Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PR UNLISTED LAPAROSCOPY PROCEDURE SPLEEN

Professional

Both

$1,940.00

Service Code	HCPCS 38129
Min. Negotiated Rate	$1,649.00
Max. Negotiated Rate	$1,649.00
Rate for Payer: Cash Price	$1,164.00
Rate for Payer: Health Management Network Commercial	$1,649.00

PR UNLISTED LAPAROSCOPY PROCEDURE STOMACH

Professional

Both

$3,719.00

Service Code	HCPCS 43659
Min. Negotiated Rate	$3,161.15
Max. Negotiated Rate	$3,161.15
Rate for Payer: Cash Price	$2,231.40
Rate for Payer: Health Management Network Commercial	$3,161.15

PR UNLISTED LAPAROSCOPY PROCEDURE URETER

Professional

Both

$2,195.00

Service Code	HCPCS 50949
Min. Negotiated Rate	$1,865.75
Max. Negotiated Rate	$1,865.75
Rate for Payer: Cash Price	$1,317.00
Rate for Payer: Health Management Network Commercial	$1,865.75

PR UNLISTED LAPAROSCOPY PX ABD PERTONEUM & OMENTUM

Professional

Both

$1,461.00

Service Code	HCPCS 49329
Min. Negotiated Rate	$548.58
Max. Negotiated Rate	$1,241.85
Rate for Payer: AlohaCare Medicaid	$548.58
Rate for Payer: Cash Price	$876.60
Rate for Payer: Cash Price	$876.60
Rate for Payer: Health Management Network Commercial	$1,241.85
Rate for Payer: Ohana Health Plan Medicaid	$548.58
Rate for Payer: UnitedHealthcare Medicaid	$548.58

PR UNLISTED LAPAROSCOPY PX INTESTINE XCP RECTUM

Professional

Both

$1,582.00

Service Code	HCPCS 44238
Min. Negotiated Rate	$1,344.70
Max. Negotiated Rate	$1,344.70
Rate for Payer: Cash Price	$949.20
Rate for Payer: Health Management Network Commercial	$1,344.70

PR UNLISTED LAPS PX HRNAP HERNIORRHAPHY HERNIOTOMY

Professional

Both

$1,434.00

Service Code	HCPCS 49659
Min. Negotiated Rate	$1,218.90
Max. Negotiated Rate	$1,218.90
Rate for Payer: Cash Price	$860.40
Rate for Payer: Health Management Network Commercial	$1,218.90

PR UNLISTED MUSCULOSKELETAL PROCEDURE HEAD

Professional

Both

$1,472.00

Service Code	HCPCS 21499
Min. Negotiated Rate	$1,251.20
Max. Negotiated Rate	$1,251.20
Rate for Payer: Cash Price	$883.20
Rate for Payer: Health Management Network Commercial	$1,251.20

PR UNLISTED OTORHINOLARYNGOLOGICAL SERVICE/PX

Professional

Both

$77.00

Service Code	HCPCS 92700
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$65.45
Rate for Payer: Cash Price	$46.20
Rate for Payer: Health Management Network Commercial	$65.45

PR UNLISTED PROCEDURE ABDOMEN PERITONEUM & OMENTUM

Professional

Both

$1,666.00

Service Code	HCPCS 49999
Min. Negotiated Rate	$695.22
Max. Negotiated Rate	$1,416.10
Rate for Payer: AlohaCare Medicaid	$695.22
Rate for Payer: Cash Price	$999.60
Rate for Payer: Cash Price	$999.60
Rate for Payer: Health Management Network Commercial	$1,416.10
Rate for Payer: Ohana Health Plan Medicaid	$695.22
Rate for Payer: UnitedHealthcare Medicaid	$695.22

PR UNLISTED PROCEDURE ACCESSORY SINUSES

Professional

Both

$412.00

Service Code	HCPCS 31299
Min. Negotiated Rate	$350.20
Max. Negotiated Rate	$350.20
Rate for Payer: Cash Price	$247.20
Rate for Payer: Health Management Network Commercial	$350.20

PR UNLISTED PROCEDURE ANUS

Professional

Both

$1,003.00

Service Code	HCPCS 46999
Min. Negotiated Rate	$852.55
Max. Negotiated Rate	$852.55
Rate for Payer: Cash Price	$601.80
Rate for Payer: Health Management Network Commercial	$852.55

PR UNLISTED PROCEDURE ARTHROSCOPY

Professional

Both

$1,971.00

Service Code	HCPCS 29999
Min. Negotiated Rate	$1,675.35
Max. Negotiated Rate	$1,675.35
Rate for Payer: Cash Price	$1,182.60
Rate for Payer: Health Management Network Commercial	$1,675.35

PR UNLISTED PROCEDURE CARDIAC SURGERY

Professional

Both

$574.00

Service Code	HCPCS 33999
Min. Negotiated Rate	$487.90
Max. Negotiated Rate	$971.74
Rate for Payer: AlohaCare Medicaid	$971.74
Rate for Payer: Cash Price	$344.40
Rate for Payer: Cash Price	$344.40
Rate for Payer: Health Management Network Commercial	$487.90
Rate for Payer: Ohana Health Plan Medicaid	$971.74
Rate for Payer: UnitedHealthcare Medicaid	$971.74

