Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PR UNLISTED PROCEDURE NERVOUS SYSTEM

Professional

Both

$1,444.00

Service Code	HCPCS 64999
Min. Negotiated Rate	$932.99
Max. Negotiated Rate	$1,227.40
Rate for Payer: AlohaCare Medicaid	$932.99
Rate for Payer: Cash Price	$866.40
Rate for Payer: Cash Price	$866.40
Rate for Payer: Health Management Network Commercial	$1,227.40
Rate for Payer: Ohana Health Plan Medicaid	$932.99
Rate for Payer: UnitedHealthcare Medicaid	$932.99

PR UNLISTED PROCEDURE NOSE

Professional

Both

$500.00

Service Code	HCPCS 30999
Min. Negotiated Rate	$425.00
Max. Negotiated Rate	$425.00
Rate for Payer: Cash Price	$300.00
Rate for Payer: Health Management Network Commercial	$425.00

PR UNLISTED PROCEDURE PHARYNX ADENOIDS/TONSILS

Professional

Both

$1,140.00

Service Code	HCPCS 42999
Min. Negotiated Rate	$969.00
Max. Negotiated Rate	$969.00
Rate for Payer: Cash Price	$684.00
Rate for Payer: Health Management Network Commercial	$969.00

PR UNLISTED PROCEDURE RECTUM

Professional

Both

$197.00

Service Code	HCPCS 45999
Min. Negotiated Rate	$167.45
Max. Negotiated Rate	$167.45
Rate for Payer: Cash Price	$118.20
Rate for Payer: Health Management Network Commercial	$167.45

PR UNLISTED PROCEDURE SMALL INTESTINE

Professional

Both

$2,338.00

Service Code	HCPCS 44799
Min. Negotiated Rate	$141.75
Max. Negotiated Rate	$1,987.30
Rate for Payer: AlohaCare Medicaid	$141.75
Rate for Payer: Cash Price	$1,402.80
Rate for Payer: Cash Price	$1,402.80
Rate for Payer: Health Management Network Commercial	$1,987.30
Rate for Payer: Ohana Health Plan Medicaid	$141.75
Rate for Payer: UnitedHealthcare Medicaid	$141.75

PR UNLISTED PROCEDURE STOMACH

Professional

Both

$692.00

Service Code	HCPCS 43999
Min. Negotiated Rate	$588.20
Max. Negotiated Rate	$588.20
Rate for Payer: Cash Price	$415.20
Rate for Payer: Health Management Network Commercial	$588.20

PR UNLISTED PROCEDURE TONGUE FLOOR MOUTH

Professional

Both

$168.00

Service Code	HCPCS 41599
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$142.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Health Management Network Commercial	$142.80

PR UNLISTED PROCEDURE TRACHEA BRONCHI

Professional

Both

$163.00

Service Code	HCPCS 31899
Min. Negotiated Rate	$138.55
Max. Negotiated Rate	$138.55
Rate for Payer: Cash Price	$97.80
Rate for Payer: Health Management Network Commercial	$138.55

PR UNLISTED PROCEDURE URINARY SYSTEM

Professional

Both

$1,563.00

Service Code	HCPCS 53899
Min. Negotiated Rate	$1,328.55
Max. Negotiated Rate	$1,328.55
Rate for Payer: Cash Price	$937.80
Rate for Payer: Health Management Network Commercial	$1,328.55

PR UNLISTED PROCEDURE VASCULAR SURGERY

Professional

Both

$287.00

Service Code	HCPCS 37799
Min. Negotiated Rate	$243.95
Max. Negotiated Rate	$475.92
Rate for Payer: AlohaCare Medicaid	$475.92
Rate for Payer: Cash Price	$172.20
Rate for Payer: Cash Price	$172.20
Rate for Payer: Health Management Network Commercial	$243.95
Rate for Payer: Ohana Health Plan Medicaid	$475.92
Rate for Payer: UnitedHealthcare Medicaid	$475.92

