Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC X-RAY ANKLE 2 VW - XR ANKLE 2 VIEWS

Facility

$438.00

Service Code	HCPCS 73600
Hospital Charge Code	3207360001
Hospital Revenue Code	320
Min. Negotiated Rate	$372.30
Max. Negotiated Rate	$424.86
Rate for Payer: Cash Price	$262.80
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: MDX Hawaii PPO	$424.86

HC X-RAY ANKLE 3+ VW - XR ANKLE 3+ VIEWS

Facility

$438.00

Service Code	HCPCS 73610
Hospital Charge Code	3207361001
Hospital Revenue Code	320
Min. Negotiated Rate	$17.34
Max. Negotiated Rate	$424.86
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$262.80
Rate for Payer: Cash Price	$262.80
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association ABD	$17.34
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.95
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$275.94
Rate for Payer: Kaiser Permanente Medicaid	$223.38
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$424.86
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$17.34
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$62.59

HC X-RAY ANKLE 3+ VW - XR ANKLE 3+ VIEWS

Facility

$438.00

Service Code	HCPCS 73610
Hospital Charge Code	3207361001
Hospital Revenue Code	320
Min. Negotiated Rate	$372.30
Max. Negotiated Rate	$424.86
Rate for Payer: Cash Price	$262.80
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: MDX Hawaii PPO	$424.86

HC X-RAY ANTEGRADE PYELOGRAM TUBE - FL LOOPOGRAM

Facility

$1,776.00

Service Code	HCPCS 74425
Hospital Charge Code	3207442502
Hospital Revenue Code	320
Min. Negotiated Rate	$42.98
Max. Negotiated Rate	$1,722.72
Rate for Payer: AlohaCare Medicaid	$412.14
Rate for Payer: AlohaCare Medicare	$412.14
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Devoted Health Medicare	$453.35
Rate for Payer: Hawaii Medical Service Association ABD	$42.98
Rate for Payer: Hawaii Medical Service Association Commercial	$515.17
Rate for Payer: Hawaii Medical Service Association Medicare	$412.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$46.81
Rate for Payer: Hawaii Western Management Group Commercial	$412.14
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: Humana Medicare	$412.14
Rate for Payer: Kaiser Permanente Commercial	$1,118.88
Rate for Payer: Kaiser Permanente Medicaid	$905.76
Rate for Payer: Kaiser Permanente Medicare	$412.14
Rate for Payer: MDX Hawaii PPO	$1,722.72
Rate for Payer: Ohana Health Plan Medicaid	$453.35
Rate for Payer: Ohana Health Plan Medicare	$412.14
Rate for Payer: UnitedHealthcare Medicaid	$42.98
Rate for Payer: UnitedHealthcare Medicare	$412.14
Rate for Payer: University Health Alliance Commercial	$295.02

HC X-RAY ANTEGRADE PYELOGRAM TUBE - FL LOOPOGRAM

Facility

$1,776.00

Service Code	HCPCS 74425
Hospital Charge Code	3207442502
Hospital Revenue Code	320
Min. Negotiated Rate	$1,509.60
Max. Negotiated Rate	$1,722.72
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: MDX Hawaii PPO	$1,722.72

HC X-RAY ARM, INFANT - XR UPPER EXTREMITY 2+ VIEWS INFANT

Facility

$529.00

Service Code	HCPCS 73092
Hospital Charge Code	3207309201
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$513.13
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$317.40
Rate for Payer: Cash Price	$317.40
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.57
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$333.27
Rate for Payer: Kaiser Permanente Medicaid	$269.79
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$513.13
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$56.28

HC X-RAY ARM, INFANT - XR UPPER EXTREMITY 2+ VIEWS INFANT

Facility

$529.00

Service Code	HCPCS 73092
Hospital Charge Code	3207309201
Hospital Revenue Code	320
Min. Negotiated Rate	$449.65
Max. Negotiated Rate	$513.13
Rate for Payer: Cash Price	$317.40
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: MDX Hawaii PPO	$513.13

HC X-RAY BILE/PANCREAS ENDOSCOPY - FL ERCP BILIARY AND PANCREAS

Facility

$1,225.00

Service Code	HCPCS 74330
Hospital Charge Code	3207433001
Hospital Revenue Code	320
Min. Negotiated Rate	$1,041.25
Max. Negotiated Rate	$1,188.25
Rate for Payer: Cash Price	$735.00
Rate for Payer: Health Management Network Commercial	$1,041.25
Rate for Payer: MDX Hawaii PPO	$1,188.25