PR UNLISTED PROCEDURE COLON

Professional

Both

$3,967.00

Service Code	HCPCS 45399
Min. Negotiated Rate	$3,371.95
Max. Negotiated Rate	$3,371.95
Rate for Payer: Cash Price	$2,380.20
Rate for Payer: Health Management Network Commercial	$3,371.95

PR UNLISTED PROCEDURE DENTOALVEOLAR STRUCTURES

Professional

Both

$306.00

Service Code	HCPCS 41899
Min. Negotiated Rate	$35.12
Max. Negotiated Rate	$260.10
Rate for Payer: AlohaCare Medicaid	$35.12
Rate for Payer: Cash Price	$183.60
Rate for Payer: Cash Price	$183.60
Rate for Payer: Health Management Network Commercial	$260.10
Rate for Payer: Ohana Health Plan Medicaid	$35.12
Rate for Payer: UnitedHealthcare Medicaid	$35.12

PR UNLISTED PROCEDURE ESOPHAGUS

Professional

Both

$2,209.00

Service Code	HCPCS 43499
Min. Negotiated Rate	$400.67
Max. Negotiated Rate	$1,877.65
Rate for Payer: AlohaCare Medicaid	$400.67
Rate for Payer: Cash Price	$1,325.40
Rate for Payer: Cash Price	$1,325.40
Rate for Payer: Health Management Network Commercial	$1,877.65
Rate for Payer: Ohana Health Plan Medicaid	$400.67
Rate for Payer: UnitedHealthcare Medicaid	$400.67

PR UNLISTED PROCEDURE EXCISION PRESSURE ULCER

Professional

Both

$244.00

Service Code	HCPCS 15999
Min. Negotiated Rate	$207.40
Max. Negotiated Rate	$207.40
Rate for Payer: Cash Price	$146.40
Rate for Payer: Health Management Network Commercial	$207.40

PR UNLISTED PROCEDURE EXTERNAL EAR

Professional

Both

$214.00

Service Code	HCPCS 69399
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$181.90
Rate for Payer: Cash Price	$128.40
Rate for Payer: Health Management Network Commercial	$181.90

PR UNLISTED PROCEDURE FEMUR/KNEE

Professional

Both

$1,095.00

Service Code	HCPCS 27599
Min. Negotiated Rate	$930.75
Max. Negotiated Rate	$930.75
Rate for Payer: Cash Price	$657.00
Rate for Payer: Health Management Network Commercial	$930.75

PR UNLISTED PROCEDURE FOOT/TOES

Professional

Both

$537.00

Service Code	HCPCS 28899
Min. Negotiated Rate	$456.45
Max. Negotiated Rate	$456.45
Rate for Payer: Cash Price	$322.20
Rate for Payer: Health Management Network Commercial	$456.45

PR UNLISTED PROCEDURE HANDS/FINGERS

Professional

Both

$1,154.00

Service Code	HCPCS 26989
Min. Negotiated Rate	$980.90
Max. Negotiated Rate	$980.90
Rate for Payer: Cash Price	$692.40
Rate for Payer: Health Management Network Commercial	$980.90

PR UNLISTED PROCEDURE HUMERUS/ELBOW

Professional

Both

$1,310.00

Service Code	HCPCS 24999
Min. Negotiated Rate	$1,113.50
Max. Negotiated Rate	$1,113.50
Rate for Payer: Cash Price	$786.00
Rate for Payer: Health Management Network Commercial	$1,113.50

PR UNLISTED PROCEDURE LIPS

Professional

Both

$946.00

Service Code	HCPCS 40799
Min. Negotiated Rate	$804.10
Max. Negotiated Rate	$804.10
Rate for Payer: Cash Price	$567.60
Rate for Payer: Health Management Network Commercial	$804.10

PR UNLISTED PROCEDURE LUNGS & PLEURA

Professional

Both

$1,274.00

Service Code	HCPCS 32999
Min. Negotiated Rate	$205.69
Max. Negotiated Rate	$1,082.90
Rate for Payer: AlohaCare Medicaid	$205.69
Rate for Payer: Cash Price	$764.40
Rate for Payer: Cash Price	$764.40
Rate for Payer: Health Management Network Commercial	$1,082.90
Rate for Payer: Ohana Health Plan Medicaid	$205.69
Rate for Payer: UnitedHealthcare Medicaid	$205.69

PR UNLISTED PROCEDURE MIDDLE EAR

Professional

Both

$1,305.00

Service Code	HCPCS 69799
Min. Negotiated Rate	$1,109.25
Max. Negotiated Rate	$1,109.25
Rate for Payer: Cash Price	$783.00
Rate for Payer: Health Management Network Commercial	$1,109.25

Know your out-of-pocket cost for care.

All Charges