Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PR IM ADM INTRANSL/ORAL EA VACCINE

Professional

Both

$23.06

Service Code	HCPCS 90474
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$19.60
Rate for Payer: AlohaCare Medicare	$13.18
Rate for Payer: Cash Price	$13.84
Rate for Payer: Cash Price	$13.84
Rate for Payer: Devoted Health Medicare	$14.50
Rate for Payer: Hawaii Medical Service Association Medicare	$13.18
Rate for Payer: Hawaii Western Management Group Commercial	$11.00
Rate for Payer: Health Management Network Commercial	$19.60
Rate for Payer: Kaiser Permanente Commercial	$15.82
Rate for Payer: Kaiser Permanente Medicaid	$15.82
Rate for Payer: Kaiser Permanente Medicare	$15.82
Rate for Payer: Ohana Health Plan Medicare	$13.18
Rate for Payer: UnitedHealthcare Medicare	$13.18

PR IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE

Professional

Both

$42.18

Service Code	HCPCS 90471
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$35.85
Rate for Payer: AlohaCare Medicare	$24.10
Rate for Payer: Cash Price	$25.31
Rate for Payer: Cash Price	$25.31
Rate for Payer: Devoted Health Medicare	$26.51
Rate for Payer: Hawaii Medical Service Association Medicare	$24.10
Rate for Payer: Hawaii Western Management Group Commercial	$18.00
Rate for Payer: Health Management Network Commercial	$35.85
Rate for Payer: Kaiser Permanente Commercial	$28.92
Rate for Payer: Kaiser Permanente Medicaid	$28.92
Rate for Payer: Kaiser Permanente Medicare	$28.92
Rate for Payer: Ohana Health Plan Medicare	$24.10
Rate for Payer: UnitedHealthcare Medicare	$24.10

PR IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE

Professional

Both

$30.38

Service Code	HCPCS 90472
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$25.82
Rate for Payer: AlohaCare Medicare	$17.36
Rate for Payer: Cash Price	$18.23
Rate for Payer: Cash Price	$18.23
Rate for Payer: Devoted Health Medicare	$19.10
Rate for Payer: Hawaii Medical Service Association Medicare	$17.36
Rate for Payer: Hawaii Western Management Group Commercial	$9.00
Rate for Payer: Health Management Network Commercial	$25.82
Rate for Payer: Kaiser Permanente Commercial	$20.83
Rate for Payer: Kaiser Permanente Medicaid	$20.83
Rate for Payer: Kaiser Permanente Medicare	$20.83
Rate for Payer: Ohana Health Plan Medicare	$17.36
Rate for Payer: UnitedHealthcare Medicare	$17.36

PR IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT VAC/TOX

Professional

Both

$44.03

Service Code	HCPCS 90460
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$37.43
Rate for Payer: AlohaCare Medicare	$25.16
Rate for Payer: Cash Price	$26.42
Rate for Payer: Cash Price	$26.42
Rate for Payer: Devoted Health Medicare	$27.68
Rate for Payer: Hawaii Medical Service Association Medicare	$25.16
Rate for Payer: Hawaii Western Management Group Commercial	$18.00
Rate for Payer: Health Management Network Commercial	$37.43
Rate for Payer: Kaiser Permanente Commercial	$30.19
Rate for Payer: Kaiser Permanente Medicaid	$30.19
Rate for Payer: Kaiser Permanente Medicare	$30.19
Rate for Payer: Ohana Health Plan Medicare	$25.16
Rate for Payer: UnitedHealthcare Medicare	$25.16

PR IM ADM THRU 18YR ANY RTE ADDL VAC/TOX COMPT

Professional

Both

$15.50

Service Code	HCPCS 90461
Min. Negotiated Rate	$8.86
Max. Negotiated Rate	$13.18
Rate for Payer: AlohaCare Medicare	$8.86
Rate for Payer: Cash Price	$9.30
Rate for Payer: Cash Price	$9.30
Rate for Payer: Devoted Health Medicare	$9.75
Rate for Payer: Hawaii Medical Service Association Medicare	$8.86
Rate for Payer: Hawaii Western Management Group Commercial	$9.00
Rate for Payer: Health Management Network Commercial	$13.18
Rate for Payer: Kaiser Permanente Commercial	$10.63
Rate for Payer: Kaiser Permanente Medicaid	$10.63
Rate for Payer: Kaiser Permanente Medicare	$10.63
Rate for Payer: Ohana Health Plan Medicare	$8.86
Rate for Payer: UnitedHealthcare Medicare	$8.86

