Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

POVIDONE-IODINE 5 % EYE SOLUTION [19791]

Facility

$75.00

Service Code	NDC 00065041130
Hospital Revenue Code	250
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$45.00
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: MDX Hawaii PPO	$72.75

POWER DRIVER ON-CONTROL

Facility

$2,400.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,040.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00

POWER DRIVER ON-CONTROL

Facility

$2,400.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,280.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,749.36

POWERPORT SLIM 6FR 1716000

Facility

$889.00

Service Code	HCPCS C1788
Hospital Revenue Code	278
Min. Negotiated Rate	$453.39
Max. Negotiated Rate	$862.33
Rate for Payer: Cash Price	$533.40
Rate for Payer: Hawaii Western Management Group Commercial	$622.30
Rate for Payer: Health Management Network Commercial	$755.65
Rate for Payer: Kaiser Permanente Commercial	$560.07
Rate for Payer: Kaiser Permanente Medicaid	$453.39
Rate for Payer: MDX Hawaii PPO	$862.33
Rate for Payer: University Health Alliance Commercial	$497.84

POWERPORT SLIM 6FR 1716000

Facility

$889.00

Service Code	HCPCS C1788
Hospital Revenue Code	278
Min. Negotiated Rate	$497.84
Max. Negotiated Rate	$862.33
Rate for Payer: Cash Price	$533.40
Rate for Payer: Hawaii Western Management Group Commercial	$622.30
Rate for Payer: Health Management Network Commercial	$755.65
Rate for Payer: MDX Hawaii PPO	$862.33
Rate for Payer: University Health Alliance Commercial	$497.84

POWER RASP 4.0 AR-8400PR

Facility

$544.00

Hospital Revenue Code	272
Min. Negotiated Rate	$462.40
Max. Negotiated Rate	$527.68
Rate for Payer: Cash Price	$326.40
Rate for Payer: Health Management Network Commercial	$462.40
Rate for Payer: MDX Hawaii PPO	$527.68

POWER RASP 4.0 AR-8400PR

Facility

$544.00

Hospital Revenue Code	272
Min. Negotiated Rate	$277.44
Max. Negotiated Rate	$527.68
Rate for Payer: Cash Price	$326.40
Rate for Payer: Hawaii Western Management Group Commercial	$516.80
Rate for Payer: Health Management Network Commercial	$462.40
Rate for Payer: Kaiser Permanente Commercial	$342.72
Rate for Payer: Kaiser Permanente Medicaid	$277.44
Rate for Payer: MDX Hawaii PPO	$527.68
Rate for Payer: University Health Alliance Commercial	$396.52

PR 1ST CARE PR DAY NML NB XCPT HOSP/BIRTHING CENTER

Professional

Both

$174.37

Service Code	HCPCS 99461
Min. Negotiated Rate	$47.09
Max. Negotiated Rate	$148.21
Rate for Payer: AlohaCare Medicaid	$61.22
Rate for Payer: AlohaCare Medicare	$53.31
Rate for Payer: Cash Price	$104.62
Rate for Payer: Cash Price	$104.62
Rate for Payer: Devoted Health Medicare	$58.64
Rate for Payer: Hawaii Medical Service Association ABD	$61.22
Rate for Payer: Hawaii Medical Service Association Medicare	$53.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$61.22
Rate for Payer: Hawaii Western Management Group Commercial	$47.09
Rate for Payer: Health Management Network Commercial	$148.21
Rate for Payer: Kaiser Permanente Commercial	$63.97
Rate for Payer: Kaiser Permanente Medicaid	$63.97
Rate for Payer: Kaiser Permanente Medicare	$63.97
Rate for Payer: Ohana Health Plan Medicaid	$61.22
Rate for Payer: Ohana Health Plan Medicare	$53.31
Rate for Payer: UnitedHealthcare Medicaid	$61.22
Rate for Payer: UnitedHealthcare Medicare	$53.31
Rate for Payer: University Health Alliance Commercial	$75.09

