Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC INJ DISKOGRAM CERV

Facility

$13,845.00

Service Code	HCPCS 62291
Hospital Charge Code	3616229101
Hospital Revenue Code	361
Min. Negotiated Rate	$126.12
Max. Negotiated Rate	$13,429.65
Rate for Payer: Cash Price	$8,307.00
Rate for Payer: Cash Price	$8,307.00
Rate for Payer: Cash Price	$8,307.00
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Health Management Network Commercial	$11,768.25
Rate for Payer: Kaiser Permanente Commercial	$8,722.35
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$13,429.65
Rate for Payer: UnitedHealthcare Medicaid	$126.12
Rate for Payer: University Health Alliance Commercial	$10,091.62

HC INJ DISKOGRAM CERV

Facility

$13,845.00

Service Code	HCPCS 62291
Hospital Charge Code	3616229101
Hospital Revenue Code	361
Min. Negotiated Rate	$11,768.25
Max. Negotiated Rate	$13,429.65
Rate for Payer: Cash Price	$8,307.00
Rate for Payer: Health Management Network Commercial	$11,768.25
Rate for Payer: MDX Hawaii PPO	$13,429.65

HC INJ DX/THER AGNT PARAVERT FACET JOINT,IMG GUIDE,CERV/THORAC, 1ST LEVEL

Facility

$3,543.00

Service Code	HCPCS 64490
Hospital Charge Code	3616449001
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,044.87
Rate for Payer: AlohaCare Medicare	$1,044.87
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Devoted Health Medicare	$1,149.36
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,044.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$3,365.85
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: Humana Medicare	$1,044.87
Rate for Payer: Kaiser Permanente Commercial	$2,232.09
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,044.87
Rate for Payer: MDX Hawaii PPO	$3,436.71
Rate for Payer: Ohana Health Plan Medicaid	$1,149.36
Rate for Payer: Ohana Health Plan Medicare	$1,044.87
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,044.87
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC INJ DX/THER AGNT PARAVERT FACET JOINT,IMG GUIDE,CERV/THORAC, 1ST LEVEL

Facility

$3,543.00

Service Code	HCPCS 64490
Hospital Charge Code	3616449001
Hospital Revenue Code	450
Min. Negotiated Rate	$3,011.55
Max. Negotiated Rate	$3,436.71
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: MDX Hawaii PPO	$3,436.71

HC INJ DX/THER AGNT PARAVERT FACET JOINT,IMG GUIDE,LUMBAR/SAC, 1ST LEVEL

Facility

$3,543.00

Service Code	HCPCS 64493
Hospital Charge Code	3616449301
Hospital Revenue Code	450
Min. Negotiated Rate	$3,011.55
Max. Negotiated Rate	$3,436.71
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: MDX Hawaii PPO	$3,436.71

HC INJ DX/THER AGNT PARAVERT FACET JOINT,IMG GUIDE,LUMBAR/SAC, 1ST LEVEL

Facility

$3,543.00

Service Code	HCPCS 64493
Hospital Charge Code	3616449301
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,044.87
Rate for Payer: AlohaCare Medicare	$1,044.87
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Devoted Health Medicare	$1,149.36
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,044.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$3,365.85
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: Humana Medicare	$1,044.87
Rate for Payer: Kaiser Permanente Commercial	$2,232.09
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,044.87
Rate for Payer: MDX Hawaii PPO	$3,436.71
Rate for Payer: Ohana Health Plan Medicaid	$1,149.36
Rate for Payer: Ohana Health Plan Medicare	$1,044.87
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,044.87
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC INJECT ANES/STEROID FORAMEN CERV/THORACIC W IMG GUIDE ,1 LEVEL

Facility

$3,543.00

Service Code	HCPCS 64479
Hospital Charge Code	3616447901
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,044.87
Rate for Payer: AlohaCare Medicare	$1,044.87
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Devoted Health Medicare	$1,149.36
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,044.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$3,365.85
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: Humana Medicare	$1,044.87
Rate for Payer: Kaiser Permanente Commercial	$2,232.09
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,044.87
Rate for Payer: MDX Hawaii PPO	$3,436.71
Rate for Payer: Ohana Health Plan Medicaid	$1,149.36
Rate for Payer: Ohana Health Plan Medicare	$1,044.87
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,044.87
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC INJECT ANES/STEROID FORAMEN CERV/THORACIC W IMG GUIDE ,1 LEVEL

Facility

$3,543.00

Service Code	HCPCS 64479
Hospital Charge Code	3616447901
Hospital Revenue Code	450
Min. Negotiated Rate	$3,011.55
Max. Negotiated Rate	$3,436.71
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: MDX Hawaii PPO	$3,436.71

