Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC TELETHX ISODOSE PLAN CPLX

Facility

$1,457.00

Service Code	HCPCS 77307
Hospital Charge Code	3337730701
Hospital Revenue Code	333
Min. Negotiated Rate	$98.69
Max. Negotiated Rate	$1,413.29
Rate for Payer: AlohaCare Medicaid	$442.33
Rate for Payer: AlohaCare Medicare	$442.33
Rate for Payer: Cash Price	$874.20
Rate for Payer: Cash Price	$874.20
Rate for Payer: Devoted Health Medicare	$486.56
Rate for Payer: Hawaii Medical Service Association ABD	$187.98
Rate for Payer: Hawaii Medical Service Association Commercial	$552.91
Rate for Payer: Hawaii Medical Service Association Medicare	$442.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$98.69
Rate for Payer: Hawaii Western Management Group Commercial	$442.33
Rate for Payer: Health Management Network Commercial	$1,238.45
Rate for Payer: Humana Medicare	$442.33
Rate for Payer: Kaiser Permanente Commercial	$917.91
Rate for Payer: Kaiser Permanente Medicaid	$743.07
Rate for Payer: Kaiser Permanente Medicare	$442.33
Rate for Payer: MDX Hawaii PPO	$1,413.29
Rate for Payer: Ohana Health Plan Medicaid	$486.56
Rate for Payer: Ohana Health Plan Medicare	$442.33
Rate for Payer: UnitedHealthcare Medicaid	$187.31
Rate for Payer: UnitedHealthcare Medicare	$442.33
Rate for Payer: University Health Alliance Commercial	$572.22

HC TELETHX ISODOSE PLAN CPLX

Facility

$1,457.00

Service Code	HCPCS 77307
Hospital Charge Code	3337730701
Hospital Revenue Code	333
Min. Negotiated Rate	$1,238.45
Max. Negotiated Rate	$1,413.29
Rate for Payer: Cash Price	$874.20
Rate for Payer: Health Management Network Commercial	$1,238.45
Rate for Payer: MDX Hawaii PPO	$1,413.29

HC TELETHX ISODOSE PLAN SIMPLE

Facility

$1,457.00

Service Code	HCPCS 77306
Hospital Charge Code	3337730601
Hospital Revenue Code	333
Min. Negotiated Rate	$64.60
Max. Negotiated Rate	$1,413.29
Rate for Payer: AlohaCare Medicaid	$442.33
Rate for Payer: AlohaCare Medicare	$442.33
Rate for Payer: Cash Price	$874.20
Rate for Payer: Cash Price	$874.20
Rate for Payer: Devoted Health Medicare	$486.56
Rate for Payer: Hawaii Medical Service Association Commercial	$552.91
Rate for Payer: Hawaii Medical Service Association Medicare	$442.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$64.60
Rate for Payer: Hawaii Western Management Group Commercial	$442.33
Rate for Payer: Health Management Network Commercial	$1,238.45
Rate for Payer: Humana Medicare	$442.33
Rate for Payer: Kaiser Permanente Commercial	$917.91
Rate for Payer: Kaiser Permanente Medicaid	$743.07
Rate for Payer: Kaiser Permanente Medicare	$442.33
Rate for Payer: MDX Hawaii PPO	$1,413.29
Rate for Payer: Ohana Health Plan Medicaid	$486.56
Rate for Payer: Ohana Health Plan Medicare	$442.33
Rate for Payer: UnitedHealthcare Medicaid	$97.01
Rate for Payer: UnitedHealthcare Medicare	$442.33
Rate for Payer: University Health Alliance Commercial	$303.86

HC TELETHX ISODOSE PLAN SIMPLE

Facility

$1,457.00

Service Code	HCPCS 77306
Hospital Charge Code	3337730601
Hospital Revenue Code	333
Min. Negotiated Rate	$1,238.45
Max. Negotiated Rate	$1,413.29
Rate for Payer: Cash Price	$874.20
Rate for Payer: Health Management Network Commercial	$1,238.45
Rate for Payer: MDX Hawaii PPO	$1,413.29

