Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION [6677]

Facility

$66.00

Service Code	HCPCS J2720
Hospital Revenue Code	636
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cash Price	$39.60
Rate for Payer: Hawaii Medical Service Association ABD	$1.64
Rate for Payer: Hawaii Medical Service Association ABD	$1.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.64
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Hawaii Western Management Group Commercial	$62.70
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$41.58
Rate for Payer: Kaiser Permanente Commercial	$20.79
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: UnitedHealthcare Medicaid	$19.80
Rate for Payer: UnitedHealthcare Medicaid	$39.60
Rate for Payer: University Health Alliance Commercial	$24.05
Rate for Payer: University Health Alliance Commercial	$48.11

PROTECTOR ARM 1STEP STND 40433

Facility

$163.00

Hospital Revenue Code	272
Min. Negotiated Rate	$138.55
Max. Negotiated Rate	$158.11
Rate for Payer: Cash Price	$97.80
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: MDX Hawaii PPO	$158.11

PROTECTOR ARM 1STEP STND 40433

Facility

$163.00

Hospital Revenue Code	272
Min. Negotiated Rate	$83.13
Max. Negotiated Rate	$158.11
Rate for Payer: Cash Price	$97.80
Rate for Payer: Hawaii Western Management Group Commercial	$154.85
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Kaiser Permanente Commercial	$102.69
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: University Health Alliance Commercial	$118.81

PROTECTOR HEEL PREVALON

Facility

$225.00

Hospital Revenue Code	274
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Hawaii Western Management Group Commercial	$157.50
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: University Health Alliance Commercial	$126.00

PROTECTOR HEEL PREVALON

Facility

$225.00

Hospital Revenue Code	274
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Hawaii Western Management Group Commercial	$157.50
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$141.75
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: University Health Alliance Commercial	$126.00

PR OTOLARYNGOLOGIC EXAM UNDER GENERAL ANESTHESIA

Professional

Both

$170.00

Service Code	HCPCS 92502
Min. Negotiated Rate	$76.47
Max. Negotiated Rate	$144.50
Rate for Payer: AlohaCare Medicaid	$99.56
Rate for Payer: AlohaCare Medicare	$89.58
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Devoted Health Medicare	$98.54
Rate for Payer: Hawaii Medical Service Association Medicare	$89.58
Rate for Payer: Hawaii Western Management Group Commercial	$76.47
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Kaiser Permanente Commercial	$107.50
Rate for Payer: Kaiser Permanente Medicaid	$107.50
Rate for Payer: Kaiser Permanente Medicare	$107.50
Rate for Payer: Ohana Health Plan Medicaid	$99.56
Rate for Payer: Ohana Health Plan Medicare	$89.58
Rate for Payer: UnitedHealthcare Medicaid	$99.56
Rate for Payer: UnitedHealthcare Medicare	$89.58

PR OTOPLASTY PROTRUDING EAR W/WO SIZE RDCTJ

Professional

Both

$1,217.37

Service Code	HCPCS 69300
Min. Negotiated Rate	$346.32
Max. Negotiated Rate	$1,034.76
Rate for Payer: AlohaCare Medicaid	$493.54
Rate for Payer: AlohaCare Medicare	$438.92
Rate for Payer: Cash Price	$730.42
Rate for Payer: Cash Price	$730.42
Rate for Payer: Devoted Health Medicare	$482.81
Rate for Payer: Hawaii Medical Service Association ABD	$493.54
Rate for Payer: Hawaii Medical Service Association Commercial	$809.40
Rate for Payer: Hawaii Medical Service Association Medicare	$438.92
Rate for Payer: Hawaii Medical Service Association Non-ABD	$493.54
Rate for Payer: Hawaii Western Management Group Commercial	$346.32
Rate for Payer: Health Management Network Commercial	$1,034.76
Rate for Payer: Kaiser Permanente Commercial	$526.70
Rate for Payer: Kaiser Permanente Medicaid	$526.70
Rate for Payer: Kaiser Permanente Medicare	$526.70
Rate for Payer: Ohana Health Plan Medicaid	$493.54
Rate for Payer: Ohana Health Plan Medicare	$438.92
Rate for Payer: UnitedHealthcare Medicaid	$493.54
Rate for Payer: UnitedHealthcare Medicare	$438.92
Rate for Payer: University Health Alliance Commercial	$637.48

