Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC RBC LEUKOPOOR EA UNIT

Facility

$1,803.00

Service Code	HCPCS P9016
Hospital Charge Code	381P901601
Hospital Revenue Code	381
Min. Negotiated Rate	$1,532.55
Max. Negotiated Rate	$1,748.91
Rate for Payer: Cash Price	$1,081.80
Rate for Payer: Health Management Network Commercial	$1,532.55
Rate for Payer: MDX Hawaii PPO	$1,748.91

HC RBC LEUKO REDUC IRRAD EA

Facility

$2,534.00

Service Code	HCPCS P9040
Hospital Charge Code	381P904001
Hospital Revenue Code	381
Min. Negotiated Rate	$191.85
Max. Negotiated Rate	$2,457.98
Rate for Payer: AlohaCare Medicaid	$306.89
Rate for Payer: AlohaCare Medicare	$306.89
Rate for Payer: Cash Price	$1,520.40
Rate for Payer: Cash Price	$1,520.40
Rate for Payer: Devoted Health Medicare	$337.58
Rate for Payer: Hawaii Medical Service Association Commercial	$383.61
Rate for Payer: Hawaii Medical Service Association Medicare	$306.89
Rate for Payer: Hawaii Western Management Group Commercial	$2,407.30
Rate for Payer: Health Management Network Commercial	$2,153.90
Rate for Payer: Humana Medicare	$306.89
Rate for Payer: Kaiser Permanente Commercial	$1,596.42
Rate for Payer: Kaiser Permanente Medicaid	$1,292.34
Rate for Payer: Kaiser Permanente Medicare	$306.89
Rate for Payer: MDX Hawaii PPO	$2,457.98
Rate for Payer: Ohana Health Plan Medicaid	$337.58
Rate for Payer: Ohana Health Plan Medicare	$306.89
Rate for Payer: UnitedHealthcare Medicaid	$191.85
Rate for Payer: UnitedHealthcare Medicare	$306.89
Rate for Payer: University Health Alliance Commercial	$1,847.03

HC RBC LEUKO REDUC IRRAD EA

Facility

$3,548.00

Service Code	HCPCS P9040
Hospital Charge Code	390P904001
Hospital Revenue Code	390
Min. Negotiated Rate	$191.85
Max. Negotiated Rate	$3,441.56
Rate for Payer: AlohaCare Medicaid	$306.89
Rate for Payer: AlohaCare Medicare	$306.89
Rate for Payer: Cash Price	$2,128.80
Rate for Payer: Cash Price	$2,128.80
Rate for Payer: Devoted Health Medicare	$337.58
Rate for Payer: Hawaii Medical Service Association Commercial	$383.61
Rate for Payer: Hawaii Medical Service Association Medicare	$306.89
Rate for Payer: Hawaii Western Management Group Commercial	$3,370.60
Rate for Payer: Health Management Network Commercial	$3,015.80
Rate for Payer: Humana Medicare	$306.89
Rate for Payer: Kaiser Permanente Commercial	$2,235.24
Rate for Payer: Kaiser Permanente Medicaid	$1,809.48
Rate for Payer: Kaiser Permanente Medicare	$306.89
Rate for Payer: MDX Hawaii PPO	$3,441.56
Rate for Payer: Ohana Health Plan Medicaid	$337.58
Rate for Payer: Ohana Health Plan Medicare	$306.89
Rate for Payer: UnitedHealthcare Medicaid	$191.85
Rate for Payer: UnitedHealthcare Medicare	$306.89
Rate for Payer: University Health Alliance Commercial	$2,586.14

HC RBC LEUKO REDUC IRRAD EA

Facility

$3,548.00

Service Code	HCPCS P9040
Hospital Charge Code	390P904001
Hospital Revenue Code	390
Min. Negotiated Rate	$3,015.80
Max. Negotiated Rate	$3,441.56
Rate for Payer: Cash Price	$2,128.80
Rate for Payer: Health Management Network Commercial	$3,015.80
Rate for Payer: MDX Hawaii PPO	$3,441.56

HC RBC LEUKO REDUC IRRAD EA

Facility

$2,534.00

Service Code	HCPCS P9040
Hospital Charge Code	381P904001
Hospital Revenue Code	381
Min. Negotiated Rate	$2,153.90
Max. Negotiated Rate	$2,457.98
Rate for Payer: Cash Price	$1,520.40
Rate for Payer: Health Management Network Commercial	$2,153.90
Rate for Payer: MDX Hawaii PPO	$2,457.98