HC TEMPORARY EXTERNAL PACING

Facility

$2,604.00

Service Code	HCPCS 92953
Hospital Charge Code	4819295301
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,525.88
Rate for Payer: AlohaCare Medicaid	$780.80
Rate for Payer: AlohaCare Medicare	$780.80
Rate for Payer: Cash Price	$1,562.40
Rate for Payer: Cash Price	$1,562.40
Rate for Payer: Cash Price	$1,562.40
Rate for Payer: Cash Price	$1,562.40
Rate for Payer: Devoted Health Medicare	$858.88
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	$780.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,473.80
Rate for Payer: Health Management Network Commercial	$2,213.40
Rate for Payer: Humana Medicare	$780.80
Rate for Payer: Kaiser Permanente Commercial	$1,640.52
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$780.80
Rate for Payer: MDX Hawaii PPO	$2,525.88
Rate for Payer: Ohana Health Plan Medicaid	$858.88
Rate for Payer: Ohana Health Plan Medicare	$780.80
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$780.80
Rate for Payer: University Health Alliance Commercial	$1,898.06

HC TEMPORARY EXTERNAL PACING

Facility

$2,604.00

Service Code	HCPCS 92953
Hospital Charge Code	4819295301
Hospital Revenue Code	450
Min. Negotiated Rate	$2,213.40
Max. Negotiated Rate	$2,525.88
Rate for Payer: Cash Price	$1,562.40
Rate for Payer: Health Management Network Commercial	$2,213.40
Rate for Payer: MDX Hawaii PPO	$2,525.88

HC TESTICULAR IMAGING WITH VASCULAR FLOW

Facility

$1,999.00

Service Code	HCPCS 78761
Hospital Charge Code	3407876101
Hospital Revenue Code	340
Min. Negotiated Rate	$105.50
Max. Negotiated Rate	$1,939.03
Rate for Payer: AlohaCare Medicaid	$472.27
Rate for Payer: AlohaCare Medicare	$472.27
Rate for Payer: Cash Price	$1,199.40
Rate for Payer: Cash Price	$1,199.40
Rate for Payer: Devoted Health Medicare	$519.50
Rate for Payer: Hawaii Medical Service Association ABD	$105.50
Rate for Payer: Hawaii Medical Service Association Commercial	$590.34
Rate for Payer: Hawaii Medical Service Association Medicare	$472.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$114.35
Rate for Payer: Hawaii Western Management Group Commercial	$472.27
Rate for Payer: Health Management Network Commercial	$1,699.15
Rate for Payer: Humana Medicare	$472.27
Rate for Payer: Kaiser Permanente Commercial	$1,259.37
Rate for Payer: Kaiser Permanente Medicaid	$1,019.49
Rate for Payer: Kaiser Permanente Medicare	$472.27
Rate for Payer: MDX Hawaii PPO	$1,939.03
Rate for Payer: Ohana Health Plan Medicaid	$519.50
Rate for Payer: Ohana Health Plan Medicare	$472.27
Rate for Payer: UnitedHealthcare Medicaid	$105.50
Rate for Payer: UnitedHealthcare Medicare	$472.27
Rate for Payer: University Health Alliance Commercial	$394.35

HC TESTICULAR IMAGING WITH VASCULAR FLOW

Facility

$1,999.00

Service Code	HCPCS 78761
Hospital Charge Code	3407876101
Hospital Revenue Code	340
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

HC TGSAP HL NEO 5-50DNA/DNA&RNA

Facility

$6,372.00

Service Code	HCPCS 81450
Hospital Charge Code	3108145001
Hospital Revenue Code	310
Min. Negotiated Rate	$5,416.20
Max. Negotiated Rate	$6,180.84
Rate for Payer: Cash Price	$3,823.20
Rate for Payer: Health Management Network Commercial	$5,416.20
Rate for Payer: MDX Hawaii PPO	$6,180.84

