Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PROMETHAZINE TABLETS (PHENERGAN) 25 MG (TAKE HOME) [4080392]

Facility

$15.00

Service Code	HCPCS Q0169
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: MDX Hawaii PPO	$14.55

PR OMNTC EPIPLOECTOMY RESCJ OMENTUM SPX

Professional

Both

$1,366.00

Service Code	HCPCS 49255
Min. Negotiated Rate	$613.60
Max. Negotiated Rate	$1,161.10
Rate for Payer: AlohaCare Medicaid	$797.62
Rate for Payer: AlohaCare Medicare	$745.50
Rate for Payer: Cash Price	$819.60
Rate for Payer: Cash Price	$819.60
Rate for Payer: Devoted Health Medicare	$820.05
Rate for Payer: Hawaii Medical Service Association Medicare	$745.50
Rate for Payer: Hawaii Western Management Group Commercial	$613.60
Rate for Payer: Health Management Network Commercial	$1,161.10
Rate for Payer: Kaiser Permanente Commercial	$894.60
Rate for Payer: Kaiser Permanente Medicaid	$894.60
Rate for Payer: Kaiser Permanente Medicare	$894.60
Rate for Payer: Ohana Health Plan Medicaid	$797.62
Rate for Payer: Ohana Health Plan Medicare	$745.50
Rate for Payer: UnitedHealthcare Medicaid	$797.62
Rate for Payer: UnitedHealthcare Medicare	$745.50

PR ONDANSETRON ORAL

Professional

Both

$1.00

Service Code	HCPCS Q0162
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$51.15
Rate for Payer: AlohaCare Medicare	$0.02
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.02
Rate for Payer: Hawaii Western Management Group Commercial	$51.15
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.02
Rate for Payer: Kaiser Permanente Medicaid	$0.02
Rate for Payer: Kaiser Permanente Medicare	$0.02
Rate for Payer: Ohana Health Plan Medicare	$0.02
Rate for Payer: UnitedHealthcare Medicare	$0.02

PR ONLINE DIGITAL E/M SVC EST PT <7 D 11-20 MINUTES

Professional

Both

$55.84

Service Code	HCPCS 99422
Min. Negotiated Rate	$22.41
Max. Negotiated Rate	$47.46
Rate for Payer: AlohaCare Medicaid	$25.42
Rate for Payer: AlohaCare Medicare	$22.41
Rate for Payer: Cash Price	$33.50
Rate for Payer: Cash Price	$33.50
Rate for Payer: Devoted Health Medicare	$24.65
Rate for Payer: Hawaii Medical Service Association ABD	$25.42
Rate for Payer: Hawaii Medical Service Association Commercial	$32.06
Rate for Payer: Hawaii Medical Service Association Medicare	$22.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$25.42
Rate for Payer: Hawaii Western Management Group Commercial	$32.10
Rate for Payer: Health Management Network Commercial	$47.46
Rate for Payer: Kaiser Permanente Commercial	$26.89
Rate for Payer: Kaiser Permanente Medicaid	$26.89
Rate for Payer: Kaiser Permanente Medicare	$26.89
Rate for Payer: Ohana Health Plan Medicaid	$25.42
Rate for Payer: Ohana Health Plan Medicare	$22.41
Rate for Payer: UnitedHealthcare Medicaid	$25.42
Rate for Payer: UnitedHealthcare Medicare	$22.41

PR ONLINE DIGITAL E/M SVC EST PT <7 D 21+ MINUTES

Professional

Both

$88.99

Service Code	HCPCS 99423
Min. Negotiated Rate	$35.28
Max. Negotiated Rate	$75.64
Rate for Payer: AlohaCare Medicaid	$40.75
Rate for Payer: AlohaCare Medicare	$35.28
Rate for Payer: Cash Price	$53.39
Rate for Payer: Cash Price	$53.39
Rate for Payer: Devoted Health Medicare	$38.81
Rate for Payer: Hawaii Medical Service Association ABD	$40.75
Rate for Payer: Hawaii Medical Service Association Commercial	$51.66
Rate for Payer: Hawaii Medical Service Association Medicare	$35.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$40.75
Rate for Payer: Hawaii Western Management Group Commercial	$51.96
Rate for Payer: Health Management Network Commercial	$75.64
Rate for Payer: Kaiser Permanente Commercial	$42.34
Rate for Payer: Kaiser Permanente Medicaid	$42.34
Rate for Payer: Kaiser Permanente Medicare	$42.34
Rate for Payer: Ohana Health Plan Medicaid	$40.75
Rate for Payer: Ohana Health Plan Medicare	$35.28
Rate for Payer: UnitedHealthcare Medicaid	$40.75
Rate for Payer: UnitedHealthcare Medicare	$35.28

