Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC TX INCOMPLETE ABORTION ANY TRIMESTER SURGICAL

Facility

$12,390.00

Service Code	HCPCS 59812
Hospital Charge Code	4505981201
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$12,018.30
Rate for Payer: AlohaCare Medicaid	$3,824.16
Rate for Payer: AlohaCare Medicare	$3,824.16
Rate for Payer: Cash Price	$7,434.00
Rate for Payer: Cash Price	$7,434.00
Rate for Payer: Cash Price	$7,434.00
Rate for Payer: Devoted Health Medicare	$4,206.58
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	$3,824.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Hawaii Western Management Group Commercial	$11,770.50
Rate for Payer: Health Management Network Commercial	$10,531.50
Rate for Payer: Humana Medicare	$3,824.16
Rate for Payer: Kaiser Permanente Commercial	$7,805.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,824.16
Rate for Payer: MDX Hawaii PPO	$12,018.30
Rate for Payer: Ohana Health Plan Medicaid	$4,206.58
Rate for Payer: Ohana Health Plan Medicare	$3,824.16
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,824.16
Rate for Payer: University Health Alliance Commercial	$11,157.19

HC TX INCOMPLETE ABORTION ANY TRIMESTER SURGICAL

Facility

$12,390.00

Service Code	HCPCS 59812
Hospital Charge Code	4505981201
Hospital Revenue Code	450
Min. Negotiated Rate	$10,531.50
Max. Negotiated Rate	$12,018.30
Rate for Payer: Cash Price	$7,434.00
Rate for Payer: Health Management Network Commercial	$10,531.50
Rate for Payer: MDX Hawaii PPO	$12,018.30

HC UA MICRO ONLY

Facility

$26.00

Service Code	HCPCS 81015
Hospital Charge Code	3078101501
Hospital Revenue Code	307
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$25.22
Rate for Payer: AlohaCare Medicaid	$3.05
Rate for Payer: AlohaCare Medicare	$3.05
Rate for Payer: Cash Price	$15.60
Rate for Payer: Cash Price	$15.60
Rate for Payer: Devoted Health Medicare	$3.35
Rate for Payer: Hawaii Medical Service Association ABD	$4.20
Rate for Payer: Hawaii Medical Service Association Commercial	$3.81
Rate for Payer: Hawaii Medical Service Association Medicare	$3.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.41
Rate for Payer: Hawaii Western Management Group Commercial	$3.05
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Humana Medicare	$3.05
Rate for Payer: Kaiser Permanente Commercial	$16.38
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: Kaiser Permanente Medicare	$3.05
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: Ohana Health Plan Medicaid	$3.35
Rate for Payer: Ohana Health Plan Medicare	$3.05
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: UnitedHealthcare Medicare	$3.05
Rate for Payer: University Health Alliance Commercial	$7.84

HC UA MICRO ONLY

Facility

$26.00

Service Code	HCPCS 81015
Hospital Charge Code	3078101501
Hospital Revenue Code	307
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: MDX Hawaii PPO	$25.22

HC UA MICRO REFLEX CULT

Facility

$26.00

Service Code	HCPCS 81015
Hospital Charge Code	3078101502
Hospital Revenue Code	307
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: MDX Hawaii PPO	$25.22

HC UA MICRO REFLEX CULT

Facility

$26.00

Service Code	HCPCS 81015
Hospital Charge Code	3078101502
Hospital Revenue Code	307
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$25.22
Rate for Payer: AlohaCare Medicaid	$3.05
Rate for Payer: AlohaCare Medicare	$3.05
Rate for Payer: Cash Price	$15.60
Rate for Payer: Cash Price	$15.60
Rate for Payer: Devoted Health Medicare	$3.35
Rate for Payer: Hawaii Medical Service Association ABD	$4.20
Rate for Payer: Hawaii Medical Service Association Commercial	$3.81
Rate for Payer: Hawaii Medical Service Association Medicare	$3.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.41
Rate for Payer: Hawaii Western Management Group Commercial	$3.05
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Humana Medicare	$3.05
Rate for Payer: Kaiser Permanente Commercial	$16.38
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: Kaiser Permanente Medicare	$3.05
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: Ohana Health Plan Medicaid	$3.35
Rate for Payer: Ohana Health Plan Medicare	$3.05
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: UnitedHealthcare Medicare	$3.05
Rate for Payer: University Health Alliance Commercial	$7.84