PROVENA SOLO 3FR SINGLE LUMEN

Facility

$1,096.00

Service Code	HCPCS C1751
Hospital Revenue Code	272
Min. Negotiated Rate	$931.60
Max. Negotiated Rate	$1,063.12
Rate for Payer: Cash Price	$657.60
Rate for Payer: Health Management Network Commercial	$931.60
Rate for Payer: MDX Hawaii PPO	$1,063.12

PROVENA SOLO 3FR SINGLE LUMEN

Facility

$1,096.00

Service Code	HCPCS C1751
Hospital Revenue Code	272
Min. Negotiated Rate	$558.96
Max. Negotiated Rate	$1,063.12
Rate for Payer: Cash Price	$657.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,041.20
Rate for Payer: Health Management Network Commercial	$931.60
Rate for Payer: Kaiser Permanente Commercial	$690.48
Rate for Payer: Kaiser Permanente Medicaid	$558.96
Rate for Payer: MDX Hawaii PPO	$1,063.12
Rate for Payer: University Health Alliance Commercial	$798.87

PROXIMAL BODY PTC ARS741702

Facility

$13,112.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$7,342.72
Max. Negotiated Rate	$12,718.64
Rate for Payer: Cash Price	$7,867.20
Rate for Payer: Hawaii Western Management Group Commercial	$9,178.40
Rate for Payer: Health Management Network Commercial	$11,145.20
Rate for Payer: MDX Hawaii PPO	$12,718.64
Rate for Payer: University Health Alliance Commercial	$7,342.72

PROXIMAL BODY PTC ARS741702

Facility

$13,112.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,687.12
Max. Negotiated Rate	$12,718.64
Rate for Payer: Cash Price	$7,867.20
Rate for Payer: Hawaii Western Management Group Commercial	$9,178.40
Rate for Payer: Health Management Network Commercial	$11,145.20
Rate for Payer: Kaiser Permanente Commercial	$8,260.56
Rate for Payer: Kaiser Permanente Medicaid	$6,687.12
Rate for Payer: MDX Hawaii PPO	$12,718.64
Rate for Payer: University Health Alliance Commercial	$7,342.72

PROXIMAL OLECRANON PLATE

Facility

$2,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,173.00
Max. Negotiated Rate	$2,231.00
Rate for Payer: Cash Price	$1,380.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,610.00
Rate for Payer: Health Management Network Commercial	$1,955.00
Rate for Payer: Kaiser Permanente Commercial	$1,449.00
Rate for Payer: Kaiser Permanente Medicaid	$1,173.00
Rate for Payer: MDX Hawaii PPO	$2,231.00
Rate for Payer: University Health Alliance Commercial	$1,288.00

PROXIMAL OLECRANON PLATE

Facility

$2,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,288.00
Max. Negotiated Rate	$2,231.00
Rate for Payer: Cash Price	$1,380.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,610.00
Rate for Payer: Health Management Network Commercial	$1,955.00
Rate for Payer: MDX Hawaii PPO	$2,231.00
Rate for Payer: University Health Alliance Commercial	$1,288.00

PROXMAL HUMERUS 4 HOLE 627205

Facility

$3,774.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,113.44
Max. Negotiated Rate	$3,660.78
Rate for Payer: Cash Price	$2,264.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,641.80
Rate for Payer: Health Management Network Commercial	$3,207.90
Rate for Payer: MDX Hawaii PPO	$3,660.78
Rate for Payer: University Health Alliance Commercial	$2,113.44

PROXMAL HUMERUS 4 HOLE 627205

Facility

$3,774.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,924.74
Max. Negotiated Rate	$3,660.78
Rate for Payer: Cash Price	$2,264.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,641.80
Rate for Payer: Health Management Network Commercial	$3,207.90
Rate for Payer: Kaiser Permanente Commercial	$2,377.62
Rate for Payer: Kaiser Permanente Medicaid	$1,924.74
Rate for Payer: MDX Hawaii PPO	$3,660.78
Rate for Payer: University Health Alliance Commercial	$2,113.44