HC TGSAP HL NEO 5-50DNA/DNA&RNA

Facility

$6,372.00

Service Code	HCPCS 81450
Hospital Charge Code	3108145001
Hospital Revenue Code	310
Min. Negotiated Rate	$569.65
Max. Negotiated Rate	$6,180.84
Rate for Payer: AlohaCare Medicaid	$759.53
Rate for Payer: AlohaCare Medicare	$759.53
Rate for Payer: Cash Price	$3,823.20
Rate for Payer: Cash Price	$3,823.20
Rate for Payer: Devoted Health Medicare	$835.48
Rate for Payer: Hawaii Medical Service Association ABD	$648.40
Rate for Payer: Hawaii Medical Service Association Commercial	$949.41
Rate for Payer: Hawaii Medical Service Association Medicare	$759.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$648.40
Rate for Payer: Hawaii Western Management Group Commercial	$759.53
Rate for Payer: Health Management Network Commercial	$5,416.20
Rate for Payer: Humana Medicare	$759.53
Rate for Payer: Kaiser Permanente Commercial	$4,014.36
Rate for Payer: Kaiser Permanente Medicaid	$3,249.72
Rate for Payer: Kaiser Permanente Medicare	$759.53
Rate for Payer: MDX Hawaii PPO	$6,180.84
Rate for Payer: Ohana Health Plan Medicaid	$835.48
Rate for Payer: Ohana Health Plan Medicare	$759.53
Rate for Payer: UnitedHealthcare Medicaid	$569.65
Rate for Payer: UnitedHealthcare Medicare	$759.53
Rate for Payer: University Health Alliance Commercial	$4,644.55

HC THERAP ENEMA INTUSSUSCEPT

Facility

$885.00

Service Code	HCPCS 74283
Hospital Charge Code	3207428301
Hospital Revenue Code	320
Min. Negotiated Rate	$752.25
Max. Negotiated Rate	$858.45
Rate for Payer: Cash Price	$531.00
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: MDX Hawaii PPO	$858.45

HC THERAP ENEMA INTUSSUSCEPT

Facility

$885.00

Service Code	HCPCS 74283
Hospital Charge Code	3207428301
Hospital Revenue Code	320
Min. Negotiated Rate	$84.41
Max. Negotiated Rate	$858.45
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$531.00
Rate for Payer: Cash Price	$531.00
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$84.41
Rate for Payer: Hawaii Medical Service Association Commercial	$259.01
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$91.88
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$557.55
Rate for Payer: Kaiser Permanente Medicaid	$451.35
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$858.45
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$84.41
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$365.71

HC THERA RAD PORT FILM(S)

Facility

$247.00

Service Code	HCPCS 77417
Hospital Charge Code	3337741701
Hospital Revenue Code	333
Min. Negotiated Rate	$21.11
Max. Negotiated Rate	$239.59
Rate for Payer: Cash Price	$148.20
Rate for Payer: Cash Price	$148.20
Rate for Payer: Hawaii Medical Service Association ABD	$21.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.17
Rate for Payer: Hawaii Western Management Group Commercial	$234.65
Rate for Payer: Health Management Network Commercial	$209.95
Rate for Payer: Kaiser Permanente Commercial	$155.61
Rate for Payer: Kaiser Permanente Medicaid	$125.97
Rate for Payer: MDX Hawaii PPO	$239.59
Rate for Payer: UnitedHealthcare Medicaid	$21.11
Rate for Payer: University Health Alliance Commercial	$40.50

HC THERA RAD PORT FILM(S)

Facility

$247.00

Service Code	HCPCS 77417
Hospital Charge Code	3337741701
Hospital Revenue Code	333
Min. Negotiated Rate	$209.95
Max. Negotiated Rate	$239.59
Rate for Payer: Cash Price	$148.20
Rate for Payer: Health Management Network Commercial	$209.95
Rate for Payer: MDX Hawaii PPO	$239.59

HC THER IVNTJ 1ST 15 MIN

Facility

$103.00

Service Code	HCPCS 97129 GN
Hospital Charge Code	4409712901
Hospital Revenue Code	440
Min. Negotiated Rate	$87.55
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$61.80
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: MDX Hawaii PPO	$99.91

HC THER IVNTJ 1ST 15 MIN

Facility

$103.00

Service Code	HCPCS 97129 GN
Hospital Charge Code	4409712901
Hospital Revenue Code	440
Min. Negotiated Rate	$22.57
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$61.80
Rate for Payer: Cash Price	$61.80
Rate for Payer: Hawaii Western Management Group Commercial	$97.85
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Kaiser Permanente Commercial	$64.89
Rate for Payer: Kaiser Permanente Medicaid	$52.53
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: UnitedHealthcare Medicaid	$22.57
Rate for Payer: University Health Alliance Commercial	$75.08

