Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC US, ABDOMEN LIMITED - US ABDOMEN LIMITED SPLEEN

Facility

$529.00

Service Code	HCPCS 76705
Hospital Charge Code	4027670501
Hospital Revenue Code	402
Min. Negotiated Rate	$46.98
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	$46.98
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	$50.90
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	$46.98
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$200.93

HC US, ABDOMEN LIMITED - US ABDOMEN LIMITED SPLEEN

Facility

$529.00

Service Code	HCPCS 76705
Hospital Charge Code	4027670501
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 US AMNIOCENTESIS DIAGNOSTIC

Facility

$3,465.00

Service Code	HCPCS 59000
Hospital Charge Code	3615900001
Hospital Revenue Code	402
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$3,361.05
Rate for Payer: AlohaCare Medicaid	$1,088.08
Rate for Payer: AlohaCare Medicare	$1,088.08
Rate for Payer: Cash Price	$2,079.00
Rate for Payer: Cash Price	$2,079.00
Rate for Payer: Cash Price	$2,079.00
Rate for Payer: Devoted Health Medicare	$1,196.89
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	$1,088.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$3,291.75
Rate for Payer: Health Management Network Commercial	$2,945.25
Rate for Payer: Humana Medicare	$1,088.08
Rate for Payer: Kaiser Permanente Commercial	$2,182.95
Rate for Payer: Kaiser Permanente Medicaid	$1,767.15
Rate for Payer: Kaiser Permanente Medicare	$1,088.08
Rate for Payer: MDX Hawaii PPO	$3,361.05
Rate for Payer: Ohana Health Plan Medicaid	$1,196.89
Rate for Payer: Ohana Health Plan Medicare	$1,088.08
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,088.08
Rate for Payer: University Health Alliance Commercial	$2,525.64

HC US AMNIOCENTESIS DIAGNOSTIC

Facility

$3,465.00

Service Code	HCPCS 59000
Hospital Charge Code	3615900001
Hospital Revenue Code	402
Min. Negotiated Rate	$2,945.25
Max. Negotiated Rate	$3,361.05
Rate for Payer: Cash Price	$2,079.00
Rate for Payer: Health Management Network Commercial	$2,945.25
Rate for Payer: MDX Hawaii PPO	$3,361.05

HC US, CHEST,REAL TIME - US CHEST

Facility

$529.00

Service Code	HCPCS 76604
Hospital Charge Code	4027660401
Hospital Revenue Code	402
Min. Negotiated Rate	$42.98
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	$42.98
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	$46.81
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	$42.98
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$171.44

HC US, CHEST,REAL TIME - US CHEST

Facility

$529.00

Service Code	HCPCS 76604
Hospital Charge Code	4027660401
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 US ELASTOGRAPHY PARENCHYMA

Facility

$529.00

Service Code	HCPCS 76981
Hospital Charge Code	4027698101
Hospital Revenue Code	402
Min. Negotiated Rate	$54.16
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	$54.16
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	$73.97
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	$69.60
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$225.11

HC US ELASTOGRAPHY PARENCHYMA

Facility

$529.00

Service Code	HCPCS 76981
Hospital Charge Code	4027698101
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 US EXAM INFANT HIPS DYNAMIC - XR INFANT HIPS WITH MANIPULATION

Facility

$438.00

Service Code	HCPCS 76885
Hospital Charge Code	4027688501
Hospital Revenue Code	402
Min. Negotiated Rate	$50.35
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	$50.35
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	$54.65
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	$50.35
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$192.77

HC US EXAM INFANT HIPS DYNAMIC - XR INFANT HIPS WITH MANIPULATION

Facility

$438.00

Service Code	HCPCS 76885
Hospital Charge Code	4027688501
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 US EXAM INFANT HIPS STATIC - US HIP PEDIATRIC LMT BI WO MANIPULATION

Facility

$438.00

Service Code	HCPCS 76886
Hospital Charge Code	4027688604
Hospital Revenue Code	402
Min. Negotiated Rate	$46.98
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	$46.98
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	$50.90
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	$46.98
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$183.30

HC US EXAM INFANT HIPS STATIC - US HIP PEDIATRIC LMT BI WO MANIPULATION

Facility

$438.00

Service Code	HCPCS 76886
Hospital Charge Code	4027688604
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 US, EYE A-SCAN - US EYE A SCAN

Facility

$529.00

Service Code	HCPCS 76511
Hospital Charge Code	4027651101
Hospital Revenue Code	402
Min. Negotiated Rate	$52.81
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	$52.81
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	$73.08
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	$52.81
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$215.08