PR PALATOPHARYNGOPLASTY

Professional

Both

$1,222.00

Service Code	HCPCS 42145
Min. Negotiated Rate	$622.38
Max. Negotiated Rate	$1,038.70
Rate for Payer: AlohaCare Medicaid	$718.47
Rate for Payer: AlohaCare Medicare	$622.38
Rate for Payer: Cash Price	$733.20
Rate for Payer: Cash Price	$733.20
Rate for Payer: Devoted Health Medicare	$684.62
Rate for Payer: Hawaii Medical Service Association Medicare	$622.38
Rate for Payer: Hawaii Western Management Group Commercial	$671.32
Rate for Payer: Health Management Network Commercial	$1,038.70
Rate for Payer: Kaiser Permanente Commercial	$746.86
Rate for Payer: Kaiser Permanente Medicaid	$746.86
Rate for Payer: Kaiser Permanente Medicare	$746.86
Rate for Payer: Ohana Health Plan Medicaid	$718.47
Rate for Payer: Ohana Health Plan Medicare	$622.38
Rate for Payer: UnitedHealthcare Medicaid	$718.47
Rate for Payer: UnitedHealthcare Medicare	$622.38

PR PARATHYROID AUTOTRANSPLANTATION ADD-ON

Professional

Both

$401.00

Service Code	HCPCS 60512
Min. Negotiated Rate	$197.34
Max. Negotiated Rate	$340.85
Rate for Payer: AlohaCare Medicaid	$234.77
Rate for Payer: AlohaCare Medicare	$203.24
Rate for Payer: Cash Price	$240.60
Rate for Payer: Cash Price	$240.60
Rate for Payer: Devoted Health Medicare	$223.56
Rate for Payer: Hawaii Medical Service Association Medicare	$203.24
Rate for Payer: Hawaii Western Management Group Commercial	$197.34
Rate for Payer: Health Management Network Commercial	$340.85
Rate for Payer: Kaiser Permanente Commercial	$243.89
Rate for Payer: Kaiser Permanente Medicaid	$243.89
Rate for Payer: Kaiser Permanente Medicare	$243.89
Rate for Payer: Ohana Health Plan Medicaid	$234.77
Rate for Payer: Ohana Health Plan Medicare	$203.24
Rate for Payer: UnitedHealthcare Medicaid	$234.77
Rate for Payer: UnitedHealthcare Medicare	$203.24

PR PARATHYROIDECTOMY/EXPLORATION PARATHYROIDS

Professional

Both

$1,664.00

Service Code	HCPCS 60500
Min. Negotiated Rate	$808.34
Max. Negotiated Rate	$1,414.40
Rate for Payer: AlohaCare Medicaid	$972.70
Rate for Payer: AlohaCare Medicare	$880.82
Rate for Payer: Cash Price	$998.40
Rate for Payer: Cash Price	$998.40
Rate for Payer: Devoted Health Medicare	$968.90
Rate for Payer: Hawaii Medical Service Association Medicare	$880.82
Rate for Payer: Hawaii Western Management Group Commercial	$808.34
Rate for Payer: Health Management Network Commercial	$1,414.40
Rate for Payer: Kaiser Permanente Commercial	$1,056.98
Rate for Payer: Kaiser Permanente Medicaid	$1,056.98
Rate for Payer: Kaiser Permanente Medicare	$1,056.98
Rate for Payer: Ohana Health Plan Medicaid	$972.70
Rate for Payer: Ohana Health Plan Medicare	$880.82
Rate for Payer: UnitedHealthcare Medicaid	$972.70
Rate for Payer: UnitedHealthcare Medicare	$880.82