HC THER IVNTJ 1ST 15 MIN

Facility

$103.00

Service Code	HCPCS 97129 GO
Hospital Charge Code	4309712901
Hospital Revenue Code	430
Min. Negotiated Rate	$22.57
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$61.80
Rate for Payer: Cash Price	$61.80
Rate for Payer: Hawaii Western Management Group Commercial	$97.85
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Kaiser Permanente Commercial	$64.89
Rate for Payer: Kaiser Permanente Medicaid	$52.53
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: UnitedHealthcare Medicaid	$22.57
Rate for Payer: University Health Alliance Commercial	$75.08

HC THER IVNTJ 1ST 15 MIN

Facility

$103.00

Service Code	HCPCS 97129 GO
Hospital Charge Code	4309712901
Hospital Revenue Code	430
Min. Negotiated Rate	$87.55
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$61.80
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: MDX Hawaii PPO	$99.91

HC THER RAD SET FIELD SIMP

Facility

$931.00

Service Code	HCPCS 77280
Hospital Charge Code	3337728001
Hospital Revenue Code	333
Min. Negotiated Rate	$122.62
Max. Negotiated Rate	$903.07
Rate for Payer: AlohaCare Medicaid	$158.78
Rate for Payer: AlohaCare Medicare	$158.78
Rate for Payer: Cash Price	$558.60
Rate for Payer: Cash Price	$558.60
Rate for Payer: Devoted Health Medicare	$174.66
Rate for Payer: Hawaii Medical Service Association ABD	$122.62
Rate for Payer: Hawaii Medical Service Association Commercial	$198.47
Rate for Payer: Hawaii Medical Service Association Medicare	$158.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$128.75
Rate for Payer: Hawaii Western Management Group Commercial	$158.78
Rate for Payer: Health Management Network Commercial	$791.35
Rate for Payer: Humana Medicare	$158.78
Rate for Payer: Kaiser Permanente Commercial	$586.53
Rate for Payer: Kaiser Permanente Medicaid	$474.81
Rate for Payer: Kaiser Permanente Medicare	$158.78
Rate for Payer: MDX Hawaii PPO	$903.07
Rate for Payer: Ohana Health Plan Medicaid	$174.66
Rate for Payer: Ohana Health Plan Medicare	$158.78
Rate for Payer: UnitedHealthcare Medicaid	$122.62
Rate for Payer: UnitedHealthcare Medicare	$158.78
Rate for Payer: University Health Alliance Commercial	$381.04

HC THER RAD SET FIELD SIMP

Facility

$931.00

Service Code	HCPCS 77280
Hospital Charge Code	3337728001
Hospital Revenue Code	333
Min. Negotiated Rate	$791.35
Max. Negotiated Rate	$903.07
Rate for Payer: Cash Price	$558.60
Rate for Payer: Health Management Network Commercial	$791.35
Rate for Payer: MDX Hawaii PPO	$903.07

HC THER RAD SIM AID FLD 3D

Facility

$5,445.00

Service Code	HCPCS 77295
Hospital Charge Code	3337729501
Hospital Revenue Code	333
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$5,281.65
Rate for Payer: AlohaCare Medicaid	$1,635.14
Rate for Payer: AlohaCare Medicare	$1,635.14
Rate for Payer: Cash Price	$3,267.00
Rate for Payer: Cash Price	$3,267.00
Rate for Payer: Devoted Health Medicare	$1,798.65
Rate for Payer: Hawaii Medical Service Association ABD	$1,027.08
Rate for Payer: Hawaii Medical Service Association Commercial	$2,043.92
Rate for Payer: Hawaii Medical Service Association Medicare	$1,635.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,014.37
Rate for Payer: Hawaii Western Management Group Commercial	$1,635.14
Rate for Payer: Health Management Network Commercial	$4,628.25
Rate for Payer: Humana Medicare	$1,635.14
Rate for Payer: Kaiser Permanente Commercial	$3,430.35
Rate for Payer: Kaiser Permanente Medicaid	$2,776.95
Rate for Payer: Kaiser Permanente Medicare	$1,635.14
Rate for Payer: MDX Hawaii PPO	$5,281.65
Rate for Payer: Ohana Health Plan Medicaid	$1,798.65
Rate for Payer: Ohana Health Plan Medicare	$1,635.14
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: UnitedHealthcare Medicare	$1,635.14
Rate for Payer: University Health Alliance Commercial	$1,847.52