HC RBC SED RATE, NONAUTO - SEDIMENTATION RATE, MANUAL

Facility

$36.00

Service Code	HCPCS 85651
Hospital Charge Code	3058565101
Hospital Revenue Code	305
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$4.27
Rate for Payer: AlohaCare Medicare	$4.27
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Devoted Health Medicare	$4.70
Rate for Payer: Hawaii Medical Service Association ABD	$4.91
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$4.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.16
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$4.27
Rate for Payer: Kaiser Permanente Commercial	$22.68
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$4.27
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$4.70
Rate for Payer: Ohana Health Plan Medicare	$4.27
Rate for Payer: UnitedHealthcare Medicaid	$4.91
Rate for Payer: UnitedHealthcare Medicare	$4.27
Rate for Payer: University Health Alliance Commercial	$9.18

HC RBC SED RATE, NONAUTO - SEDIMENTATION RATE, MANUAL

Facility

$36.00

Service Code	HCPCS 85651
Hospital Charge Code	3058565101
Hospital Revenue Code	305
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$34.92

HC RBC SICKLE CELL TEST - SICKLE CELL SCREEN

Facility

$46.00

Service Code	HCPCS 85660
Hospital Charge Code	3058566001
Hospital Revenue Code	305
Min. Negotiated Rate	$39.10
Max. Negotiated Rate	$44.62
Rate for Payer: Cash Price	$27.60
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: MDX Hawaii PPO	$44.62

HC RBC SICKLE CELL TEST - SICKLE CELL SCREEN

Facility

$46.00

Service Code	HCPCS 85660
Hospital Charge Code	3058566001
Hospital Revenue Code	305
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$44.62
Rate for Payer: AlohaCare Medicaid	$5.51
Rate for Payer: AlohaCare Medicare	$5.51
Rate for Payer: Cash Price	$27.60
Rate for Payer: Cash Price	$27.60
Rate for Payer: Devoted Health Medicare	$6.06
Rate for Payer: Hawaii Medical Service Association ABD	$7.63
Rate for Payer: Hawaii Medical Service Association Commercial	$6.89
Rate for Payer: Hawaii Medical Service Association Medicare	$5.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.01
Rate for Payer: Hawaii Western Management Group Commercial	$5.51
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Humana Medicare	$5.51
Rate for Payer: Kaiser Permanente Commercial	$28.98
Rate for Payer: Kaiser Permanente Medicaid	$23.46
Rate for Payer: Kaiser Permanente Medicare	$5.51
Rate for Payer: MDX Hawaii PPO	$44.62
Rate for Payer: Ohana Health Plan Medicaid	$6.06
Rate for Payer: Ohana Health Plan Medicare	$5.51
Rate for Payer: UnitedHealthcare Medicaid	$7.63
Rate for Payer: UnitedHealthcare Medicare	$5.51
Rate for Payer: University Health Alliance Commercial	$14.26

HC RECMPL WND HEAD,FAC,HAND 1.1-2.5 CM

Facility

$1,590.00

Service Code	HCPCS 13131
Hospital Charge Code	4501313101
Hospital Revenue Code	450
Min. Negotiated Rate	$480.23
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$528.25
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	$480.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,510.50
Rate for Payer: Health Management Network Commercial	$1,351.50
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Commercial	$1,001.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: MDX Hawaii PPO	$1,542.30
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$1,158.95

HC RECMPL WND HEAD,FAC,HAND 1.1-2.5 CM

Facility

$1,590.00

Service Code	HCPCS 13131
Hospital Charge Code	4501313101
Hospital Revenue Code	450
Min. Negotiated Rate	$1,351.50
Max. Negotiated Rate	$1,542.30
Rate for Payer: Cash Price	$954.00
Rate for Payer: Health Management Network Commercial	$1,351.50
Rate for Payer: MDX Hawaii PPO	$1,542.30

HC RECMPL WND HEAD,FAC,HAND 2.6-7.5 CM

Facility

$2,436.00

Service Code	HCPCS 13132
Hospital Charge Code	4501313201
Hospital Revenue Code	450
Min. Negotiated Rate	$480.23
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Devoted Health Medicare	$528.25
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	$480.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,314.20
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Commercial	$1,534.68
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: MDX Hawaii PPO	$2,362.92
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$10,679.55

HC RECMPL WND HEAD,FAC,HAND 2.6-7.5 CM

Facility

$2,436.00

Service Code	HCPCS 13132
Hospital Charge Code	4501313201
Hospital Revenue Code	450
Min. Negotiated Rate	$2,070.60
Max. Negotiated Rate	$2,362.92
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: MDX Hawaii PPO	$2,362.92

HC RECMPL WND LID,NOS,EAR 1.1-2.5 CM

Facility

$2,436.00

Service Code	HCPCS 13151
Hospital Charge Code	4501315101
Hospital Revenue Code	450
Min. Negotiated Rate	$2,070.60
Max. Negotiated Rate	$2,362.92
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: MDX Hawaii PPO	$2,362.92