PR PARING/CUTTING BENIGN HYPERKERATOTIC LESION 1

Professional

Both

$135.87

Service Code	HCPCS 11055
Min. Negotiated Rate	$13.46
Max. Negotiated Rate	$115.49
Rate for Payer: AlohaCare Medicaid	$15.27
Rate for Payer: AlohaCare Medicare	$13.46
Rate for Payer: Cash Price	$81.52
Rate for Payer: Cash Price	$81.52
Rate for Payer: Devoted Health Medicare	$14.81
Rate for Payer: Hawaii Medical Service Association ABD	$15.27
Rate for Payer: Hawaii Medical Service Association Commercial	$31.99
Rate for Payer: Hawaii Medical Service Association Medicare	$13.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.27
Rate for Payer: Hawaii Western Management Group Commercial	$21.32
Rate for Payer: Health Management Network Commercial	$115.49
Rate for Payer: Kaiser Permanente Commercial	$16.15
Rate for Payer: Kaiser Permanente Medicaid	$16.15
Rate for Payer: Kaiser Permanente Medicare	$16.15
Rate for Payer: Ohana Health Plan Medicaid	$15.27
Rate for Payer: Ohana Health Plan Medicare	$13.46
Rate for Payer: UnitedHealthcare Medicaid	$15.27
Rate for Payer: UnitedHealthcare Medicare	$13.46
Rate for Payer: University Health Alliance Commercial	$16.47

PR PARING/CUTTING BENIGN HYPERKERATOTIC LESION 2-4

Professional

Both

$156.28

Service Code	HCPCS 11056
Min. Negotiated Rate	$19.42
Max. Negotiated Rate	$132.84
Rate for Payer: AlohaCare Medicaid	$21.60
Rate for Payer: AlohaCare Medicare	$19.42
Rate for Payer: Cash Price	$93.77
Rate for Payer: Cash Price	$93.77
Rate for Payer: Devoted Health Medicare	$21.36
Rate for Payer: Hawaii Medical Service Association ABD	$21.60
Rate for Payer: Hawaii Medical Service Association Commercial	$45.17
Rate for Payer: Hawaii Medical Service Association Medicare	$19.42
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.60
Rate for Payer: Hawaii Western Management Group Commercial	$28.86
Rate for Payer: Health Management Network Commercial	$132.84
Rate for Payer: Kaiser Permanente Commercial	$23.30
Rate for Payer: Kaiser Permanente Medicaid	$23.30
Rate for Payer: Kaiser Permanente Medicare	$23.30
Rate for Payer: Ohana Health Plan Medicaid	$21.60
Rate for Payer: Ohana Health Plan Medicare	$19.42
Rate for Payer: UnitedHealthcare Medicaid	$21.60
Rate for Payer: UnitedHealthcare Medicare	$19.42
Rate for Payer: University Health Alliance Commercial	$23.71

PR PARTIAL EXCISION BONE CLAVICLE

Professional

Both

$1,244.00

Service Code	HCPCS 23180
Min. Negotiated Rate	$437.06
Max. Negotiated Rate	$1,057.40
Rate for Payer: AlohaCare Medicaid	$687.95
Rate for Payer: AlohaCare Medicare	$669.93
Rate for Payer: Cash Price	$746.40
Rate for Payer: Cash Price	$746.40
Rate for Payer: Devoted Health Medicare	$736.92
Rate for Payer: Hawaii Medical Service Association Medicare	$669.93
Rate for Payer: Hawaii Western Management Group Commercial	$437.06
Rate for Payer: Health Management Network Commercial	$1,057.40
Rate for Payer: Kaiser Permanente Commercial	$803.92
Rate for Payer: Kaiser Permanente Medicaid	$803.92
Rate for Payer: Kaiser Permanente Medicare	$803.92
Rate for Payer: Ohana Health Plan Medicaid	$687.95
Rate for Payer: Ohana Health Plan Medicare	$669.93
Rate for Payer: UnitedHealthcare Medicaid	$687.95
Rate for Payer: UnitedHealthcare Medicare	$669.93

PR PARTIAL EXCISION BONE TALUS/CALCANEUS

Professional

Both

$1,277.99

Service Code	HCPCS 28120
Min. Negotiated Rate	$340.60
Max. Negotiated Rate	$1,086.29
Rate for Payer: AlohaCare Medicaid	$519.05
Rate for Payer: AlohaCare Medicare	$482.30
Rate for Payer: Cash Price	$766.79
Rate for Payer: Cash Price	$766.79
Rate for Payer: Devoted Health Medicare	$530.53
Rate for Payer: Hawaii Medical Service Association ABD	$519.05
Rate for Payer: Hawaii Medical Service Association Commercial	$772.97
Rate for Payer: Hawaii Medical Service Association Medicare	$482.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$519.05
Rate for Payer: Hawaii Western Management Group Commercial	$340.60
Rate for Payer: Health Management Network Commercial	$1,086.29
Rate for Payer: Kaiser Permanente Commercial	$578.76
Rate for Payer: Kaiser Permanente Medicaid	$578.76
Rate for Payer: Kaiser Permanente Medicare	$578.76
Rate for Payer: Ohana Health Plan Medicaid	$519.05
Rate for Payer: Ohana Health Plan Medicare	$482.30
Rate for Payer: UnitedHealthcare Medicaid	$519.05
Rate for Payer: UnitedHealthcare Medicare	$482.30
Rate for Payer: University Health Alliance Commercial	$674.05