PR UNLISTED PX ABDOMEN MUSCULOSKELETAL SYSTEM

Professional

Both

$497.00

Service Code	HCPCS 22999
Min. Negotiated Rate	$422.45
Max. Negotiated Rate	$757.48
Rate for Payer: AlohaCare Medicaid	$757.48
Rate for Payer: Cash Price	$298.20
Rate for Payer: Cash Price	$298.20
Rate for Payer: Health Management Network Commercial	$422.45
Rate for Payer: Ohana Health Plan Medicaid	$757.48
Rate for Payer: UnitedHealthcare Medicaid	$757.48

PR UNLISTED PX FEMALE GENITAL SYSTEM NONOBSTETRICAL

Professional

Both

$1,641.00

Service Code	HCPCS 58999
Min. Negotiated Rate	$375.03
Max. Negotiated Rate	$1,394.85
Rate for Payer: AlohaCare Medicaid	$375.03
Rate for Payer: Cash Price	$984.60
Rate for Payer: Cash Price	$984.60
Rate for Payer: Health Management Network Commercial	$1,394.85
Rate for Payer: Ohana Health Plan Medicaid	$375.03
Rate for Payer: UnitedHealthcare Medicaid	$375.03

PR UNLISTED PX SKIN MUC MEMBRANE & SUBQ TISSUE

Professional

Both

$353.00

Service Code	HCPCS 17999
Min. Negotiated Rate	$300.05
Max. Negotiated Rate	$329.32
Rate for Payer: AlohaCare Medicaid	$329.32
Rate for Payer: Cash Price	$211.80
Rate for Payer: Cash Price	$211.80
Rate for Payer: Health Management Network Commercial	$300.05
Rate for Payer: Ohana Health Plan Medicaid	$329.32
Rate for Payer: UnitedHealthcare Medicaid	$329.32

PR UPG PACEMAKER SYS CONVERT 1CHMBR SYS 2CHMBR SYS

Professional

Both

$802.00

Service Code	HCPCS 33214
Min. Negotiated Rate	$398.32
Max. Negotiated Rate	$681.70
Rate for Payer: AlohaCare Medicaid	$469.52
Rate for Payer: AlohaCare Medicare	$418.09
Rate for Payer: Cash Price	$481.20
Rate for Payer: Cash Price	$481.20
Rate for Payer: Devoted Health Medicare	$459.90
Rate for Payer: Hawaii Medical Service Association Medicare	$418.09
Rate for Payer: Hawaii Western Management Group Commercial	$398.32
Rate for Payer: Health Management Network Commercial	$681.70
Rate for Payer: Kaiser Permanente Commercial	$501.71
Rate for Payer: Kaiser Permanente Medicaid	$501.71
Rate for Payer: Kaiser Permanente Medicare	$501.71
Rate for Payer: Ohana Health Plan Medicaid	$469.52
Rate for Payer: Ohana Health Plan Medicare	$418.09
Rate for Payer: UnitedHealthcare Medicaid	$469.52
Rate for Payer: UnitedHealthcare Medicare	$418.09

PR URETERAL ENDOSCOPY VIA URETEROSTOMY

Professional

Both

$713.26

Service Code	HCPCS 50951
Min. Negotiated Rate	$133.64
Max. Negotiated Rate	$606.27
Rate for Payer: AlohaCare Medicaid	$303.13
Rate for Payer: AlohaCare Medicare	$266.68
Rate for Payer: Cash Price	$427.96
Rate for Payer: Cash Price	$427.96
Rate for Payer: Devoted Health Medicare	$293.35
Rate for Payer: Hawaii Medical Service Association ABD	$303.13
Rate for Payer: Hawaii Medical Service Association Commercial	$505.36
Rate for Payer: Hawaii Medical Service Association Medicare	$266.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$303.13
Rate for Payer: Hawaii Western Management Group Commercial	$133.64
Rate for Payer: Health Management Network Commercial	$606.27
Rate for Payer: Kaiser Permanente Commercial	$320.02
Rate for Payer: Kaiser Permanente Medicaid	$320.02
Rate for Payer: Kaiser Permanente Medicare	$320.02
Rate for Payer: Ohana Health Plan Medicaid	$303.13
Rate for Payer: Ohana Health Plan Medicare	$266.68
Rate for Payer: UnitedHealthcare Medicaid	$303.13
Rate for Payer: UnitedHealthcare Medicare	$266.68
Rate for Payer: University Health Alliance Commercial	$398.02