HC US, EYE A-SCAN - US EYE A SCAN

Facility

$529.00

Service Code	HCPCS 76511
Hospital Charge Code	4027651101
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 US GUIDANCE AMNIOCENTESIS IMG S&I

Facility

$290.00

Service Code	HCPCS 76946
Hospital Charge Code	4027694601
Hospital Revenue Code	402
Min. Negotiated Rate	$50.35
Max. Negotiated Rate	$281.30
Rate for Payer: Cash Price	$174.00
Rate for Payer: Cash Price	$174.00
Rate for Payer: Hawaii Medical Service Association ABD	$50.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$52.87
Rate for Payer: Hawaii Western Management Group Commercial	$275.50
Rate for Payer: Health Management Network Commercial	$246.50
Rate for Payer: Kaiser Permanente Commercial	$182.70
Rate for Payer: Kaiser Permanente Medicaid	$147.90
Rate for Payer: MDX Hawaii PPO	$281.30
Rate for Payer: UnitedHealthcare Medicaid	$50.35
Rate for Payer: University Health Alliance Commercial	$113.53

HC US GUIDANCE AMNIOCENTESIS IMG S&I

Facility

$290.00

Service Code	HCPCS 76946
Hospital Charge Code	4027694601
Hospital Revenue Code	402
Min. Negotiated Rate	$246.50
Max. Negotiated Rate	$281.30
Rate for Payer: Cash Price	$174.00
Rate for Payer: Health Management Network Commercial	$246.50
Rate for Payer: MDX Hawaii PPO	$281.30

HC US GUIDED ARTERIORVENOUS REPAIR

Facility

$1,549.00

Service Code	HCPCS 76936
Hospital Charge Code	4027693601
Hospital Revenue Code	402
Min. Negotiated Rate	$207.51
Max. Negotiated Rate	$1,502.53
Rate for Payer: AlohaCare Medicaid	$255.08
Rate for Payer: AlohaCare Medicare	$255.08
Rate for Payer: Cash Price	$929.40
Rate for Payer: Cash Price	$929.40
Rate for Payer: Devoted Health Medicare	$280.59
Rate for Payer: Hawaii Medical Service Association ABD	$207.51
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	$222.70
Rate for Payer: Hawaii Western Management Group Commercial	$255.08
Rate for Payer: Health Management Network Commercial	$1,316.65
Rate for Payer: Humana Medicare	$255.08
Rate for Payer: Kaiser Permanente Commercial	$975.87
Rate for Payer: Kaiser Permanente Medicaid	$789.99
Rate for Payer: Kaiser Permanente Medicare	$255.08
Rate for Payer: MDX Hawaii PPO	$1,502.53
Rate for Payer: Ohana Health Plan Medicaid	$280.59
Rate for Payer: Ohana Health Plan Medicare	$255.08
Rate for Payer: UnitedHealthcare Medicaid	$207.51
Rate for Payer: UnitedHealthcare Medicare	$255.08
Rate for Payer: University Health Alliance Commercial	$672.22

HC US GUIDED ARTERIORVENOUS REPAIR

Facility

$1,549.00

Service Code	HCPCS 76936
Hospital Charge Code	4027693601
Hospital Revenue Code	402
Min. Negotiated Rate	$1,316.65
Max. Negotiated Rate	$1,502.53
Rate for Payer: Cash Price	$929.40
Rate for Payer: Health Management Network Commercial	$1,316.65
Rate for Payer: MDX Hawaii PPO	$1,502.53

HC US GUIDE, TISSUE ABLATION - US GUIDANCE TISSUE ABLATION

Facility

$1,141.00

Service Code	HCPCS 76940
Hospital Charge Code	4027694010
Hospital Revenue Code	402
Min. Negotiated Rate	$52.30
Max. Negotiated Rate	$1,106.77
Rate for Payer: Cash Price	$684.60
Rate for Payer: Cash Price	$684.60
Rate for Payer: Hawaii Medical Service Association ABD	$52.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$61.14
Rate for Payer: Hawaii Western Management Group Commercial	$1,083.95
Rate for Payer: Health Management Network Commercial	$969.85
Rate for Payer: Kaiser Permanente Commercial	$718.83
Rate for Payer: Kaiser Permanente Medicaid	$581.91
Rate for Payer: MDX Hawaii PPO	$1,106.77
Rate for Payer: UnitedHealthcare Medicaid	$52.30
Rate for Payer: University Health Alliance Commercial	$831.67