HC X-RAY BILE/PANCREAS ENDOSCOPY - FL ERCP BILIARY AND PANCREAS

Facility

$1,225.00

Service Code	HCPCS 74330
Hospital Charge Code	3207433001
Hospital Revenue Code	320
Min. Negotiated Rate	$103.94
Max. Negotiated Rate	$1,188.25
Rate for Payer: Cash Price	$735.00
Rate for Payer: Cash Price	$735.00
Rate for Payer: Hawaii Medical Service Association ABD	$103.94
Rate for Payer: Hawaii Medical Service Association Non-ABD	$112.58
Rate for Payer: Hawaii Western Management Group Commercial	$1,163.75
Rate for Payer: Health Management Network Commercial	$1,041.25
Rate for Payer: Kaiser Permanente Commercial	$771.75
Rate for Payer: Kaiser Permanente Medicaid	$624.75
Rate for Payer: MDX Hawaii PPO	$1,188.25
Rate for Payer: UnitedHealthcare Medicaid	$103.94
Rate for Payer: University Health Alliance Commercial	$892.90

HC X-RAY CLAVICLE - XR CLAVICLE

Facility

$438.00

Service Code	HCPCS 73000
Hospital Charge Code	3207300001
Hospital Revenue Code	320
Min. Negotiated Rate	$372.30
Max. Negotiated Rate	$424.86
Rate for Payer: Cash Price	$262.80
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: MDX Hawaii PPO	$424.86

HC X-RAY CLAVICLE - XR CLAVICLE

Facility

$438.00

Service Code	HCPCS 73000
Hospital Charge Code	3207300001
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$424.86
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$262.80
Rate for Payer: Cash Price	$262.80
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$275.94
Rate for Payer: Kaiser Permanente Medicaid	$223.38
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$424.86
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$56.28

HC X-RAY COLON AIR CONTRAST - FL BARIUM ENEMA AIR CONTRAST

Facility

$885.00

Service Code	HCPCS 74280
Hospital Charge Code	3207428001
Hospital Revenue Code	320
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$858.45
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$531.00
Rate for Payer: Cash Price	$531.00
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$89.58
Rate for Payer: Hawaii Medical Service Association Commercial	$259.01
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$86.80
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$557.55
Rate for Payer: Kaiser Permanente Medicaid	$451.35
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$858.45
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$89.58
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$370.48

HC X-RAY COLON AIR CONTRAST - FL BARIUM ENEMA AIR CONTRAST

Facility

$885.00

Service Code	HCPCS 74280
Hospital Charge Code	3207428001
Hospital Revenue Code	320
Min. Negotiated Rate	$752.25
Max. Negotiated Rate	$858.45
Rate for Payer: Cash Price	$531.00
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: MDX Hawaii PPO	$858.45

HC X-RAY COLON CONTRAST - FL BARIUM ENEMA SINGLE CONTRAST WATER SOLUBLE

Facility

$885.00

Service Code	HCPCS 74270
Hospital Charge Code	3207427001
Hospital Revenue Code	320
Min. Negotiated Rate	$56.53
Max. Negotiated Rate	$858.45
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$531.00
Rate for Payer: Cash Price	$531.00
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$56.53
Rate for Payer: Hawaii Medical Service Association Commercial	$259.01
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$61.14
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$557.55
Rate for Payer: Kaiser Permanente Medicaid	$451.35
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$858.45
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$56.53
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$246.75

HC X-RAY COLON CONTRAST - FL BARIUM ENEMA SINGLE CONTRAST WATER SOLUBLE

Facility

$885.00

Service Code	HCPCS 74270
Hospital Charge Code	3207427001
Hospital Revenue Code	320
Min. Negotiated Rate	$752.25
Max. Negotiated Rate	$858.45
Rate for Payer: Cash Price	$531.00
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: MDX Hawaii PPO	$858.45

HC XRAY CONTROL CATHETER CHANGE - IR GJ TUBE CHANGE

Facility

$735.00

Service Code	HCPCS 75984
Hospital Charge Code	3237598401
Hospital Revenue Code	323
Min. Negotiated Rate	$64.32
Max. Negotiated Rate	$712.95
Rate for Payer: Cash Price	$441.00
Rate for Payer: Cash Price	$441.00
Rate for Payer: Hawaii Medical Service Association ABD	$64.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$69.85
Rate for Payer: Hawaii Western Management Group Commercial	$698.25
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: Kaiser Permanente Commercial	$463.05
Rate for Payer: Kaiser Permanente Medicaid	$374.85
Rate for Payer: MDX Hawaii PPO	$712.95
Rate for Payer: UnitedHealthcare Medicaid	$64.32
Rate for Payer: University Health Alliance Commercial	$231.05

