Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC PBB ECHO TRANSESOPHAGEAL

Facility

$654.00

Service Code	HCPCS 93314
Hospital Charge Code	48393314PB
Hospital Revenue Code	483
Min. Negotiated Rate	$126.66
Max. Negotiated Rate	$634.38
Rate for Payer: Cash Price	$392.40
Rate for Payer: Cash Price	$392.40
Rate for Payer: Hawaii Medical Service Association ABD	$126.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$132.99
Rate for Payer: Hawaii Western Management Group Commercial	$621.30
Rate for Payer: Health Management Network Commercial	$555.90
Rate for Payer: Kaiser Permanente Commercial	$412.02
Rate for Payer: Kaiser Permanente Medicaid	$333.54
Rate for Payer: MDX Hawaii PPO	$634.38
Rate for Payer: UnitedHealthcare Medicaid	$126.66
Rate for Payer: University Health Alliance Commercial	$476.70

HC PBB ECHO TRANSESOPHAGEAL

Facility

$654.00

Service Code	HCPCS 93314
Hospital Charge Code	48393314PB
Hospital Revenue Code	483
Min. Negotiated Rate	$555.90
Max. Negotiated Rate	$634.38
Rate for Payer: Cash Price	$392.40
Rate for Payer: Health Management Network Commercial	$555.90
Rate for Payer: MDX Hawaii PPO	$634.38

HC PBB HOSPITAL OUTPT CLINIC VISIT

Facility

$513.00

Service Code	HCPCS G0463
Hospital Charge Code	510G046301
Hospital Revenue Code	510
Min. Negotiated Rate	$96.65
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$307.80
Rate for Payer: AlohaCare Medicaid	$157.28
Rate for Payer: AlohaCare Medicare	$157.28
Rate for Payer: Cash Price	$307.80
Rate for Payer: Devoted Health Medicare	$173.01
Rate for Payer: Hawaii Medical Service Association Commercial	$196.60
Rate for Payer: Hawaii Medical Service Association Medicare	$157.28
Rate for Payer: Hawaii Western Management Group Commercial	$487.35
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Humana Medicare	$157.28
Rate for Payer: Kaiser Permanente Commercial	$323.19
Rate for Payer: Kaiser Permanente Medicaid	$261.63
Rate for Payer: Kaiser Permanente Medicare	$157.28
Rate for Payer: MDX Hawaii PPO	$497.61
Rate for Payer: Ohana Health Plan Medicaid	$173.01
Rate for Payer: Ohana Health Plan Medicare	$157.28
Rate for Payer: UnitedHealthcare Medicaid	$96.65
Rate for Payer: UnitedHealthcare Medicare	$157.28
Rate for Payer: University Health Alliance Commercial	$373.93

HC PBB HOSPITAL OUTPT CLINIC VISIT

Facility

$513.00

Service Code	HCPCS G0463
Hospital Charge Code	510G046301
Hospital Revenue Code	510
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 PBB I&D DEEP ABSC/HEMATOMA NECK/CHEST

Facility

$11,390.00

Service Code	HCPCS 21501
Hospital Charge Code	76121501PB
Hospital Revenue Code	761
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$11,048.30
Rate for Payer: AlohaCare Medicaid	$3,431.47
Rate for Payer: AlohaCare Medicare	$3,431.47
Rate for Payer: Cash Price	$6,834.00
Rate for Payer: Cash Price	$6,834.00
Rate for Payer: Cash Price	$6,834.00
Rate for Payer: Devoted Health Medicare	$3,774.62
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	$3,431.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Hawaii Western Management Group Commercial	$10,820.50
Rate for Payer: Health Management Network Commercial	$9,681.50
Rate for Payer: Humana Medicare	$3,431.47
Rate for Payer: Kaiser Permanente Commercial	$7,175.70
Rate for Payer: Kaiser Permanente Medicaid	$5,808.90
Rate for Payer: Kaiser Permanente Medicare	$3,431.47
Rate for Payer: MDX Hawaii PPO	$11,048.30
Rate for Payer: Ohana Health Plan Medicaid	$3,774.62
Rate for Payer: Ohana Health Plan Medicare	$3,431.47
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,431.47
Rate for Payer: University Health Alliance Commercial	$5,160.40

HC PBB I&D DEEP ABSC/HEMATOMA NECK/CHEST

Facility

$11,390.00

Service Code	HCPCS 21501
Hospital Charge Code	76121501PB
Hospital Revenue Code	761
Min. Negotiated Rate	$9,681.50
Max. Negotiated Rate	$11,048.30
Rate for Payer: Cash Price	$6,834.00
Rate for Payer: Health Management Network Commercial	$9,681.50
Rate for Payer: MDX Hawaii PPO	$11,048.30