HC INJECT ANES/STEROID FORAMEN LUMBAR/SACRAL W IMG GUIDE ,1 LEVEL

Facility

$3,543.00

Service Code	HCPCS 64483
Hospital Charge Code	3616448301
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,044.87
Rate for Payer: AlohaCare Medicare	$1,044.87
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Devoted Health Medicare	$1,149.36
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,044.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$3,365.85
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: Humana Medicare	$1,044.87
Rate for Payer: Kaiser Permanente Commercial	$2,232.09
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,044.87
Rate for Payer: MDX Hawaii PPO	$3,436.71
Rate for Payer: Ohana Health Plan Medicaid	$1,149.36
Rate for Payer: Ohana Health Plan Medicare	$1,044.87
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,044.87
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC INJECT ANES/STEROID FORAMEN LUMBAR/SACRAL W IMG GUIDE ,1 LEVEL

Facility

$3,543.00

Service Code	HCPCS 64483
Hospital Charge Code	3616448301
Hospital Revenue Code	450
Min. Negotiated Rate	$3,011.55
Max. Negotiated Rate	$3,436.71
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: MDX Hawaii PPO	$3,436.71

HC INJECT ANES/STEROID FORAMEN LUMBAR/SACRAL W IMG GUIDE ,1 LEVEL

Facility

$3,543.00

Service Code	HCPCS 64483
Hospital Charge Code	3616448301
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,044.87
Rate for Payer: AlohaCare Medicare	$1,044.87
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Devoted Health Medicare	$1,149.36
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,044.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: Humana Medicare	$1,044.87
Rate for Payer: Kaiser Permanente Commercial	$2,232.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,044.87
Rate for Payer: MDX Hawaii PPO	$3,436.71
Rate for Payer: Ohana Health Plan Medicaid	$1,149.36
Rate for Payer: Ohana Health Plan Medicare	$1,044.87
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,044.87
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC INJECT ANES/STEROID FORAMEN LUMBAR/SACRAL W IMG GUIDE ,1 LEVEL

Facility

$3,543.00

Service Code	HCPCS 64483
Hospital Charge Code	3616448301
Hospital Revenue Code	361
Min. Negotiated Rate	$3,011.55
Max. Negotiated Rate	$3,436.71
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: MDX Hawaii PPO	$3,436.71

HC INJECT DISKOGRAM,LUMBAR,EA LEVEL

Facility

$15,459.00

Service Code	HCPCS 62290
Hospital Charge Code	3616229001
Hospital Revenue Code	361
Min. Negotiated Rate	$131.61
Max. Negotiated Rate	$14,995.23
Rate for Payer: Cash Price	$9,275.40
Rate for Payer: Cash Price	$9,275.40
Rate for Payer: Cash Price	$9,275.40
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Health Management Network Commercial	$13,140.15
Rate for Payer: Kaiser Permanente Commercial	$9,739.17
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$14,995.23
Rate for Payer: UnitedHealthcare Medicaid	$131.61
Rate for Payer: University Health Alliance Commercial	$11,268.07

HC INJECT DISKOGRAM,LUMBAR,EA LEVEL

Facility

$15,459.00

Service Code	HCPCS 62290
Hospital Charge Code	3616229001
Hospital Revenue Code	361
Min. Negotiated Rate	$13,140.15
Max. Negotiated Rate	$14,995.23
Rate for Payer: Cash Price	$9,275.40
Rate for Payer: Health Management Network Commercial	$13,140.15
Rate for Payer: MDX Hawaii PPO	$14,995.23

HC INJECTION FOR BLADDER X-RAY

Facility

$1,194.00

Service Code	HCPCS 51600
Hospital Charge Code	3205160001
Hospital Revenue Code	320
Min. Negotiated Rate	$32.89
Max. Negotiated Rate	$2,536.00
Rate for Payer: Cash Price	$716.40
Rate for Payer: Cash Price	$716.40
Rate for Payer: Cash Price	$716.40
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$1,134.30
Rate for Payer: Health Management Network Commercial	$1,014.90
Rate for Payer: Kaiser Permanente Commercial	$752.22
Rate for Payer: Kaiser Permanente Medicaid	$608.94
Rate for Payer: MDX Hawaii PPO	$1,158.18
Rate for Payer: UnitedHealthcare Medicaid	$32.89
Rate for Payer: University Health Alliance Commercial	$870.31