PR IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ

Professional

Both

$1,622.53

Service Code	HCPCS 49405
Min. Negotiated Rate	$163.83
Max. Negotiated Rate	$1,379.15
Rate for Payer: AlohaCare Medicaid	$189.19
Rate for Payer: AlohaCare Medicare	$163.83
Rate for Payer: Cash Price	$973.52
Rate for Payer: Cash Price	$973.52
Rate for Payer: Devoted Health Medicare	$180.21
Rate for Payer: Hawaii Medical Service Association ABD	$189.19
Rate for Payer: Hawaii Medical Service Association Commercial	$335.87
Rate for Payer: Hawaii Medical Service Association Medicare	$163.83
Rate for Payer: Hawaii Medical Service Association Non-ABD	$189.19
Rate for Payer: Hawaii Western Management Group Commercial	$996.06
Rate for Payer: Health Management Network Commercial	$1,379.15
Rate for Payer: Kaiser Permanente Commercial	$196.60
Rate for Payer: Kaiser Permanente Medicaid	$196.60
Rate for Payer: Kaiser Permanente Medicare	$196.60
Rate for Payer: Ohana Health Plan Medicaid	$189.19
Rate for Payer: Ohana Health Plan Medicare	$163.83
Rate for Payer: UnitedHealthcare Medicaid	$189.19
Rate for Payer: UnitedHealthcare Medicare	$163.83
Rate for Payer: University Health Alliance Commercial	$253.75

PRIMAQUINE 26.3 MG (15 MG BASE) TABLET [179299]

Facility

$9.00

Service Code	NDC 00024159601
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

PRIMAQUINE 26.3 MG (15 MG BASE) TABLET [179299]

Facility

$9.00

Service Code	NDC 00024159601
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: University Health Alliance Commercial	$6.56

PR IMG-GUIDED FLU COLLJ DRG CATH SOFT TISS PERQ

Professional

Both

$1,203.93

Service Code	HCPCS 10030
Min. Negotiated Rate	$115.65
Max. Negotiated Rate	$1,023.34
Rate for Payer: AlohaCare Medicaid	$132.13
Rate for Payer: AlohaCare Medicare	$115.65
Rate for Payer: Cash Price	$722.36
Rate for Payer: Cash Price	$722.36
Rate for Payer: Devoted Health Medicare	$127.22
Rate for Payer: Hawaii Medical Service Association ABD	$132.13
Rate for Payer: Hawaii Medical Service Association Commercial	$243.58
Rate for Payer: Hawaii Medical Service Association Medicare	$115.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$132.13
Rate for Payer: Hawaii Western Management Group Commercial	$893.88
Rate for Payer: Health Management Network Commercial	$1,023.34
Rate for Payer: Kaiser Permanente Commercial	$138.78
Rate for Payer: Kaiser Permanente Medicaid	$138.78
Rate for Payer: Kaiser Permanente Medicare	$138.78
Rate for Payer: Ohana Health Plan Medicaid	$132.13
Rate for Payer: Ohana Health Plan Medicare	$115.65
Rate for Payer: UnitedHealthcare Medicaid	$132.13
Rate for Payer: UnitedHealthcare Medicare	$115.65
Rate for Payer: University Health Alliance Commercial	$160.00

PR IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ

Professional

Both

$1,621.86

Service Code	HCPCS 49406
Min. Negotiated Rate	$163.83
Max. Negotiated Rate	$1,378.58
Rate for Payer: AlohaCare Medicaid	$189.19
Rate for Payer: AlohaCare Medicare	$163.83
Rate for Payer: Cash Price	$973.12
Rate for Payer: Cash Price	$973.12
Rate for Payer: Devoted Health Medicare	$180.21
Rate for Payer: Hawaii Medical Service Association ABD	$189.19
Rate for Payer: Hawaii Medical Service Association Commercial	$336.51
Rate for Payer: Hawaii Medical Service Association Medicare	$163.83
Rate for Payer: Hawaii Medical Service Association Non-ABD	$189.19
Rate for Payer: Hawaii Western Management Group Commercial	$995.54
Rate for Payer: Health Management Network Commercial	$1,378.58
Rate for Payer: Kaiser Permanente Commercial	$196.60
Rate for Payer: Kaiser Permanente Medicaid	$196.60
Rate for Payer: Kaiser Permanente Medicare	$196.60
Rate for Payer: Ohana Health Plan Medicaid	$189.19
Rate for Payer: Ohana Health Plan Medicare	$163.83
Rate for Payer: UnitedHealthcare Medicaid	$189.19
Rate for Payer: UnitedHealthcare Medicare	$163.83
Rate for Payer: University Health Alliance Commercial	$253.25

PRIMIDONE 250 MG TABLET [6544]

Facility

$4.00

Service Code	NDC 00527123101
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

PRIMIDONE 250 MG TABLET [6544]