PR 1ST HOSP/BIRTHING CENTER CARE PER DAY NML NB

Professional

Both

$158.00

Service Code	HCPCS 99460
Min. Negotiated Rate	$77.34
Max. Negotiated Rate	$134.30
Rate for Payer: AlohaCare Medicaid	$93.11
Rate for Payer: AlohaCare Medicare	$80.88
Rate for Payer: Cash Price	$94.80
Rate for Payer: Cash Price	$94.80
Rate for Payer: Devoted Health Medicare	$88.97
Rate for Payer: Hawaii Medical Service Association Medicare	$80.88
Rate for Payer: Hawaii Western Management Group Commercial	$77.34
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: Kaiser Permanente Commercial	$97.06
Rate for Payer: Kaiser Permanente Medicaid	$97.06
Rate for Payer: Kaiser Permanente Medicare	$97.06
Rate for Payer: Ohana Health Plan Medicaid	$93.11
Rate for Payer: Ohana Health Plan Medicare	$80.88
Rate for Payer: UnitedHealthcare Medicaid	$93.11
Rate for Payer: UnitedHealthcare Medicare	$80.88

PR 1ST HOSP/BIRTHING CENTER NB ADMIT & DSCHG SM DAT

Professional

Both

$185.00

Service Code	HCPCS 99463
Min. Negotiated Rate	$95.68
Max. Negotiated Rate	$157.25
Rate for Payer: AlohaCare Medicaid	$109.27
Rate for Payer: AlohaCare Medicare	$95.68
Rate for Payer: Cash Price	$111.00
Rate for Payer: Cash Price	$111.00
Rate for Payer: Devoted Health Medicare	$105.25
Rate for Payer: Hawaii Medical Service Association Medicare	$95.68
Rate for Payer: Hawaii Western Management Group Commercial	$97.81
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Kaiser Permanente Commercial	$114.82
Rate for Payer: Kaiser Permanente Medicaid	$114.82
Rate for Payer: Kaiser Permanente Medicare	$114.82
Rate for Payer: Ohana Health Plan Medicaid	$109.27
Rate for Payer: Ohana Health Plan Medicare	$95.68
Rate for Payer: UnitedHealthcare Medicaid	$109.27
Rate for Payer: UnitedHealthcare Medicare	$95.68

PR 1ST HOSPITAL IP/OBS CARE HIGH MDM 75 MINUTES

Professional

Both

$297.00

Service Code	HCPCS 99223
Min. Negotiated Rate	$149.55
Max. Negotiated Rate	$252.45
Rate for Payer: AlohaCare Medicaid	$174.14
Rate for Payer: AlohaCare Medicare	$156.50
Rate for Payer: Cash Price	$178.20
Rate for Payer: Cash Price	$178.20
Rate for Payer: Devoted Health Medicare	$172.15
Rate for Payer: Hawaii Medical Service Association Medicare	$156.50
Rate for Payer: Hawaii Western Management Group Commercial	$149.55
Rate for Payer: Health Management Network Commercial	$252.45
Rate for Payer: Kaiser Permanente Commercial	$187.80
Rate for Payer: Kaiser Permanente Medicaid	$187.80
Rate for Payer: Kaiser Permanente Medicare	$187.80
Rate for Payer: Ohana Health Plan Medicaid	$174.14
Rate for Payer: Ohana Health Plan Medicare	$156.50
Rate for Payer: UnitedHealthcare Medicaid	$174.14
Rate for Payer: UnitedHealthcare Medicare	$156.50

PR 1ST HOSPITAL IP/OBS CARE MODERATE MDM 55 MINUTES

Professional

Both

$223.00

Service Code	HCPCS 99222
Min. Negotiated Rate	$113.39
Max. Negotiated Rate	$189.55
Rate for Payer: AlohaCare Medicaid	$131.00
Rate for Payer: AlohaCare Medicare	$116.73
Rate for Payer: Cash Price	$133.80
Rate for Payer: Cash Price	$133.80
Rate for Payer: Devoted Health Medicare	$128.40
Rate for Payer: Hawaii Medical Service Association Medicare	$116.73
Rate for Payer: Hawaii Western Management Group Commercial	$113.39
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Kaiser Permanente Commercial	$140.08
Rate for Payer: Kaiser Permanente Medicaid	$140.08
Rate for Payer: Kaiser Permanente Medicare	$140.08
Rate for Payer: Ohana Health Plan Medicaid	$131.00
Rate for Payer: Ohana Health Plan Medicare	$116.73
Rate for Payer: UnitedHealthcare Medicaid	$131.00
Rate for Payer: UnitedHealthcare Medicare	$116.73