PR URETERAL ENDOSC VIA URETEROT W/DEST&/INC W/WO BX

Professional

Both

$785.00

Service Code	HCPCS 50976
Min. Negotiated Rate	$402.18
Max. Negotiated Rate	$667.25
Rate for Payer: AlohaCare Medicaid	$458.43
Rate for Payer: AlohaCare Medicare	$402.18
Rate for Payer: Cash Price	$471.00
Rate for Payer: Cash Price	$471.00
Rate for Payer: Devoted Health Medicare	$442.40
Rate for Payer: Hawaii Medical Service Association Medicare	$402.18
Rate for Payer: Hawaii Western Management Group Commercial	$419.64
Rate for Payer: Health Management Network Commercial	$667.25
Rate for Payer: Kaiser Permanente Commercial	$482.62
Rate for Payer: Kaiser Permanente Medicaid	$482.62
Rate for Payer: Kaiser Permanente Medicare	$482.62
Rate for Payer: Ohana Health Plan Medicaid	$458.43
Rate for Payer: Ohana Health Plan Medicare	$402.18
Rate for Payer: UnitedHealthcare Medicaid	$458.43
Rate for Payer: UnitedHealthcare Medicare	$402.18

PR URETEROENTEROSTOMY ANAST URETER INTESTINE

Professional

Both

$1,597.00

Service Code	HCPCS 50800
Min. Negotiated Rate	$831.48
Max. Negotiated Rate	$1,357.45
Rate for Payer: AlohaCare Medicaid	$931.65
Rate for Payer: AlohaCare Medicare	$834.77
Rate for Payer: Cash Price	$958.20
Rate for Payer: Cash Price	$958.20
Rate for Payer: Devoted Health Medicare	$918.25
Rate for Payer: Hawaii Medical Service Association Medicare	$834.77
Rate for Payer: Hawaii Western Management Group Commercial	$831.48
Rate for Payer: Health Management Network Commercial	$1,357.45
Rate for Payer: Kaiser Permanente Commercial	$1,001.72
Rate for Payer: Kaiser Permanente Medicaid	$1,001.72
Rate for Payer: Kaiser Permanente Medicare	$1,001.72
Rate for Payer: Ohana Health Plan Medicaid	$931.65
Rate for Payer: Ohana Health Plan Medicare	$834.77
Rate for Payer: UnitedHealthcare Medicaid	$931.65
Rate for Payer: UnitedHealthcare Medicare	$834.77

PR URETERONEOCYSTOSTOMY ANAST 1 URETER BLADDER

Professional

Both

$1,906.00

Service Code	HCPCS 50780
Min. Negotiated Rate	$998.77
Max. Negotiated Rate	$1,620.10
Rate for Payer: AlohaCare Medicaid	$1,112.55
Rate for Payer: AlohaCare Medicare	$998.77
Rate for Payer: Cash Price	$1,143.60
Rate for Payer: Cash Price	$1,143.60
Rate for Payer: Devoted Health Medicare	$1,098.65
Rate for Payer: Hawaii Medical Service Association Medicare	$998.77
Rate for Payer: Hawaii Western Management Group Commercial	$1,195.48
Rate for Payer: Health Management Network Commercial	$1,620.10
Rate for Payer: Kaiser Permanente Commercial	$1,198.52
Rate for Payer: Kaiser Permanente Medicaid	$1,198.52
Rate for Payer: Kaiser Permanente Medicare	$1,198.52
Rate for Payer: Ohana Health Plan Medicaid	$1,112.55
Rate for Payer: Ohana Health Plan Medicare	$998.77
Rate for Payer: UnitedHealthcare Medicaid	$1,112.55
Rate for Payer: UnitedHealthcare Medicare	$998.77