PR ONLINE DIGITAL E/M SVC EST PT <7 D 5-10 MINUTES

Professional

Both

$28.58

Service Code	HCPCS 99421
Min. Negotiated Rate	$11.02
Max. Negotiated Rate	$24.29
Rate for Payer: AlohaCare Medicaid	$12.90
Rate for Payer: AlohaCare Medicare	$11.02
Rate for Payer: Cash Price	$17.15
Rate for Payer: Cash Price	$17.15
Rate for Payer: Devoted Health Medicare	$12.12
Rate for Payer: Hawaii Medical Service Association ABD	$12.90
Rate for Payer: Hawaii Medical Service Association Commercial	$16.27
Rate for Payer: Hawaii Medical Service Association Medicare	$11.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.90
Rate for Payer: Hawaii Western Management Group Commercial	$16.14
Rate for Payer: Health Management Network Commercial	$24.29
Rate for Payer: Kaiser Permanente Commercial	$13.22
Rate for Payer: Kaiser Permanente Medicaid	$13.22
Rate for Payer: Kaiser Permanente Medicare	$13.22
Rate for Payer: Ohana Health Plan Medicaid	$12.90
Rate for Payer: Ohana Health Plan Medicare	$11.02
Rate for Payer: UnitedHealthcare Medicaid	$12.90
Rate for Payer: UnitedHealthcare Medicare	$11.02

PR OOPHORECTOMY PARTIAL/TOTAL UNI/BI

Professional

Both

$972.00

Service Code	HCPCS 58940
Min. Negotiated Rate	$403.78
Max. Negotiated Rate	$826.20
Rate for Payer: AlohaCare Medicaid	$571.25
Rate for Payer: AlohaCare Medicare	$518.20
Rate for Payer: Cash Price	$583.20
Rate for Payer: Cash Price	$583.20
Rate for Payer: Devoted Health Medicare	$570.02
Rate for Payer: Hawaii Medical Service Association Medicare	$518.20
Rate for Payer: Hawaii Western Management Group Commercial	$403.78
Rate for Payer: Health Management Network Commercial	$826.20
Rate for Payer: Kaiser Permanente Commercial	$621.84
Rate for Payer: Kaiser Permanente Medicaid	$621.84
Rate for Payer: Kaiser Permanente Medicare	$621.84
Rate for Payer: Ohana Health Plan Medicaid	$571.25
Rate for Payer: Ohana Health Plan Medicare	$518.20
Rate for Payer: UnitedHealthcare Medicaid	$571.25
Rate for Payer: UnitedHealthcare Medicare	$518.20

PROPAFENONE 150 MG TABLET [11146]

Facility

$6.00

Service Code	NDC 62559023001
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

PROPAFENONE 150 MG TABLET [11146]

Facility

$6.00

Service Code	NDC 62559023001
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

PROPAFENONE 225 MG TABLET [11147]

Facility

$9.00

Service Code	NDC 62559023101
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

PROPAFENONE 225 MG TABLET [11147]

Facility

$9.00

Service Code	NDC 62559023101
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

PROPARACAINE 0.5 % EYE DROPS [6644]

Facility

$154.00

Service Code	NDC 61314001601
Hospital Revenue Code	637
Min. Negotiated Rate	$78.54
Max. Negotiated Rate	$149.38
Rate for Payer: Cash Price	$92.40
Rate for Payer: Hawaii Western Management Group Commercial	$146.30
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: Kaiser Permanente Commercial	$97.02
Rate for Payer: Kaiser Permanente Medicaid	$78.54
Rate for Payer: MDX Hawaii PPO	$149.38
Rate for Payer: University Health Alliance Commercial	$112.25

PROPARACAINE 0.5 % EYE DROPS [6644]

Facility

$154.00

Service Code	NDC 61314001601
Hospital Revenue Code	250
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$149.38
Rate for Payer: Cash Price	$92.40
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: MDX Hawaii PPO	$149.38

PROPARACAINE 0.5 % EYE DROPS [6644]

Facility

$148.00

Service Code	NDC 24208073006
Hospital Revenue Code	637
Min. Negotiated Rate	$75.48
Max. Negotiated Rate	$143.56
Rate for Payer: Cash Price	$88.80
Rate for Payer: Hawaii Western Management Group Commercial	$140.60
Rate for Payer: Health Management Network Commercial	$125.80
Rate for Payer: Kaiser Permanente Commercial	$93.24
Rate for Payer: Kaiser Permanente Medicaid	$75.48
Rate for Payer: MDX Hawaii PPO	$143.56
Rate for Payer: University Health Alliance Commercial	$107.88

PROPARACAINE 0.5 % EYE DROPS [6644]