PR 1ST HOSPITAL IP/OBS CARE SF/LOW MDM 40 MINUTES

Professional

Both

$141.00

Service Code	HCPCS 99221
Min. Negotiated Rate	$68.50
Max. Negotiated Rate	$119.85
Rate for Payer: AlohaCare Medicaid	$82.48
Rate for Payer: AlohaCare Medicare	$73.69
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cash Price	$84.60
Rate for Payer: Devoted Health Medicare	$81.06
Rate for Payer: Hawaii Medical Service Association Medicare	$73.69
Rate for Payer: Hawaii Western Management Group Commercial	$68.50
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: Kaiser Permanente Commercial	$88.43
Rate for Payer: Kaiser Permanente Medicaid	$88.43
Rate for Payer: Kaiser Permanente Medicare	$88.43
Rate for Payer: Ohana Health Plan Medicaid	$82.48
Rate for Payer: Ohana Health Plan Medicare	$73.69
Rate for Payer: UnitedHealthcare Medicaid	$82.48
Rate for Payer: UnitedHealthcare Medicare	$73.69

PR 1ST INPATIENT CRITICAL CARE PR DAY AGE 28 DAYS/<

Professional

Both

$1,517.00

Service Code	HCPCS 99468
Min. Negotiated Rate	$161.59
Max. Negotiated Rate	$1,289.45
Rate for Payer: AlohaCare Medicaid	$896.57
Rate for Payer: AlohaCare Medicare	$779.52
Rate for Payer: Cash Price	$910.20
Rate for Payer: Cash Price	$910.20
Rate for Payer: Devoted Health Medicare	$857.47
Rate for Payer: Hawaii Medical Service Association Medicare	$779.52
Rate for Payer: Hawaii Western Management Group Commercial	$161.59
Rate for Payer: Health Management Network Commercial	$1,289.45
Rate for Payer: Kaiser Permanente Commercial	$935.42
Rate for Payer: Kaiser Permanente Medicaid	$935.42
Rate for Payer: Kaiser Permanente Medicare	$935.42
Rate for Payer: Ohana Health Plan Medicaid	$896.57
Rate for Payer: Ohana Health Plan Medicare	$779.52
Rate for Payer: UnitedHealthcare Medicaid	$896.57
Rate for Payer: UnitedHealthcare Medicare	$779.52

PR 2D TTE W OR W/O FOL W/CON,FU

Professional

Both

$196.00

Service Code	HCPCS C8924
Min. Negotiated Rate	$166.60
Max. Negotiated Rate	$166.60
Rate for Payer: Cash Price	$117.60
Rate for Payer: Health Management Network Commercial	$166.60

PR 3D ECHO IMG&PST-PXESSING TEE/TTE CGEN CAR ANOMAL

Professional

Both

$105.75

Service Code	HCPCS 93319
Min. Negotiated Rate	$20.56
Max. Negotiated Rate	$89.89
Rate for Payer: AlohaCare Medicaid	$23.13
Rate for Payer: AlohaCare Medicare	$20.56
Rate for Payer: Cash Price	$63.45
Rate for Payer: Cash Price	$63.45
Rate for Payer: Devoted Health Medicare	$22.62
Rate for Payer: Hawaii Medical Service Association ABD	$23.13
Rate for Payer: Hawaii Medical Service Association Commercial	$39.83
Rate for Payer: Hawaii Medical Service Association Medicare	$20.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.13
Rate for Payer: Health Management Network Commercial	$89.89
Rate for Payer: Kaiser Permanente Commercial	$24.67
Rate for Payer: Kaiser Permanente Medicaid	$24.67
Rate for Payer: Kaiser Permanente Medicare	$24.67
Rate for Payer: Ohana Health Plan Medicaid	$23.13
Rate for Payer: Ohana Health Plan Medicare	$20.56
Rate for Payer: UnitedHealthcare Medicaid	$23.13
Rate for Payer: UnitedHealthcare Medicare	$20.56

PR 4VHPV VACCINE 3 DOSE SCHEDULE FOR IM USE

Professional

Both

$303.00

Service Code	HCPCS 90649
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$257.55
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cash Price	$181.80
Rate for Payer: Hawaii Western Management Group Commercial	$174.49
Rate for Payer: Health Management Network Commercial	$257.55
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

PR 9VHPV VACC 2/3 DOSE SCHED IM USE

Professional

Both

$460.00

Service Code	HCPCS 90651
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$391.00
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$276.00
Rate for Payer: Cash Price	$276.00
Rate for Payer: Hawaii Western Management Group Commercial	$234.35
Rate for Payer: Health Management Network Commercial	$391.00
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