PR URETEROPLASTY PLASTIC OPERATION URETER

Professional

Both

$1,599.00

Service Code	HCPCS 50700
Min. Negotiated Rate	$787.80
Max. Negotiated Rate	$1,359.15
Rate for Payer: AlohaCare Medicaid	$933.30
Rate for Payer: AlohaCare Medicare	$834.12
Rate for Payer: Cash Price	$959.40
Rate for Payer: Cash Price	$959.40
Rate for Payer: Devoted Health Medicare	$917.53
Rate for Payer: Hawaii Medical Service Association Medicare	$834.12
Rate for Payer: Hawaii Western Management Group Commercial	$787.80
Rate for Payer: Health Management Network Commercial	$1,359.15
Rate for Payer: Kaiser Permanente Commercial	$1,000.94
Rate for Payer: Kaiser Permanente Medicaid	$1,000.94
Rate for Payer: Kaiser Permanente Medicare	$1,000.94
Rate for Payer: Ohana Health Plan Medicaid	$933.30
Rate for Payer: Ohana Health Plan Medicare	$834.12
Rate for Payer: UnitedHealthcare Medicaid	$933.30
Rate for Payer: UnitedHealthcare Medicare	$834.12

PR URETEROTOMY INSERTION INDWELLING STENT ALL TYPES

Professional

Both

$1,705.00

Service Code	HCPCS 50605
Min. Negotiated Rate	$620.36
Max. Negotiated Rate	$1,449.25
Rate for Payer: AlohaCare Medicaid	$996.81
Rate for Payer: AlohaCare Medicare	$917.26
Rate for Payer: Cash Price	$1,023.00
Rate for Payer: Cash Price	$1,023.00
Rate for Payer: Devoted Health Medicare	$1,008.99
Rate for Payer: Hawaii Medical Service Association Medicare	$917.26
Rate for Payer: Hawaii Western Management Group Commercial	$620.36
Rate for Payer: Health Management Network Commercial	$1,449.25
Rate for Payer: Kaiser Permanente Commercial	$1,100.71
Rate for Payer: Kaiser Permanente Medicaid	$1,100.71
Rate for Payer: Kaiser Permanente Medicare	$1,100.71
Rate for Payer: Ohana Health Plan Medicaid	$996.81
Rate for Payer: Ohana Health Plan Medicare	$917.26
Rate for Payer: UnitedHealthcare Medicaid	$996.81
Rate for Payer: UnitedHealthcare Medicare	$917.26

PR URETHRECTOMY TOT W/CYSTOST FEMALE

Professional

Both

$1,355.00

Service Code	HCPCS 53210
Min. Negotiated Rate	$555.62
Max. Negotiated Rate	$1,151.75
Rate for Payer: AlohaCare Medicaid	$785.43
Rate for Payer: AlohaCare Medicare	$697.77
Rate for Payer: Cash Price	$813.00
Rate for Payer: Cash Price	$813.00
Rate for Payer: Devoted Health Medicare	$767.55
Rate for Payer: Hawaii Medical Service Association Medicare	$697.77
Rate for Payer: Hawaii Western Management Group Commercial	$555.62
Rate for Payer: Health Management Network Commercial	$1,151.75
Rate for Payer: Kaiser Permanente Commercial	$837.32
Rate for Payer: Kaiser Permanente Medicaid	$837.32
Rate for Payer: Kaiser Permanente Medicare	$837.32
Rate for Payer: Ohana Health Plan Medicaid	$785.43
Rate for Payer: Ohana Health Plan Medicare	$697.77
Rate for Payer: UnitedHealthcare Medicaid	$785.43
Rate for Payer: UnitedHealthcare Medicare	$697.77

PR URETHROMEATOPLASTY W/MUCOSAL ADVANCEMENT

Professional

Both

$723.00

Service Code	HCPCS 53450
Min. Negotiated Rate	$263.90
Max. Negotiated Rate	$614.55
Rate for Payer: AlohaCare Medicaid	$420.81
Rate for Payer: AlohaCare Medicare	$384.81
Rate for Payer: Cash Price	$433.80
Rate for Payer: Cash Price	$433.80
Rate for Payer: Devoted Health Medicare	$423.29
Rate for Payer: Hawaii Medical Service Association Medicare	$384.81
Rate for Payer: Hawaii Western Management Group Commercial	$263.90
Rate for Payer: Health Management Network Commercial	$614.55
Rate for Payer: Kaiser Permanente Commercial	$461.77
Rate for Payer: Kaiser Permanente Medicaid	$461.77
Rate for Payer: Kaiser Permanente Medicare	$461.77
Rate for Payer: Ohana Health Plan Medicaid	$420.81
Rate for Payer: Ohana Health Plan Medicare	$384.81
Rate for Payer: UnitedHealthcare Medicaid	$420.81
Rate for Payer: UnitedHealthcare Medicare	$384.81