HC PBB I&D MOUTH/TONG INTRA,MASTICATOR

Facility

$1,984.00

Service Code	HCPCS 41009
Hospital Charge Code	76141009PB
Hospital Revenue Code	761
Min. Negotiated Rate	$200.41
Max. Negotiated Rate	$2,536.00
Rate for Payer: AlohaCare Medicaid	$637.13
Rate for Payer: AlohaCare Medicare	$637.13
Rate for Payer: Cash Price	$1,190.40
Rate for Payer: Cash Price	$1,190.40
Rate for Payer: Cash Price	$1,190.40
Rate for Payer: Devoted Health Medicare	$700.84
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	$637.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$1,884.80
Rate for Payer: Health Management Network Commercial	$1,686.40
Rate for Payer: Humana Medicare	$637.13
Rate for Payer: Kaiser Permanente Commercial	$1,249.92
Rate for Payer: Kaiser Permanente Medicaid	$1,011.84
Rate for Payer: Kaiser Permanente Medicare	$637.13
Rate for Payer: MDX Hawaii PPO	$1,924.48
Rate for Payer: Ohana Health Plan Medicaid	$700.84
Rate for Payer: Ohana Health Plan Medicare	$637.13
Rate for Payer: UnitedHealthcare Medicaid	$200.41
Rate for Payer: UnitedHealthcare Medicare	$637.13
Rate for Payer: University Health Alliance Commercial	$1,446.14

HC PBB I&D MOUTH/TONG INTRA,MASTICATOR

Facility

$1,984.00

Service Code	HCPCS 41009
Hospital Charge Code	76141009PB
Hospital Revenue Code	761
Min. Negotiated Rate	$1,686.40
Max. Negotiated Rate	$1,924.48
Rate for Payer: Cash Price	$1,190.40
Rate for Payer: Health Management Network Commercial	$1,686.40
Rate for Payer: MDX Hawaii PPO	$1,924.48

HC PBB I&D MOUTH/TONG INTRA,SUBLING,SUPERF

Facility

$905.00

Service Code	HCPCS 41005
Hospital Charge Code	76141005PB
Hospital Revenue Code	761
Min. Negotiated Rate	$74.43
Max. Negotiated Rate	$2,536.00
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: Devoted Health Medicare	$307.78
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	$279.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
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	$461.55
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 Medicaid	$74.43
Rate for Payer: UnitedHealthcare Medicare	$279.80
Rate for Payer: University Health Alliance Commercial	$659.65

HC PBB I&D MOUTH/TONG INTRA,SUBLING,SUPERF

Facility

$905.00

Service Code	HCPCS 41005
Hospital Charge Code	76141005PB
Hospital Revenue Code	761
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 PBB I&D MOUTH/TONG INTRA,SUBMENTAL

Facility

$5,772.00

Service Code	HCPCS 41007
Hospital Charge Code	76141007PB
Hospital Revenue Code	761
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$5,598.84
Rate for Payer: AlohaCare Medicaid	$1,832.96
Rate for Payer: AlohaCare Medicare	$1,832.96
Rate for Payer: Cash Price	$3,463.20
Rate for Payer: Cash Price	$3,463.20
Rate for Payer: Cash Price	$3,463.20
Rate for Payer: Devoted Health Medicare	$2,016.26
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	$1,832.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$5,483.40
Rate for Payer: Health Management Network Commercial	$4,906.20
Rate for Payer: Humana Medicare	$1,832.96
Rate for Payer: Kaiser Permanente Commercial	$3,636.36
Rate for Payer: Kaiser Permanente Medicaid	$2,943.72
Rate for Payer: Kaiser Permanente Medicare	$1,832.96
Rate for Payer: MDX Hawaii PPO	$5,598.84
Rate for Payer: Ohana Health Plan Medicaid	$2,016.26
Rate for Payer: Ohana Health Plan Medicare	$1,832.96
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,832.96
Rate for Payer: University Health Alliance Commercial	$4,207.21

HC PBB I&D MOUTH/TONG INTRA,SUBMENTAL

Facility

$5,772.00

Service Code	HCPCS 41007
Hospital Charge Code	76141007PB
Hospital Revenue Code	761
Min. Negotiated Rate	$4,906.20
Max. Negotiated Rate	$5,598.84
Rate for Payer: Cash Price	$3,463.20
Rate for Payer: Health Management Network Commercial	$4,906.20
Rate for Payer: MDX Hawaii PPO	$5,598.84