HC THER RAD SIM AID FLD 3D

Facility

$5,445.00

Service Code	HCPCS 77295
Hospital Charge Code	3337729501
Hospital Revenue Code	333
Min. Negotiated Rate	$4,628.25
Max. Negotiated Rate	$5,281.65
Rate for Payer: Cash Price	$3,267.00
Rate for Payer: Health Management Network Commercial	$4,628.25
Rate for Payer: MDX Hawaii PPO	$5,281.65

HC THER RAD SIMULAJ FIELD INTRM

Facility

$1,557.00

Service Code	HCPCS 77285
Hospital Charge Code	3337728501
Hospital Revenue Code	333
Min. Negotiated Rate	$183.68
Max. Negotiated Rate	$1,510.29
Rate for Payer: AlohaCare Medicaid	$442.33
Rate for Payer: AlohaCare Medicare	$442.33
Rate for Payer: Cash Price	$934.20
Rate for Payer: Cash Price	$934.20
Rate for Payer: Devoted Health Medicare	$486.56
Rate for Payer: Hawaii Medical Service Association ABD	$183.68
Rate for Payer: Hawaii Medical Service Association Commercial	$552.91
Rate for Payer: Hawaii Medical Service Association Medicare	$442.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$199.33
Rate for Payer: Hawaii Western Management Group Commercial	$442.33
Rate for Payer: Health Management Network Commercial	$1,323.45
Rate for Payer: Humana Medicare	$442.33
Rate for Payer: Kaiser Permanente Commercial	$980.91
Rate for Payer: Kaiser Permanente Medicaid	$794.07
Rate for Payer: Kaiser Permanente Medicare	$442.33
Rate for Payer: MDX Hawaii PPO	$1,510.29
Rate for Payer: Ohana Health Plan Medicaid	$486.56
Rate for Payer: Ohana Health Plan Medicare	$442.33
Rate for Payer: UnitedHealthcare Medicaid	$183.68
Rate for Payer: UnitedHealthcare Medicare	$442.33
Rate for Payer: University Health Alliance Commercial	$641.19

HC THER RAD SIMULAJ FIELD INTRM

Facility

$1,557.00

Service Code	HCPCS 77285
Hospital Charge Code	3337728501
Hospital Revenue Code	333
Min. Negotiated Rate	$1,323.45
Max. Negotiated Rate	$1,510.29
Rate for Payer: Cash Price	$934.20
Rate for Payer: Health Management Network Commercial	$1,323.45
Rate for Payer: MDX Hawaii PPO	$1,510.29

HC THER SIM FIELD SET CMPLX

Facility

$1,489.00

Service Code	HCPCS 77290
Hospital Charge Code	3337729001
Hospital Revenue Code	333
Min. Negotiated Rate	$214.62
Max. Negotiated Rate	$1,444.33
Rate for Payer: AlohaCare Medicaid	$442.33
Rate for Payer: AlohaCare Medicare	$442.33
Rate for Payer: Cash Price	$893.40
Rate for Payer: Cash Price	$893.40
Rate for Payer: Devoted Health Medicare	$486.56
Rate for Payer: Hawaii Medical Service Association ABD	$214.62
Rate for Payer: Hawaii Medical Service Association Commercial	$552.91
Rate for Payer: Hawaii Medical Service Association Medicare	$442.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$233.10
Rate for Payer: Hawaii Western Management Group Commercial	$442.33
Rate for Payer: Health Management Network Commercial	$1,265.65
Rate for Payer: Humana Medicare	$442.33
Rate for Payer: Kaiser Permanente Commercial	$938.07
Rate for Payer: Kaiser Permanente Medicaid	$759.39
Rate for Payer: Kaiser Permanente Medicare	$442.33
Rate for Payer: MDX Hawaii PPO	$1,444.33
Rate for Payer: Ohana Health Plan Medicaid	$486.56
Rate for Payer: Ohana Health Plan Medicare	$442.33
Rate for Payer: UnitedHealthcare Medicaid	$214.62
Rate for Payer: UnitedHealthcare Medicare	$442.33
Rate for Payer: University Health Alliance Commercial	$937.39

Know your out-of-pocket cost for care.

All Charges