Facility

$4.00

Service Code	NDC 00527123101
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.92

PRIMIDONE 50 MG TABLET [11129]

Facility

$4.00

Service Code	NDC 68084020201
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.92

PRIMIDONE 50 MG TABLET [11129]

Facility

$2.00

Service Code	NDC 53746054401
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

PRIMIDONE 50 MG TABLET [11129]

Facility

$4.00

Service Code	NDC 68084020201
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

PRIMIDONE 50 MG TABLET [11129]

Facility

$2.00

Service Code	NDC 53746054401
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

PR IMM ADMN SARSCOV2 VACCINE SINGLE DOSE

Professional

Both

$86.00

Service Code	HCPCS 90480
Min. Negotiated Rate	$73.10
Max. Negotiated Rate	$73.10
Rate for Payer: Cash Price	$51.60
Rate for Payer: Health Management Network Commercial	$73.10

PR IMM CNSL PHYS/QHP IMM NOT ADMN SAME DOS 3<10 MIN

Professional

Both

$27.00

Service Code	HCPCS 90482
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$22.95
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Management Network Commercial	$22.95

PR IMPL ABSRB MESH/PRSTH DLYD CLSR DFCT INFCTJ/TRMA

Professional

Both

$648.00

Service Code	HCPCS 15778
Min. Negotiated Rate	$338.67
Max. Negotiated Rate	$550.80
Rate for Payer: AlohaCare Medicaid	$372.79
Rate for Payer: AlohaCare Medicare	$338.67
Rate for Payer: Cash Price	$388.80
Rate for Payer: Cash Price	$388.80
Rate for Payer: Devoted Health Medicare	$372.54
Rate for Payer: Hawaii Medical Service Association Medicare	$338.67
Rate for Payer: Health Management Network Commercial	$550.80
Rate for Payer: Kaiser Permanente Commercial	$406.40
Rate for Payer: Kaiser Permanente Medicaid	$406.40
Rate for Payer: Kaiser Permanente Medicare	$406.40
Rate for Payer: Ohana Health Plan Medicaid	$372.79
Rate for Payer: Ohana Health Plan Medicare	$338.67
Rate for Payer: UnitedHealthcare Medicaid	$372.79
Rate for Payer: UnitedHealthcare Medicare	$338.67

PR IMPLNT BIO IMPLNT FOR SOFT TISSUE REINFORCEMENT

Professional

Both

$395.59

Service Code	HCPCS 15777
Min. Negotiated Rate	$178.58
Max. Negotiated Rate	$336.25
Rate for Payer: AlohaCare Medicaid	$211.64
Rate for Payer: AlohaCare Medicare	$178.58
Rate for Payer: Cash Price	$237.35
Rate for Payer: Cash Price	$237.35
Rate for Payer: Devoted Health Medicare	$196.44
Rate for Payer: Hawaii Medical Service Association Medicare	$178.58
Rate for Payer: Hawaii Western Management Group Commercial	$200.72
Rate for Payer: Health Management Network Commercial	$336.25
Rate for Payer: Kaiser Permanente Commercial	$214.30
Rate for Payer: Kaiser Permanente Medicaid	$214.30
Rate for Payer: Kaiser Permanente Medicare	$214.30
Rate for Payer: Ohana Health Plan Medicaid	$211.64
Rate for Payer: Ohana Health Plan Medicare	$178.58
Rate for Payer: UnitedHealthcare Medicaid	$211.64
Rate for Payer: UnitedHealthcare Medicare	$178.58

PR IMPLTJ NONBIOL/SYNTH IMPLT FASC RNFCMT ABDL WALL

Professional

Both

$478.00

Service Code	HCPCS 0437T
Min. Negotiated Rate	$406.30
Max. Negotiated Rate	$406.30
Rate for Payer: Cash Price	$286.80
Rate for Payer: Health Management Network Commercial	$406.30

PR INCISIONAL BIOPSY EYELID SKIN W/LID MARGIN

Professional

Both

$347.41

Service Code	HCPCS 67810
Min. Negotiated Rate	$55.35
Max. Negotiated Rate	$295.30
Rate for Payer: AlohaCare Medicaid	$68.87
Rate for Payer: AlohaCare Medicare	$55.35
Rate for Payer: Cash Price	$208.45
Rate for Payer: Cash Price	$208.45
Rate for Payer: Devoted Health Medicare	$60.88
Rate for Payer: Hawaii Medical Service Association ABD	$68.87
Rate for Payer: Hawaii Medical Service Association Commercial	$122.54
Rate for Payer: Hawaii Medical Service Association Medicare	$55.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$68.87
Rate for Payer: Hawaii Western Management Group Commercial	$95.42
Rate for Payer: Health Management Network Commercial	$295.30
Rate for Payer: Kaiser Permanente Commercial	$66.42
Rate for Payer: Kaiser Permanente Medicaid	$66.42
Rate for Payer: Kaiser Permanente Medicare	$66.42
Rate for Payer: Ohana Health Plan Medicaid	$68.87
Rate for Payer: Ohana Health Plan Medicare	$55.35
Rate for Payer: UnitedHealthcare Medicaid	$68.87
Rate for Payer: UnitedHealthcare Medicare	$55.35
Rate for Payer: University Health Alliance Commercial	$90.31