PR URETHROPLASTY 1 STG RECNST MALE ANTERIOR URETHRA

Professional

Both

$1,689.00

Service Code	HCPCS 53410
Min. Negotiated Rate	$714.22
Max. Negotiated Rate	$1,435.65
Rate for Payer: AlohaCare Medicaid	$986.46
Rate for Payer: AlohaCare Medicare	$879.67
Rate for Payer: Cash Price	$1,013.40
Rate for Payer: Cash Price	$1,013.40
Rate for Payer: Devoted Health Medicare	$967.64
Rate for Payer: Hawaii Medical Service Association Medicare	$879.67
Rate for Payer: Hawaii Western Management Group Commercial	$714.22
Rate for Payer: Health Management Network Commercial	$1,435.65
Rate for Payer: Kaiser Permanente Commercial	$1,055.60
Rate for Payer: Kaiser Permanente Medicaid	$1,055.60
Rate for Payer: Kaiser Permanente Medicare	$1,055.60
Rate for Payer: Ohana Health Plan Medicaid	$986.46
Rate for Payer: Ohana Health Plan Medicare	$879.67
Rate for Payer: UnitedHealthcare Medicaid	$986.46
Rate for Payer: UnitedHealthcare Medicare	$879.67

PR URETHROTOMY/URETHROSTOMY XT SPX PERINEAL URETHRA

Professional

Both

$533.00

Service Code	HCPCS 53010
Min. Negotiated Rate	$215.28
Max. Negotiated Rate	$453.05
Rate for Payer: AlohaCare Medicaid	$310.82
Rate for Payer: AlohaCare Medicare	$289.28
Rate for Payer: Cash Price	$319.80
Rate for Payer: Cash Price	$319.80
Rate for Payer: Devoted Health Medicare	$318.21
Rate for Payer: Hawaii Medical Service Association Medicare	$289.28
Rate for Payer: Hawaii Western Management Group Commercial	$215.28
Rate for Payer: Health Management Network Commercial	$453.05
Rate for Payer: Kaiser Permanente Commercial	$347.14
Rate for Payer: Kaiser Permanente Medicaid	$347.14
Rate for Payer: Kaiser Permanente Medicare	$347.14
Rate for Payer: Ohana Health Plan Medicaid	$310.82
Rate for Payer: Ohana Health Plan Medicare	$289.28
Rate for Payer: UnitedHealthcare Medicaid	$310.82
Rate for Payer: UnitedHealthcare Medicare	$289.28

PR URETRECECTOMY W/BLADDER CUFF SEPARATE PROCEDURE

Professional

Both

$1,786.00

Service Code	HCPCS 50650
Min. Negotiated Rate	$836.94
Max. Negotiated Rate	$1,518.10
Rate for Payer: AlohaCare Medicaid	$1,042.65
Rate for Payer: AlohaCare Medicare	$928.42
Rate for Payer: Cash Price	$1,071.60
Rate for Payer: Cash Price	$1,071.60
Rate for Payer: Devoted Health Medicare	$1,021.26
Rate for Payer: Hawaii Medical Service Association Medicare	$928.42
Rate for Payer: Hawaii Western Management Group Commercial	$836.94
Rate for Payer: Health Management Network Commercial	$1,518.10
Rate for Payer: Kaiser Permanente Commercial	$1,114.10
Rate for Payer: Kaiser Permanente Medicaid	$1,114.10
Rate for Payer: Kaiser Permanente Medicare	$1,114.10
Rate for Payer: Ohana Health Plan Medicaid	$1,042.65
Rate for Payer: Ohana Health Plan Medicare	$928.42
Rate for Payer: UnitedHealthcare Medicaid	$1,042.65
Rate for Payer: UnitedHealthcare Medicare	$928.42

Know your out-of-pocket cost for care.

All Charges