HC PBB INCIS/DRAIN ARM/ELBOW INFECT BURSA

Facility

$6,448.00

Service Code	HCPCS 23931
Hospital Charge Code	76123931PB
Hospital Revenue Code	761
Min. Negotiated Rate	$5,480.80
Max. Negotiated Rate	$6,254.56
Rate for Payer: Cash Price	$3,868.80
Rate for Payer: Health Management Network Commercial	$5,480.80
Rate for Payer: MDX Hawaii PPO	$6,254.56

HC PBB INCIS/DRAIN ARM/ELBOW INFECT BURSA

Facility

$6,448.00

Service Code	HCPCS 23931
Hospital Charge Code	76123931PB
Hospital Revenue Code	761
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$6,254.56
Rate for Payer: AlohaCare Medicaid	$1,951.11
Rate for Payer: AlohaCare Medicare	$1,951.11
Rate for Payer: Cash Price	$3,868.80
Rate for Payer: Cash Price	$3,868.80
Rate for Payer: Cash Price	$3,868.80
Rate for Payer: Devoted Health Medicare	$2,146.22
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	$1,951.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$6,125.60
Rate for Payer: Health Management Network Commercial	$5,480.80
Rate for Payer: Humana Medicare	$1,951.11
Rate for Payer: Kaiser Permanente Commercial	$4,062.24
Rate for Payer: Kaiser Permanente Medicaid	$3,288.48
Rate for Payer: Kaiser Permanente Medicare	$1,951.11
Rate for Payer: MDX Hawaii PPO	$6,254.56
Rate for Payer: Ohana Health Plan Medicaid	$2,146.22
Rate for Payer: Ohana Health Plan Medicare	$1,951.11
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,951.11
Rate for Payer: University Health Alliance Commercial	$5,160.40

HC PBB INJECT NERV BLCK,PARACERVICAL

Facility

$2,699.00

Service Code	HCPCS 64435
Hospital Charge Code	76164435PB
Hospital Revenue Code	761
Min. Negotiated Rate	$2,294.15
Max. Negotiated Rate	$2,618.03
Rate for Payer: Cash Price	$1,619.40
Rate for Payer: Health Management Network Commercial	$2,294.15
Rate for Payer: MDX Hawaii PPO	$2,618.03

HC PBB INJECT NERV BLCK,PARACERVICAL

Facility

$2,699.00

Service Code	HCPCS 64435
Hospital Charge Code	76164435PB
Hospital Revenue Code	761
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,618.03
Rate for Payer: AlohaCare Medicaid	$833.89
Rate for Payer: AlohaCare Medicare	$833.89
Rate for Payer: Cash Price	$1,619.40
Rate for Payer: Cash Price	$1,619.40
Rate for Payer: Cash Price	$1,619.40
Rate for Payer: Devoted Health Medicare	$917.28
Rate for Payer: Hawaii Medical Service Association Commercial	$1,042.36
Rate for Payer: Hawaii Medical Service Association Medicare	$833.89
Rate for Payer: Hawaii Western Management Group Commercial	$2,564.05
Rate for Payer: Health Management Network Commercial	$2,294.15
Rate for Payer: Humana Medicare	$833.89
Rate for Payer: Kaiser Permanente Commercial	$1,700.37
Rate for Payer: Kaiser Permanente Medicaid	$1,376.49
Rate for Payer: Kaiser Permanente Medicare	$833.89
Rate for Payer: MDX Hawaii PPO	$2,618.03
Rate for Payer: Ohana Health Plan Medicaid	$917.28
Rate for Payer: Ohana Health Plan Medicare	$833.89
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$833.89
Rate for Payer: University Health Alliance Commercial	$1,967.30

HC PBB MARSUP BARTHOLIN GLAND CYST

Facility

$12,390.00

Service Code	HCPCS 56440
Hospital Charge Code	76156440PB
Hospital Revenue Code	761
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	$6,318.90
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	$5,160.40

HC PBB MARSUP BARTHOLIN GLAND CYST

Facility

$12,390.00

Service Code	HCPCS 56440
Hospital Charge Code	76156440PB
Hospital Revenue Code	761
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 PBB NERVOUS SYSTEM SURGERY UNLISTED