HC RECMPL WND LID,NOS,EAR 1.1-2.5 CM

Facility

$2,436.00

Service Code	HCPCS 13151
Hospital Charge Code	4501315101
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$2,362.92
Rate for Payer: AlohaCare Medicaid	$873.10
Rate for Payer: AlohaCare Medicare	$873.10
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Devoted Health Medicare	$960.41
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	$873.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,314.20
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: Humana Medicare	$873.10
Rate for Payer: Kaiser Permanente Commercial	$1,534.68
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$873.10
Rate for Payer: MDX Hawaii PPO	$2,362.92
Rate for Payer: Ohana Health Plan Medicaid	$960.41
Rate for Payer: Ohana Health Plan Medicare	$873.10
Rate for Payer: UnitedHealthcare Medicare	$873.10
Rate for Payer: University Health Alliance Commercial	$1,775.60

HC RECMPL WND LID,NOS,EAR 2.5-7.5 CM

Facility

$2,436.00

Service Code	HCPCS 13152
Hospital Charge Code	4501315201
Hospital Revenue Code	450
Min. Negotiated Rate	$2,070.60
Max. Negotiated Rate	$2,362.92
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: MDX Hawaii PPO	$2,362.92

HC RECMPL WND LID,NOS,EAR 2.5-7.5 CM

Facility

$2,436.00

Service Code	HCPCS 13152
Hospital Charge Code	4501315201
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$873.10
Rate for Payer: AlohaCare Medicare	$873.10
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Devoted Health Medicare	$960.41
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	$873.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,314.20
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: Humana Medicare	$873.10
Rate for Payer: Kaiser Permanente Commercial	$1,534.68
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$873.10
Rate for Payer: MDX Hawaii PPO	$2,362.92
Rate for Payer: Ohana Health Plan Medicaid	$960.41
Rate for Payer: Ohana Health Plan Medicare	$873.10
Rate for Payer: UnitedHealthcare Medicare	$873.10
Rate for Payer: University Health Alliance Commercial	$6,743.44

HC RECMPL WND SCALP,EXTR 2.6-7.5 CM

Facility

$2,436.00

Service Code	HCPCS 13121
Hospital Charge Code	4501312101
Hospital Revenue Code	450
Min. Negotiated Rate	$480.23
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Devoted Health Medicare	$528.25
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	$480.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,314.20
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Commercial	$1,534.68
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: MDX Hawaii PPO	$2,362.92
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$5,160.40

HC RECMPL WND SCALP,EXTR 2.6-7.5 CM

Facility

$2,436.00

Service Code	HCPCS 13121
Hospital Charge Code	4501312101
Hospital Revenue Code	450
Min. Negotiated Rate	$2,070.60
Max. Negotiated Rate	$2,362.92
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: MDX Hawaii PPO	$2,362.92

HC RECONSTRUC OF NAIL BED

Facility

$2,436.00

Service Code	HCPCS 11760
Hospital Charge Code	4501176001
Hospital Revenue Code	450
Min. Negotiated Rate	$2,070.60
Max. Negotiated Rate	$2,362.92
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: MDX Hawaii PPO	$2,362.92

HC RECONSTRUC OF NAIL BED

Facility

$2,436.00

Service Code	HCPCS 11760
Hospital Charge Code	4501176001
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$873.10
Rate for Payer: AlohaCare Medicare	$873.10
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Devoted Health Medicare	$960.41
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	$873.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$2,314.20
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: Humana Medicare	$873.10
Rate for Payer: Kaiser Permanente Commercial	$1,534.68
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$873.10
Rate for Payer: MDX Hawaii PPO	$2,362.92
Rate for Payer: Ohana Health Plan Medicaid	$960.41
Rate for Payer: Ohana Health Plan Medicare	$873.10
Rate for Payer: UnitedHealthcare Medicare	$873.10
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC RECOVERY EA ADDL MINUTE

Facility

$17.00

Hospital Charge Code	7100000002
Hospital Revenue Code	710
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: MDX Hawaii PPO	$16.49

HC RECOVERY EA ADDL MINUTE

Facility

$17.00

Hospital Charge Code	7100000002
Hospital Revenue Code	710
Min. Negotiated Rate	$8.67
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$10.71
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: University Health Alliance Commercial	$12.39

HC RECOVERY INITIAL 15MIN

Facility

$230.00

Hospital Charge Code	7100000001
Hospital Revenue Code	710
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$138.00
Rate for Payer: Hawaii Western Management Group Commercial	$218.50
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: Kaiser Permanente Medicaid	$117.30
Rate for Payer: MDX Hawaii PPO	$223.10
Rate for Payer: University Health Alliance Commercial	$167.65

HC RECOVERY INITIAL 15MIN

Facility

$230.00

Hospital Charge Code	7100000001
Hospital Revenue Code	710
Min. Negotiated Rate	$195.50
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$138.00
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: MDX Hawaii PPO	$223.10

Know your out-of-pocket cost for care.

All Charges