Facility

$148.00

Service Code	NDC 24208073006
Hospital Revenue Code	250
Min. Negotiated Rate	$125.80
Max. Negotiated Rate	$143.56
Rate for Payer: Cash Price	$88.80
Rate for Payer: Health Management Network Commercial	$125.80
Rate for Payer: MDX Hawaii PPO	$143.56

PROPATEN VASC GRAFT HAX01A

Facility

$7,458.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$3,803.58
Max. Negotiated Rate	$7,234.26
Rate for Payer: Cash Price	$4,474.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,220.60
Rate for Payer: Health Management Network Commercial	$6,339.30
Rate for Payer: Kaiser Permanente Commercial	$4,698.54
Rate for Payer: Kaiser Permanente Medicaid	$3,803.58
Rate for Payer: MDX Hawaii PPO	$7,234.26
Rate for Payer: University Health Alliance Commercial	$4,176.48

PROPATEN VASC GRAFT HAX01A

Facility

$7,458.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$4,176.48
Max. Negotiated Rate	$7,234.26
Rate for Payer: Cash Price	$4,474.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,220.60
Rate for Payer: Health Management Network Commercial	$6,339.30
Rate for Payer: MDX Hawaii PPO	$7,234.26
Rate for Payer: University Health Alliance Commercial	$4,176.48

PROPATEN VASC GRAFT HAX02A

Facility

$9,318.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$5,218.08
Max. Negotiated Rate	$9,038.46
Rate for Payer: Cash Price	$5,590.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,522.60
Rate for Payer: Health Management Network Commercial	$7,920.30
Rate for Payer: MDX Hawaii PPO	$9,038.46
Rate for Payer: University Health Alliance Commercial	$5,218.08

PROPATEN VASC GRAFT HAX02A

Facility

$9,318.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$4,752.18
Max. Negotiated Rate	$9,038.46
Rate for Payer: Cash Price	$5,590.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,522.60
Rate for Payer: Health Management Network Commercial	$7,920.30
Rate for Payer: Kaiser Permanente Commercial	$5,870.34
Rate for Payer: Kaiser Permanente Medicaid	$4,752.18
Rate for Payer: MDX Hawaii PPO	$9,038.46
Rate for Payer: University Health Alliance Commercial	$5,218.08

PR OPEN BIOPSY/EXCISION INGUINOFEMORAL NODES

Professional

Both

$774.00

Service Code	HCPCS 38531
Min. Negotiated Rate	$431.36
Max. Negotiated Rate	$657.90
Rate for Payer: AlohaCare Medicaid	$451.97
Rate for Payer: AlohaCare Medicare	$431.36
Rate for Payer: Cash Price	$464.40
Rate for Payer: Cash Price	$464.40
Rate for Payer: Devoted Health Medicare	$474.50
Rate for Payer: Hawaii Medical Service Association Medicare	$431.36
Rate for Payer: Health Management Network Commercial	$657.90
Rate for Payer: Kaiser Permanente Commercial	$517.63
Rate for Payer: Kaiser Permanente Medicaid	$517.63
Rate for Payer: Kaiser Permanente Medicare	$517.63
Rate for Payer: Ohana Health Plan Medicaid	$451.97
Rate for Payer: Ohana Health Plan Medicare	$431.36
Rate for Payer: UnitedHealthcare Medicaid	$451.97
Rate for Payer: UnitedHealthcare Medicare	$431.36

PR OPEN EXC/DSTRJ INTRA-ABDL TUMOR/CST 5.1-10 CM

Professional

Both

$2,833.00

Service Code	HCPCS 49187
Min. Negotiated Rate	$1.61
Max. Negotiated Rate	$2,408.05
Rate for Payer: AlohaCare Medicaid	$1.61
Rate for Payer: AlohaCare Medicare	$1,510.87
Rate for Payer: Cash Price	$1,699.80
Rate for Payer: Cash Price	$1,699.80
Rate for Payer: Devoted Health Medicare	$1,661.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1,510.87
Rate for Payer: Health Management Network Commercial	$2,408.05
Rate for Payer: Kaiser Permanente Commercial	$1,813.04
Rate for Payer: Kaiser Permanente Medicaid	$1,813.04
Rate for Payer: Kaiser Permanente Medicare	$1,813.04
Rate for Payer: Ohana Health Plan Medicaid	$1.61
Rate for Payer: Ohana Health Plan Medicare	$1,510.87
Rate for Payer: UnitedHealthcare Medicaid	$1.61
Rate for Payer: UnitedHealthcare Medicare	$1,510.87

