge Code	4809326001
Hospital Revenue Code	480
Min. Negotiated Rate	$20.37
Max. Negotiated Rate	$179.45
Rate for Payer: AlohaCare Medicaid	$44.09
Rate for Payer: AlohaCare Medicare	$44.09
Rate for Payer: Cash Price	$111.00
Rate for Payer: Cash Price	$111.00
Rate for Payer: Devoted Health Medicare	$48.50
Rate for Payer: Hawaii Medical Service Association Commercial	$55.11
Rate for Payer: Hawaii Medical Service Association Medicare	$44.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.37
Rate for Payer: Hawaii Western Management Group Commercial	$175.75
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Humana Medicare	$44.09
Rate for Payer: Kaiser Permanente Commercial	$116.55
Rate for Payer: Kaiser Permanente Medicaid	$94.35
Rate for Payer: Kaiser Permanente Medicare	$44.09
Rate for Payer: MDX Hawaii PPO	$179.45
Rate for Payer: Ohana Health Plan Medicaid	$48.50
Rate for Payer: Ohana Health Plan Medicare	$44.09
Rate for Payer: UnitedHealthcare Medicaid	$81.44
Rate for Payer: UnitedHealthcare Medicare	$44.09
Rate for Payer: University Health Alliance Commercial	$134.85

HC SUBQ DEFIB EVAL INTERROGATE - IN PERSON

Facility

$185.00

Service Code	HCPCS 93261
Hospital Charge Code	4809326101
Hospital Revenue Code	480
Min. Negotiated Rate	$20.37
Max. Negotiated Rate	$179.45
Rate for Payer: AlohaCare Medicaid	$44.09
Rate for Payer: AlohaCare Medicare	$44.09
Rate for Payer: Cash Price	$111.00
Rate for Payer: Cash Price	$111.00
Rate for Payer: Devoted Health Medicare	$48.50
Rate for Payer: Hawaii Medical Service Association Commercial	$55.11
Rate for Payer: Hawaii Medical Service Association Medicare	$44.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.37
Rate for Payer: Hawaii Western Management Group Commercial	$175.75
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Humana Medicare	$44.09
Rate for Payer: Kaiser Permanente Commercial	$116.55
Rate for Payer: Kaiser Permanente Medicaid	$94.35
Rate for Payer: Kaiser Permanente Medicare	$44.09
Rate for Payer: MDX Hawaii PPO	$179.45
Rate for Payer: Ohana Health Plan Medicaid	$48.50
Rate for Payer: Ohana Health Plan Medicare	$44.09
Rate for Payer: UnitedHealthcare Medicaid	$75.30
Rate for Payer: UnitedHealthcare Medicare	$44.09
Rate for Payer: University Health Alliance Commercial	$134.85

HC SUBQ DEFIB EVAL INTERROGATE - IN PERSON

Facility

$185.00

Service Code	HCPCS 93261
Hospital Charge Code	4809326101
Hospital Revenue Code	480
Min. Negotiated Rate	$157.25
Max. Negotiated Rate	$179.45
Rate for Payer: Cash Price	$111.00
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: MDX Hawaii PPO	$179.45

HC SUBQ I/P CRITICAL CARE PR DAY AGE 28 DAYS/<

Facility

$875.00

Service Code	HCPCS 99469
Hospital Charge Code	1739946901
Hospital Revenue Code	173
Min. Negotiated Rate	$743.75
Max. Negotiated Rate	$2,250.00
Rate for Payer: Cash Price	$525.00
Rate for Payer: Cash Price	$525.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,250.00
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$1,875.00

Know your out-of-pocket cost for care.

All Charges