HC ULTRASONIC GUIDANCE, INTRAOPERATIVE - US INTRAOPERATIVE

Facility

$686.00

Service Code	HCPCS 76998
Hospital Charge Code	4027699802
Hospital Revenue Code	402
Min. Negotiated Rate	$93.99
Max. Negotiated Rate	$665.42
Rate for Payer: Cash Price	$411.60
Rate for Payer: Cash Price	$411.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$93.99
Rate for Payer: Hawaii Western Management Group Commercial	$651.70
Rate for Payer: Health Management Network Commercial	$583.10
Rate for Payer: Kaiser Permanente Commercial	$432.18
Rate for Payer: Kaiser Permanente Medicaid	$349.86
Rate for Payer: MDX Hawaii PPO	$665.42
Rate for Payer: University Health Alliance Commercial	$500.03

HC ULTRASONIC GUIDANCE, INTRAOPERATIVE - US INTRAOPERATIVE

Facility

$686.00

Service Code	HCPCS 76998
Hospital Charge Code	4027699802
Hospital Revenue Code	402
Min. Negotiated Rate	$583.10
Max. Negotiated Rate	$665.42
Rate for Payer: Cash Price	$411.60
Rate for Payer: Health Management Network Commercial	$583.10
Rate for Payer: MDX Hawaii PPO	$665.42

HC ULTRASOUND BREAST COMPLETE - US BREAST LEFT COMPLETE

Facility

$529.00

Service Code	HCPCS 76641
Hospital Charge Code	4027664102
Hospital Revenue Code	402
Min. Negotiated Rate	$34.94
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	$34.94
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	$37.51
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	$67.92
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$223.66

HC ULTRASOUND BREAST COMPLETE - US BREAST LEFT COMPLETE

Facility

$529.00

Service Code	HCPCS 76641
Hospital Charge Code	4027664102
Hospital Revenue Code	402
Min. Negotiated Rate	$449.65
Max. Negotiated Rate	$513.13
Rate for Payer: Cash Price	$317.40
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: MDX Hawaii PPO	$513.13

HC ULTRASOUND BREAST LIMITED

Facility

$438.00

Service Code	HCPCS 76642
Hospital Charge Code	4027664202
Hospital Revenue Code	402
Min. Negotiated Rate	$34.94
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	$34.94
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	$37.51
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	$55.91
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$182.63

HC ULTRASOUND BREAST LIMITED

Facility

$438.00

Service Code	HCPCS 76642
Hospital Charge Code	4027664202
Hospital Revenue Code	402
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 ULTRASOUND BREAST LIMITED

Facility

$438.00

Service Code	HCPCS 76642
Hospital Charge Code	4027664201
Hospital Revenue Code	402
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 ULTRASOUND BREAST LIMITED

Facility

$438.00

Service Code	HCPCS 76642
Hospital Charge Code	4027664201
Hospital Revenue Code	402
Min. Negotiated Rate	$34.94
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	$34.94
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	$37.51
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	$55.91
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$182.63

HC UMBILICAL ARTERY CATHETERIZATION FOR DIAGNOSIS OR THERAPY, NEWBORN

Facility

$254.00

Service Code	HCPCS 36660
Hospital Charge Code	4503666001
Hospital Revenue Code	450
Min. Negotiated Rate	$160.02
Max. Negotiated Rate	$2,536.00
Rate for Payer: Cash Price	$152.40
Rate for Payer: Cash Price	$152.40
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 Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$241.30
Rate for Payer: Health Management Network Commercial	$215.90
Rate for Payer: Kaiser Permanente Commercial	$160.02
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: MDX Hawaii PPO	$246.38
Rate for Payer: University Health Alliance Commercial	$185.14

HC UMBILICAL ARTERY CATHETERIZATION FOR DIAGNOSIS OR THERAPY, NEWBORN

Facility

$254.00

Service Code	HCPCS 36660
Hospital Charge Code	4503666001
Hospital Revenue Code	450
Min. Negotiated Rate	$215.90
Max. Negotiated Rate	$246.38
Rate for Payer: Cash Price	$152.40
Rate for Payer: Health Management Network Commercial	$215.90
Rate for Payer: MDX Hawaii PPO	$246.38

HC UNDER OTHER EMERGENCY SERVICES

Facility

$277.00

Service Code	HCPCS 99288
Hospital Charge Code	4509928801
Hospital Revenue Code	450
Min. Negotiated Rate	$235.45
Max. Negotiated Rate	$268.69
Rate for Payer: Cash Price	$166.20
Rate for Payer: Health Management Network Commercial	$235.45
Rate for Payer: MDX Hawaii PPO	$268.69