PR OPEN EXC/DSTRJ INTRA-ABDL TUMOR/CST 5 CM OR LESS

Professional

Both

$2,237.00

Service Code	HCPCS 49186
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$1,901.45
Rate for Payer: AlohaCare Medicaid	$1.27
Rate for Payer: AlohaCare Medicare	$1,200.45
Rate for Payer: Cash Price	$1,342.20
Rate for Payer: Cash Price	$1,342.20
Rate for Payer: Devoted Health Medicare	$1,320.49
Rate for Payer: Hawaii Medical Service Association Medicare	$1,200.45
Rate for Payer: Health Management Network Commercial	$1,901.45
Rate for Payer: Kaiser Permanente Commercial	$1,440.54
Rate for Payer: Kaiser Permanente Medicaid	$1,440.54
Rate for Payer: Kaiser Permanente Medicare	$1,440.54
Rate for Payer: Ohana Health Plan Medicaid	$1.27
Rate for Payer: Ohana Health Plan Medicare	$1,200.45
Rate for Payer: UnitedHealthcare Medicaid	$1.27
Rate for Payer: UnitedHealthcare Medicare	$1,200.45

PR OPEN IMPLANTATION CRANIAL NERVE NEA & PULSE GEN

Professional

Both

$1,142.49

Service Code	HCPCS 64568
Min. Negotiated Rate	$615.03
Max. Negotiated Rate	$971.12
Rate for Payer: AlohaCare Medicaid	$615.03
Rate for Payer: AlohaCare Medicare	$652.47
Rate for Payer: Cash Price	$685.49
Rate for Payer: Cash Price	$685.49
Rate for Payer: Devoted Health Medicare	$717.72
Rate for Payer: Hawaii Medical Service Association Medicare	$652.47
Rate for Payer: Hawaii Western Management Group Commercial	$650.52
Rate for Payer: Health Management Network Commercial	$971.12
Rate for Payer: Kaiser Permanente Commercial	$782.96
Rate for Payer: Kaiser Permanente Medicaid	$782.96
Rate for Payer: Kaiser Permanente Medicare	$782.96
Rate for Payer: Ohana Health Plan Medicaid	$615.03
Rate for Payer: Ohana Health Plan Medicare	$652.47
Rate for Payer: UnitedHealthcare Medicaid	$615.03
Rate for Payer: UnitedHealthcare Medicare	$652.47

PR OPEN IMPLTJ HPGLSL NRV NSTIM RA PG&RESPIR SENSOR

Professional

Both

$1,455.00

Service Code	HCPCS 64582
Min. Negotiated Rate	$722.27
Max. Negotiated Rate	$1,236.75
Rate for Payer: AlohaCare Medicaid	$851.79
Rate for Payer: AlohaCare Medicare	$722.27
Rate for Payer: Cash Price	$873.00
Rate for Payer: Cash Price	$873.00
Rate for Payer: Devoted Health Medicare	$794.50
Rate for Payer: Hawaii Medical Service Association Medicare	$722.27
Rate for Payer: Health Management Network Commercial	$1,236.75
Rate for Payer: Kaiser Permanente Commercial	$866.72
Rate for Payer: Kaiser Permanente Medicaid	$866.72
Rate for Payer: Kaiser Permanente Medicare	$866.72
Rate for Payer: Ohana Health Plan Medicaid	$851.79
Rate for Payer: Ohana Health Plan Medicare	$722.27
Rate for Payer: UnitedHealthcare Medicaid	$851.79
Rate for Payer: UnitedHealthcare Medicare	$722.27

PR OPEN/PERQ PLACEMENT INTRAVASC STENT SAME EA ADDL

Professional

Both

$3,263.22

Service Code	HCPCS 37239
Min. Negotiated Rate	$125.36
Max. Negotiated Rate	$2,773.74
Rate for Payer: AlohaCare Medicaid	$141.24
Rate for Payer: AlohaCare Medicare	$125.36
Rate for Payer: Cash Price	$1,957.93
Rate for Payer: Cash Price	$1,957.93
Rate for Payer: Devoted Health Medicare	$137.90
Rate for Payer: Hawaii Medical Service Association ABD	$141.24
Rate for Payer: Hawaii Medical Service Association Commercial	$242.67
Rate for Payer: Hawaii Medical Service Association Medicare	$125.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$141.24
Rate for Payer: Hawaii Western Management Group Commercial	$2,381.08
Rate for Payer: Health Management Network Commercial	$2,773.74
Rate for Payer: Kaiser Permanente Commercial	$150.43
Rate for Payer: Kaiser Permanente Medicaid	$150.43
Rate for Payer: Kaiser Permanente Medicare	$150.43
Rate for Payer: Ohana Health Plan Medicaid	$141.24
Rate for Payer: Ohana Health Plan Medicare	$125.36
Rate for Payer: UnitedHealthcare Medicaid	$141.24
Rate for Payer: UnitedHealthcare Medicare	$125.36
Rate for Payer: University Health Alliance Commercial	$300.00

Know your out-of-pocket cost for care.

All Charges