PR INCISIONAL BIOPSY SKIN EA SEP/ADDITIONAL LESION

Professional

Both

$134.70

Service Code	HCPCS 11107
Min. Negotiated Rate	$24.94
Max. Negotiated Rate	$114.50
Rate for Payer: AlohaCare Medicaid	$30.76
Rate for Payer: AlohaCare Medicare	$24.94
Rate for Payer: Cash Price	$80.82
Rate for Payer: Cash Price	$80.82
Rate for Payer: Devoted Health Medicare	$27.43
Rate for Payer: Hawaii Medical Service Association ABD	$30.76
Rate for Payer: Hawaii Medical Service Association Commercial	$52.21
Rate for Payer: Hawaii Medical Service Association Medicare	$24.94
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.76
Rate for Payer: Hawaii Western Management Group Commercial	$80.08
Rate for Payer: Health Management Network Commercial	$114.50
Rate for Payer: Kaiser Permanente Commercial	$29.93
Rate for Payer: Kaiser Permanente Medicaid	$29.93
Rate for Payer: Kaiser Permanente Medicare	$29.93
Rate for Payer: Ohana Health Plan Medicaid	$30.76
Rate for Payer: Ohana Health Plan Medicare	$24.94
Rate for Payer: UnitedHealthcare Medicaid	$30.76
Rate for Payer: UnitedHealthcare Medicare	$24.94
Rate for Payer: University Health Alliance Commercial	$35.94

PR INCISIONAL BIOPSY SKIN SINGLE LESION

Professional

Both

$289.29

Service Code	HCPCS 11106
Min. Negotiated Rate	$46.07
Max. Negotiated Rate	$245.90
Rate for Payer: AlohaCare Medicaid	$56.70
Rate for Payer: AlohaCare Medicare	$46.07
Rate for Payer: Cash Price	$173.57
Rate for Payer: Cash Price	$173.57
Rate for Payer: Devoted Health Medicare	$50.68
Rate for Payer: Hawaii Medical Service Association ABD	$56.70
Rate for Payer: Hawaii Medical Service Association Commercial	$98.45
Rate for Payer: Hawaii Medical Service Association Medicare	$46.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$56.70
Rate for Payer: Hawaii Western Management Group Commercial	$167.96
Rate for Payer: Health Management Network Commercial	$245.90
Rate for Payer: Kaiser Permanente Commercial	$55.28
Rate for Payer: Kaiser Permanente Medicaid	$55.28
Rate for Payer: Kaiser Permanente Medicare	$55.28
Rate for Payer: Ohana Health Plan Medicaid	$56.70
Rate for Payer: Ohana Health Plan Medicare	$46.07
Rate for Payer: UnitedHealthcare Medicaid	$56.70
Rate for Payer: UnitedHealthcare Medicare	$46.07
Rate for Payer: University Health Alliance Commercial	$65.75

PR INCISION BONE CORTEX HAND/FINGER

Professional

Both

$1,013.00

Service Code	HCPCS 26034
Min. Negotiated Rate	$371.80
Max. Negotiated Rate	$861.05
Rate for Payer: AlohaCare Medicaid	$588.07
Rate for Payer: AlohaCare Medicare	$545.09
Rate for Payer: Cash Price	$607.80
Rate for Payer: Cash Price	$607.80
Rate for Payer: Devoted Health Medicare	$599.60
Rate for Payer: Hawaii Medical Service Association Medicare	$545.09
Rate for Payer: Hawaii Western Management Group Commercial	$371.80
Rate for Payer: Health Management Network Commercial	$861.05
Rate for Payer: Kaiser Permanente Commercial	$654.11
Rate for Payer: Kaiser Permanente Medicaid	$654.11
Rate for Payer: Kaiser Permanente Medicare	$654.11
Rate for Payer: Ohana Health Plan Medicaid	$588.07
Rate for Payer: Ohana Health Plan Medicare	$545.09
Rate for Payer: UnitedHealthcare Medicaid	$588.07
Rate for Payer: UnitedHealthcare Medicare	$545.09

Know your out-of-pocket cost for care.

All Charges