PR ABDOM PARACENTESIS DX/THER W/IMAGING GUIDANCE

Professional

Both

$543.78

Service Code	HCPCS 49083
Min. Negotiated Rate	$92.74
Max. Negotiated Rate	$462.21
Rate for Payer: AlohaCare Medicaid	$105.50
Rate for Payer: AlohaCare Medicare	$92.74
Rate for Payer: Cash Price	$326.27
Rate for Payer: Cash Price	$326.27
Rate for Payer: Devoted Health Medicare	$102.01
Rate for Payer: Hawaii Medical Service Association ABD	$105.50
Rate for Payer: Hawaii Medical Service Association Commercial	$177.92
Rate for Payer: Hawaii Medical Service Association Medicare	$92.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$105.50
Rate for Payer: Health Management Network Commercial	$462.21
Rate for Payer: Kaiser Permanente Commercial	$111.29
Rate for Payer: Kaiser Permanente Medicaid	$111.29
Rate for Payer: Kaiser Permanente Medicare	$111.29
Rate for Payer: Ohana Health Plan Medicaid	$105.50
Rate for Payer: Ohana Health Plan Medicare	$92.74
Rate for Payer: UnitedHealthcare Medicaid	$105.50
Rate for Payer: UnitedHealthcare Medicare	$92.74
Rate for Payer: University Health Alliance Commercial	$140.13

PR ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE

Professional

Both

$472.27

Service Code	HCPCS 49082
Min. Negotiated Rate	$71.63
Max. Negotiated Rate	$401.43
Rate for Payer: AlohaCare Medicaid	$73.51
Rate for Payer: AlohaCare Medicare	$71.63
Rate for Payer: Cash Price	$283.36
Rate for Payer: Cash Price	$283.36
Rate for Payer: Devoted Health Medicare	$78.79
Rate for Payer: Hawaii Medical Service Association ABD	$73.51
Rate for Payer: Hawaii Medical Service Association Commercial	$123.60
Rate for Payer: Hawaii Medical Service Association Medicare	$71.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$73.51
Rate for Payer: Hawaii Western Management Group Commercial	$214.76
Rate for Payer: Health Management Network Commercial	$401.43
Rate for Payer: Kaiser Permanente Commercial	$85.96
Rate for Payer: Kaiser Permanente Medicaid	$85.96
Rate for Payer: Kaiser Permanente Medicare	$85.96
Rate for Payer: Ohana Health Plan Medicaid	$73.51
Rate for Payer: Ohana Health Plan Medicare	$71.63
Rate for Payer: UnitedHealthcare Medicaid	$73.51
Rate for Payer: UnitedHealthcare Medicare	$71.63

PR ABLATION 1/> LIVER TUMOR PERQ CRYOABLATION

Professional

Both

$11,489.96

Service Code	HCPCS 47383
Min. Negotiated Rate	$397.88
Max. Negotiated Rate	$9,766.47
Rate for Payer: AlohaCare Medicaid	$439.18
Rate for Payer: AlohaCare Medicare	$397.88
Rate for Payer: Cash Price	$6,893.98
Rate for Payer: Cash Price	$6,893.98
Rate for Payer: Devoted Health Medicare	$437.67
Rate for Payer: Hawaii Medical Service Association ABD	$439.18
Rate for Payer: Hawaii Medical Service Association Commercial	$777.24
Rate for Payer: Hawaii Medical Service Association Medicare	$397.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$439.18
Rate for Payer: Health Management Network Commercial	$9,766.47
Rate for Payer: Kaiser Permanente Commercial	$477.46
Rate for Payer: Kaiser Permanente Medicaid	$477.46
Rate for Payer: Kaiser Permanente Medicare	$477.46
Rate for Payer: Ohana Health Plan Medicaid	$439.18
Rate for Payer: Ohana Health Plan Medicare	$397.88
Rate for Payer: UnitedHealthcare Medicaid	$439.18
Rate for Payer: UnitedHealthcare Medicare	$397.88
Rate for Payer: University Health Alliance Commercial	$582.36

PR ABLATION B9 THYROID NODULE PERQ LASER W/IMG GDN

Professional

Both

$1,698.00

Service Code	HCPCS 0673T
Min. Negotiated Rate	$207.78
Max. Negotiated Rate	$1,443.30
Rate for Payer: Cash Price	$1,018.80
Rate for Payer: Cash Price	$1,018.80
Rate for Payer: Hawaii Medical Service Association ABD	$207.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$207.78
Rate for Payer: Health Management Network Commercial	$1,443.30