HC US GUIDE, TISSUE ABLATION - US GUIDANCE TISSUE ABLATION

Facility

$1,141.00

Service Code	HCPCS 76940
Hospital Charge Code	4027694010
Hospital Revenue Code	402
Min. Negotiated Rate	$969.85
Max. Negotiated Rate	$1,106.77
Rate for Payer: Cash Price	$684.60
Rate for Payer: Health Management Network Commercial	$969.85
Rate for Payer: MDX Hawaii PPO	$1,106.77

HC US GUIDE, TISSUE ABLATION - US GUIDED RF ABLATION LIVER

Facility

$1,141.00

Service Code	HCPCS 76940
Hospital Charge Code	4027694003
Hospital Revenue Code	402
Min. Negotiated Rate	$52.30
Max. Negotiated Rate	$1,106.77
Rate for Payer: Cash Price	$684.60
Rate for Payer: Cash Price	$684.60
Rate for Payer: Hawaii Medical Service Association ABD	$52.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$61.14
Rate for Payer: Hawaii Western Management Group Commercial	$1,083.95
Rate for Payer: Health Management Network Commercial	$969.85
Rate for Payer: Kaiser Permanente Commercial	$718.83
Rate for Payer: Kaiser Permanente Medicaid	$581.91
Rate for Payer: MDX Hawaii PPO	$1,106.77
Rate for Payer: UnitedHealthcare Medicaid	$52.30
Rate for Payer: University Health Alliance Commercial	$831.67

HC US GUIDE, TISSUE ABLATION - US GUIDED RF ABLATION LIVER

Facility

$1,141.00

Service Code	HCPCS 76940
Hospital Charge Code	4027694003
Hospital Revenue Code	402
Min. Negotiated Rate	$969.85
Max. Negotiated Rate	$1,106.77
Rate for Payer: Cash Price	$684.60
Rate for Payer: Health Management Network Commercial	$969.85
Rate for Payer: MDX Hawaii PPO	$1,106.77

HC US GUIDE, TISSUE ABLATION - US GUIDED RF ABLATION RENAL

Facility

$1,141.00

Service Code	HCPCS 76940
Hospital Charge Code	4027694004
Hospital Revenue Code	402
Min. Negotiated Rate	$52.30
Max. Negotiated Rate	$1,106.77
Rate for Payer: Cash Price	$684.60
Rate for Payer: Cash Price	$684.60
Rate for Payer: Hawaii Medical Service Association ABD	$52.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$61.14
Rate for Payer: Hawaii Western Management Group Commercial	$1,083.95
Rate for Payer: Health Management Network Commercial	$969.85
Rate for Payer: Kaiser Permanente Commercial	$718.83
Rate for Payer: Kaiser Permanente Medicaid	$581.91
Rate for Payer: MDX Hawaii PPO	$1,106.77
Rate for Payer: UnitedHealthcare Medicaid	$52.30
Rate for Payer: University Health Alliance Commercial	$831.67

HC US GUIDE, TISSUE ABLATION - US GUIDED RF ABLATION RENAL

Facility

$1,141.00

Service Code	HCPCS 76940
Hospital Charge Code	4027694004
Hospital Revenue Code	402
Min. Negotiated Rate	$969.85
Max. Negotiated Rate	$1,106.77
Rate for Payer: Cash Price	$684.60
Rate for Payer: Health Management Network Commercial	$969.85
Rate for Payer: MDX Hawaii PPO	$1,106.77

HC US GUIDE, VASCULAR ACCESS - US GUIDANCE INSERT IV

Facility

$556.00

Service Code	HCPCS 76937
Hospital Charge Code	4027693702
Hospital Revenue Code	402
Min. Negotiated Rate	$13.38
Max. Negotiated Rate	$539.32
Rate for Payer: Cash Price	$333.60
Rate for Payer: Cash Price	$333.60
Rate for Payer: Hawaii Medical Service Association ABD	$13.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.63
Rate for Payer: Hawaii Western Management Group Commercial	$528.20
Rate for Payer: Health Management Network Commercial	$472.60
Rate for Payer: Kaiser Permanente Commercial	$350.28
Rate for Payer: Kaiser Permanente Medicaid	$283.56
Rate for Payer: MDX Hawaii PPO	$539.32
Rate for Payer: UnitedHealthcare Medicaid	$13.38
Rate for Payer: University Health Alliance Commercial	$69.04

Know your out-of-pocket cost for care.

All Charges