Facility

$1,175.00

Service Code	HCPCS 64999
Hospital Charge Code	76164999PB
Hospital Revenue Code	761
Min. Negotiated Rate	$362.62
Max. Negotiated Rate	$1,139.75
Rate for Payer: AlohaCare Medicaid	$362.62
Rate for Payer: AlohaCare Medicare	$362.62
Rate for Payer: Cash Price	$705.00
Rate for Payer: Cash Price	$705.00
Rate for Payer: Devoted Health Medicare	$398.88
Rate for Payer: Hawaii Medical Service Association Commercial	$453.27
Rate for Payer: Hawaii Medical Service Association Medicare	$362.62
Rate for Payer: Hawaii Western Management Group Commercial	$1,116.25
Rate for Payer: Health Management Network Commercial	$998.75
Rate for Payer: Humana Medicare	$362.62
Rate for Payer: Kaiser Permanente Commercial	$740.25
Rate for Payer: Kaiser Permanente Medicaid	$599.25
Rate for Payer: Kaiser Permanente Medicare	$362.62
Rate for Payer: MDX Hawaii PPO	$1,139.75
Rate for Payer: Ohana Health Plan Medicaid	$398.88
Rate for Payer: Ohana Health Plan Medicare	$362.62
Rate for Payer: UnitedHealthcare Medicaid	$932.99
Rate for Payer: UnitedHealthcare Medicare	$362.62
Rate for Payer: University Health Alliance Commercial	$856.46

HC PBB NERVOUS SYSTEM SURGERY UNLISTED

Facility

$1,175.00

Service Code	HCPCS 64999
Hospital Charge Code	76164999PB
Hospital Revenue Code	761
Min. Negotiated Rate	$998.75
Max. Negotiated Rate	$1,139.75
Rate for Payer: Cash Price	$705.00
Rate for Payer: Health Management Network Commercial	$998.75
Rate for Payer: MDX Hawaii PPO	$1,139.75

HC PBB OFFICE O/P NEW SF 15 MIN

Facility

$594.00

Service Code	HCPCS 99202
Hospital Charge Code	51099202PB
Hospital Revenue Code	510
Min. Negotiated Rate	$48.03
Max. Negotiated Rate	$576.18
Rate for Payer: Cash Price	$356.40
Rate for Payer: Cash Price	$356.40
Rate for Payer: Hawaii Western Management Group Commercial	$564.30
Rate for Payer: Health Management Network Commercial	$504.90
Rate for Payer: Kaiser Permanente Commercial	$374.22
Rate for Payer: Kaiser Permanente Medicaid	$302.94
Rate for Payer: MDX Hawaii PPO	$576.18
Rate for Payer: UnitedHealthcare Medicaid	$48.03
Rate for Payer: University Health Alliance Commercial	$432.97

HC PBB OFFICE O/P NEW SF 15 MIN

Facility

$594.00

Service Code	HCPCS 99202
Hospital Charge Code	51099202PB
Hospital Revenue Code	510
Min. Negotiated Rate	$504.90
Max. Negotiated Rate	$576.18
Rate for Payer: Cash Price	$356.40
Rate for Payer: Health Management Network Commercial	$504.90
Rate for Payer: MDX Hawaii PPO	$576.18

HC PBB OFFICE OUTPATIENT NEW 30 MINUTES

Facility

$654.00

Service Code	HCPCS 99203
Hospital Charge Code	51099203PB
Hospital Revenue Code	510
Min. Negotiated Rate	$68.82
Max. Negotiated Rate	$634.38
Rate for Payer: Cash Price	$392.40
Rate for Payer: Cash Price	$392.40
Rate for Payer: Hawaii Western Management Group Commercial	$621.30
Rate for Payer: Health Management Network Commercial	$555.90
Rate for Payer: Kaiser Permanente Commercial	$412.02
Rate for Payer: Kaiser Permanente Medicaid	$333.54
Rate for Payer: MDX Hawaii PPO	$634.38
Rate for Payer: UnitedHealthcare Medicaid	$68.82
Rate for Payer: University Health Alliance Commercial	$476.70

HC PBB OFFICE OUTPATIENT NEW 30 MINUTES

Facility

$654.00

Service Code	HCPCS 99203
Hospital Charge Code	51099203PB
Hospital Revenue Code	510
Min. Negotiated Rate	$555.90
Max. Negotiated Rate	$634.38
Rate for Payer: Cash Price	$392.40
Rate for Payer: Health Management Network Commercial	$555.90
Rate for Payer: MDX Hawaii PPO	$634.38

HC PBB OFFICE OUTPATIENT NEW 45 MINUTES

Facility

$743.00

Service Code	HCPCS 99204
Hospital Charge Code	51099204PB
Hospital Revenue Code	510
Min. Negotiated Rate	$99.17
Max. Negotiated Rate	$720.71
Rate for Payer: Cash Price	$445.80
Rate for Payer: Cash Price	$445.80
Rate for Payer: Hawaii Western Management Group Commercial	$705.85
Rate for Payer: Health Management Network Commercial	$631.55
Rate for Payer: Kaiser Permanente Commercial	$468.09
Rate for Payer: Kaiser Permanente Medicaid	$378.93
Rate for Payer: MDX Hawaii PPO	$720.71
Rate for Payer: UnitedHealthcare Medicaid	$99.17
Rate for Payer: University Health Alliance Commercial	$541.57

Know your out-of-pocket cost for care.

All Charges