PR ABLATION RENAL TUMOR UNILATERAL PERQ CRYOTHERAPY

Professional

Both

$6,881.56

Service Code	HCPCS 50593
Min. Negotiated Rate	$396.11
Max. Negotiated Rate	$5,849.33
Rate for Payer: AlohaCare Medicaid	$450.08
Rate for Payer: AlohaCare Medicare	$396.11
Rate for Payer: Cash Price	$4,128.94
Rate for Payer: Cash Price	$4,128.94
Rate for Payer: Devoted Health Medicare	$435.72
Rate for Payer: Hawaii Medical Service Association ABD	$450.08
Rate for Payer: Hawaii Medical Service Association Commercial	$757.32
Rate for Payer: Hawaii Medical Service Association Medicare	$396.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.08
Rate for Payer: Health Management Network Commercial	$5,849.33
Rate for Payer: Kaiser Permanente Commercial	$475.33
Rate for Payer: Kaiser Permanente Medicaid	$475.33
Rate for Payer: Kaiser Permanente Medicare	$475.33
Rate for Payer: Ohana Health Plan Medicaid	$450.08
Rate for Payer: Ohana Health Plan Medicare	$396.11
Rate for Payer: UnitedHealthcare Medicaid	$450.08
Rate for Payer: UnitedHealthcare Medicare	$396.11
Rate for Payer: University Health Alliance Commercial	$596.46

PR ABLATJ BONE TUMOR CRYO PERQ W/IMG GDN WHEN PRFMD

Professional

Both

$9,688.74

Service Code	HCPCS 20983
Min. Negotiated Rate	$297.90
Max. Negotiated Rate	$8,235.43
Rate for Payer: AlohaCare Medicaid	$335.38
Rate for Payer: AlohaCare Medicare	$297.90
Rate for Payer: Cash Price	$5,813.24
Rate for Payer: Cash Price	$5,813.24
Rate for Payer: Devoted Health Medicare	$327.69
Rate for Payer: Hawaii Medical Service Association ABD	$335.38
Rate for Payer: Hawaii Medical Service Association Commercial	$624.49
Rate for Payer: Hawaii Medical Service Association Medicare	$297.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$335.38
Rate for Payer: Health Management Network Commercial	$8,235.43
Rate for Payer: Kaiser Permanente Commercial	$357.48
Rate for Payer: Kaiser Permanente Medicaid	$357.48
Rate for Payer: Kaiser Permanente Medicare	$357.48
Rate for Payer: Ohana Health Plan Medicaid	$335.38
Rate for Payer: Ohana Health Plan Medicare	$297.90
Rate for Payer: UnitedHealthcare Medicaid	$335.38
Rate for Payer: UnitedHealthcare Medicare	$297.90
Rate for Payer: University Health Alliance Commercial	$442.53

PR ABLTJ 1/> LVR TUM PRQ RF

Professional

Both

$6,659.62

Service Code	HCPCS 47382
Min. Negotiated Rate	$628.68
Max. Negotiated Rate	$5,660.68
Rate for Payer: AlohaCare Medicaid	$717.53
Rate for Payer: AlohaCare Medicare	$631.02
Rate for Payer: Cash Price	$3,995.77
Rate for Payer: Cash Price	$3,995.77
Rate for Payer: Devoted Health Medicare	$694.12
Rate for Payer: Hawaii Medical Service Association ABD	$717.53
Rate for Payer: Hawaii Medical Service Association Commercial	$1,214.99
Rate for Payer: Hawaii Medical Service Association Medicare	$631.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$717.53
Rate for Payer: Hawaii Western Management Group Commercial	$628.68
Rate for Payer: Health Management Network Commercial	$5,660.68
Rate for Payer: Kaiser Permanente Commercial	$757.22
Rate for Payer: Kaiser Permanente Medicaid	$757.22
Rate for Payer: Kaiser Permanente Medicare	$757.22
Rate for Payer: Ohana Health Plan Medicaid	$717.53
Rate for Payer: Ohana Health Plan Medicare	$631.02
Rate for Payer: UnitedHealthcare Medicaid	$717.53
Rate for Payer: UnitedHealthcare Medicare	$631.02
Rate for Payer: University Health Alliance Commercial	$1,001.80

Know your out-of-pocket cost for care.

All Charges