HC UNDER OTHER EMERGENCY SERVICES

Facility

$277.00

Service Code	HCPCS 99288
Hospital Charge Code	4509928801
Hospital Revenue Code	450
Min. Negotiated Rate	$174.51
Max. Negotiated Rate	$1,600.00
Rate for Payer: Cash Price	$166.20
Rate for Payer: Cash Price	$166.20
Rate for Payer: Cash Price	$166.20
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	$263.15
Rate for Payer: Health Management Network Commercial	$235.45
Rate for Payer: Kaiser Permanente Commercial	$174.51
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: MDX Hawaii PPO	$268.69
Rate for Payer: University Health Alliance Commercial	$201.91

HC UNLISTED ABDOMEN SURGERY PROC

Facility

$4,664.00

Service Code	HCPCS 49999
Hospital Charge Code	3614999901
Hospital Revenue Code	361
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$4,524.08
Rate for Payer: AlohaCare Medicaid	$1,071.46
Rate for Payer: AlohaCare Medicare	$1,071.46
Rate for Payer: Cash Price	$2,798.40
Rate for Payer: Cash Price	$2,798.40
Rate for Payer: Cash Price	$2,798.40
Rate for Payer: Devoted Health Medicare	$1,178.61
Rate for Payer: Hawaii Medical Service Association Commercial	$1,339.33
Rate for Payer: Hawaii Medical Service Association Medicare	$1,071.46
Rate for Payer: Health Management Network Commercial	$3,964.40
Rate for Payer: Humana Medicare	$1,071.46
Rate for Payer: Kaiser Permanente Commercial	$2,938.32
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,071.46
Rate for Payer: MDX Hawaii PPO	$4,524.08
Rate for Payer: Ohana Health Plan Medicaid	$1,178.61
Rate for Payer: Ohana Health Plan Medicare	$1,071.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,071.46
Rate for Payer: University Health Alliance Commercial	$3,399.59

HC UNLISTED ABDOMEN SURGERY PROC

Facility

$4,664.00

Service Code	HCPCS 49999
Hospital Charge Code	3614999901
Hospital Revenue Code	361
Min. Negotiated Rate	$3,964.40
Max. Negotiated Rate	$4,524.08
Rate for Payer: Cash Price	$2,798.40
Rate for Payer: Health Management Network Commercial	$3,964.40
Rate for Payer: MDX Hawaii PPO	$4,524.08

HC UNLISTED DX RADIOGRAPHIC PROCEDURE

Facility

$438.00

Service Code	HCPCS 76499
Hospital Charge Code	3207649901
Hospital Revenue Code	320
Min. Negotiated Rate	$66.48
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 Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
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	$66.48
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$319.26

HC UNLISTED DX RADIOGRAPHIC PROCEDURE

Facility

$438.00

Service Code	HCPCS 76499
Hospital Charge Code	3207649901
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 UNLISTED PROCEDURE PHARYNX ADENOIDS/TONSILS

Facility

$905.00

Service Code	HCPCS 42999
Hospital Charge Code	4504299901
Hospital Revenue Code	450
Min. Negotiated Rate	$279.80
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$279.80
Rate for Payer: AlohaCare Medicare	$279.80
Rate for Payer: Cash Price	$543.00
Rate for Payer: Cash Price	$543.00
Rate for Payer: Cash Price	$543.00
Rate for Payer: Cash Price	$543.00
Rate for Payer: Devoted Health Medicare	$307.78
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	$279.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$859.75
Rate for Payer: Health Management Network Commercial	$769.25
Rate for Payer: Humana Medicare	$279.80
Rate for Payer: Kaiser Permanente Commercial	$570.15
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$279.80
Rate for Payer: MDX Hawaii PPO	$877.85
Rate for Payer: Ohana Health Plan Medicaid	$307.78
Rate for Payer: Ohana Health Plan Medicare	$279.80
Rate for Payer: UnitedHealthcare Medicare	$279.80
Rate for Payer: University Health Alliance Commercial	$659.65

HC UNLISTED PROCEDURE PHARYNX ADENOIDS/TONSILS

Facility

$905.00

Service Code	HCPCS 42999
Hospital Charge Code	4504299901
Hospital Revenue Code	450
Min. Negotiated Rate	$769.25
Max. Negotiated Rate	$877.85
Rate for Payer: Cash Price	$543.00
Rate for Payer: Health Management Network Commercial	$769.25
Rate for Payer: MDX Hawaii PPO	$877.85

HC UNLISTED PROCEDURE, RECTUM

Facility

$3,628.00

Service Code	HCPCS 45999
Hospital Charge Code	4504599901
Hospital Revenue Code	450
Min. Negotiated Rate	$3,083.80
Max. Negotiated Rate	$3,519.16
Rate for Payer: Cash Price	$2,176.80
Rate for Payer: Health Management Network Commercial	$3,083.80
Rate for Payer: MDX Hawaii PPO	$3,519.16

Know your out-of-pocket cost for care.

All Charges