HC INJECTION FOR BLADDER X-RAY

Facility

$1,194.00

Service Code	HCPCS 51600
Hospital Charge Code	3205160001
Hospital Revenue Code	320
Min. Negotiated Rate	$1,014.90
Max. Negotiated Rate	$1,158.18
Rate for Payer: Cash Price	$716.40
Rate for Payer: Health Management Network Commercial	$1,014.90
Rate for Payer: MDX Hawaii PPO	$1,158.18

HC INJECTION FOR ELBOW ARTHROGRAM

Facility

$324.00

Service Code	HCPCS 24220
Hospital Charge Code	3612422001
Hospital Revenue Code	361
Min. Negotiated Rate	$50.57
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cash Price	$194.40
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Kaiser Permanente Commercial	$204.12
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$314.28
Rate for Payer: UnitedHealthcare Medicaid	$50.57
Rate for Payer: University Health Alliance Commercial	$236.16

HC INJECTION FOR ELBOW ARTHROGRAM

Facility

$324.00

Service Code	HCPCS 24220
Hospital Charge Code	3612422001
Hospital Revenue Code	361
Min. Negotiated Rate	$275.40
Max. Negotiated Rate	$314.28
Rate for Payer: Cash Price	$194.40
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: MDX Hawaii PPO	$314.28

HC INJECTION FOR WRIST ARTHROGRAM

Facility

$360.00

Service Code	HCPCS 25246
Hospital Charge Code	3612524601
Hospital Revenue Code	361
Min. Negotiated Rate	$54.32
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: Kaiser Permanente Commercial	$226.80
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$349.20
Rate for Payer: UnitedHealthcare Medicaid	$54.32
Rate for Payer: University Health Alliance Commercial	$262.40

HC INJECTION FOR WRIST ARTHROGRAM

Facility

$360.00

Service Code	HCPCS 25246
Hospital Charge Code	3612524601
Hospital Revenue Code	361
Min. Negotiated Rate	$306.00
Max. Negotiated Rate	$349.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: MDX Hawaii PPO	$349.20

HC INJECTION HIP ARTHROGRAM

Facility

$872.00

Service Code	HCPCS 27093
Hospital Charge Code	3612709301
Hospital Revenue Code	361
Min. Negotiated Rate	$741.20
Max. Negotiated Rate	$845.84
Rate for Payer: Cash Price	$523.20
Rate for Payer: Health Management Network Commercial	$741.20
Rate for Payer: MDX Hawaii PPO	$845.84

HC INJECTION HIP ARTHROGRAM

Facility

$872.00

Service Code	HCPCS 27093
Hospital Charge Code	3612709301
Hospital Revenue Code	361
Min. Negotiated Rate	$57.11
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$523.20
Rate for Payer: Cash Price	$523.20
Rate for Payer: Cash Price	$523.20
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Health Management Network Commercial	$741.20
Rate for Payer: Kaiser Permanente Commercial	$549.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$845.84
Rate for Payer: UnitedHealthcare Medicaid	$57.11
Rate for Payer: University Health Alliance Commercial	$635.60

HC INJECTION KNEE ARTHROGRAPHY

Facility

$1,003.00

Service Code	HCPCS 27370
Hospital Charge Code	3612737001
Hospital Revenue Code	361
Min. Negotiated Rate	$852.55
Max. Negotiated Rate	$972.91
Rate for Payer: Cash Price	$601.80
Rate for Payer: Health Management Network Commercial	$852.55
Rate for Payer: MDX Hawaii PPO	$972.91

HC INJECTION KNEE ARTHROGRAPHY

Facility

$1,003.00

Service Code	HCPCS 27370
Hospital Charge Code	3612737001
Hospital Revenue Code	361
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$601.80
Rate for Payer: Cash Price	$601.80
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Health Management Network Commercial	$852.55
Rate for Payer: Kaiser Permanente Commercial	$631.89
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$972.91
Rate for Payer: University Health Alliance Commercial	$731.09

HC INJECTION PROCEDURE MYELOGRAPHY/CT LUMBAR

Facility

$1,398.00

Service Code	HCPCS 62284
Hospital Charge Code	3616228401
Hospital Revenue Code	361
Min. Negotiated Rate	$78.52
Max. Negotiated Rate	$2,837.00
Rate for Payer: Cash Price	$838.80
Rate for Payer: Cash Price	$838.80
Rate for Payer: Cash Price	$838.80
Rate for Payer: Health Management Network Commercial	$1,188.30
Rate for Payer: Kaiser Permanente Commercial	$880.74
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: MDX Hawaii PPO	$1,356.06
Rate for Payer: UnitedHealthcare Medicaid	$78.52
Rate for Payer: University Health Alliance Commercial	$1,019.00

Know your out-of-pocket cost for care.

All Charges