PR PARTIAL EXCISION BONE TIBIA

Professional

Both

$1,465.00

Service Code	HCPCS 27640
Min. Negotiated Rate	$778.63
Max. Negotiated Rate	$1,245.25
Rate for Payer: AlohaCare Medicaid	$858.14
Rate for Payer: AlohaCare Medicare	$778.63
Rate for Payer: Cash Price	$879.00
Rate for Payer: Cash Price	$879.00
Rate for Payer: Devoted Health Medicare	$856.49
Rate for Payer: Hawaii Medical Service Association Medicare	$778.63
Rate for Payer: Hawaii Western Management Group Commercial	$889.46
Rate for Payer: Health Management Network Commercial	$1,245.25
Rate for Payer: Kaiser Permanente Commercial	$934.36
Rate for Payer: Kaiser Permanente Medicaid	$934.36
Rate for Payer: Kaiser Permanente Medicare	$934.36
Rate for Payer: Ohana Health Plan Medicaid	$858.14
Rate for Payer: Ohana Health Plan Medicare	$778.63
Rate for Payer: UnitedHealthcare Medicaid	$858.14
Rate for Payer: UnitedHealthcare Medicare	$778.63

PR PARTIAL EXCISION DISTAL PHALANX FINGER

Professional

Both

$811.00

Service Code	HCPCS 26236
Min. Negotiated Rate	$322.40
Max. Negotiated Rate	$689.35
Rate for Payer: AlohaCare Medicaid	$471.19
Rate for Payer: AlohaCare Medicare	$436.30
Rate for Payer: Cash Price	$486.60
Rate for Payer: Cash Price	$486.60
Rate for Payer: Devoted Health Medicare	$479.93
Rate for Payer: Hawaii Medical Service Association Medicare	$436.30
Rate for Payer: Hawaii Western Management Group Commercial	$322.40
Rate for Payer: Health Management Network Commercial	$689.35
Rate for Payer: Kaiser Permanente Commercial	$523.56
Rate for Payer: Kaiser Permanente Medicaid	$523.56
Rate for Payer: Kaiser Permanente Medicare	$523.56
Rate for Payer: Ohana Health Plan Medicaid	$471.19
Rate for Payer: Ohana Health Plan Medicare	$436.30
Rate for Payer: UnitedHealthcare Medicaid	$471.19
Rate for Payer: UnitedHealthcare Medicare	$436.30

PR PARTIAL HYMENECTOMY OR REVISION HYMENAL RING

Professional

Both

$359.00

Service Code	HCPCS 56700
Min. Negotiated Rate	$137.80
Max. Negotiated Rate	$305.15
Rate for Payer: AlohaCare Medicaid	$211.94
Rate for Payer: AlohaCare Medicare	$184.97
Rate for Payer: Cash Price	$215.40
Rate for Payer: Cash Price	$215.40
Rate for Payer: Devoted Health Medicare	$203.47
Rate for Payer: Hawaii Medical Service Association Medicare	$184.97
Rate for Payer: Hawaii Western Management Group Commercial	$137.80
Rate for Payer: Health Management Network Commercial	$305.15
Rate for Payer: Kaiser Permanente Commercial	$221.96
Rate for Payer: Kaiser Permanente Medicaid	$221.96
Rate for Payer: Kaiser Permanente Medicare	$221.96
Rate for Payer: Ohana Health Plan Medicaid	$211.94
Rate for Payer: Ohana Health Plan Medicare	$184.97
Rate for Payer: UnitedHealthcare Medicaid	$211.94
Rate for Payer: UnitedHealthcare Medicare	$184.97

Know your out-of-pocket cost for care.

All Charges