HC XRAY CONTROL CATHETER CHANGE - IR GJ TUBE CHANGE

Facility

$735.00

Service Code	HCPCS 75984
Hospital Charge Code	3237598401
Hospital Revenue Code	323
Min. Negotiated Rate	$624.75
Max. Negotiated Rate	$712.95
Rate for Payer: Cash Price	$441.00
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: MDX Hawaii PPO	$712.95

HC XRAY CONTROL CATHETER CHANGE - IR URETERAL STENT CHANGE

Facility

$735.00

Service Code	HCPCS 75984
Hospital Charge Code	3207598401
Hospital Revenue Code	320
Min. Negotiated Rate	$624.75
Max. Negotiated Rate	$712.95
Rate for Payer: Cash Price	$441.00
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: MDX Hawaii PPO	$712.95

HC XRAY CONTROL CATHETER CHANGE - IR URETERAL STENT CHANGE

Facility

$735.00

Service Code	HCPCS 75984
Hospital Charge Code	3207598401
Hospital Revenue Code	320
Min. Negotiated Rate	$64.32
Max. Negotiated Rate	$712.95
Rate for Payer: Cash Price	$441.00
Rate for Payer: Cash Price	$441.00
Rate for Payer: Hawaii Medical Service Association ABD	$64.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$69.85
Rate for Payer: Hawaii Western Management Group Commercial	$698.25
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: Kaiser Permanente Commercial	$463.05
Rate for Payer: Kaiser Permanente Medicaid	$374.85
Rate for Payer: MDX Hawaii PPO	$712.95
Rate for Payer: UnitedHealthcare Medicaid	$64.32
Rate for Payer: University Health Alliance Commercial	$231.05

HC X-RAY,C/T,DISK,SUPERV/INTERPRET - FL CERVICAL SPINE DISCOGRAM

Facility

$7,609.00

Service Code	HCPCS 72285
Hospital Charge Code	3207228501
Hospital Revenue Code	320
Min. Negotiated Rate	$275.95
Max. Negotiated Rate	$7,380.73
Rate for Payer: AlohaCare Medicaid	$2,306.84
Rate for Payer: AlohaCare Medicare	$2,306.84
Rate for Payer: Cash Price	$4,565.40
Rate for Payer: Cash Price	$4,565.40
Rate for Payer: Devoted Health Medicare	$2,537.52
Rate for Payer: Hawaii Medical Service Association ABD	$275.95
Rate for Payer: Hawaii Medical Service Association Commercial	$2,883.55
Rate for Payer: Hawaii Medical Service Association Medicare	$2,306.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$289.75
Rate for Payer: Hawaii Western Management Group Commercial	$2,306.84
Rate for Payer: Health Management Network Commercial	$6,467.65
Rate for Payer: Humana Medicare	$2,306.84
Rate for Payer: Kaiser Permanente Commercial	$4,793.67
Rate for Payer: Kaiser Permanente Medicaid	$3,880.59
Rate for Payer: Kaiser Permanente Medicare	$2,306.84
Rate for Payer: MDX Hawaii PPO	$7,380.73
Rate for Payer: Ohana Health Plan Medicaid	$2,537.52
Rate for Payer: Ohana Health Plan Medicare	$2,306.84
Rate for Payer: UnitedHealthcare Medicaid	$275.95
Rate for Payer: UnitedHealthcare Medicare	$2,306.84
Rate for Payer: University Health Alliance Commercial	$505.31

HC X-RAY,C/T,DISK,SUPERV/INTERPRET - FL CERVICAL SPINE DISCOGRAM

Facility

$7,609.00

Service Code	HCPCS 72285
Hospital Charge Code	3207228501
Hospital Revenue Code	320
Min. Negotiated Rate	$6,467.65
Max. Negotiated Rate	$7,380.73
Rate for Payer: Cash Price	$4,565.40
Rate for Payer: Health Management Network Commercial	$6,467.65
Rate for Payer: MDX Hawaii PPO	$7,380.73

HC X-RAY,C/T,DISK,SUPERV/INTERPRET - FL THORACIC SPINE DISCOGRAM

Facility

$7,609.00

Service Code	HCPCS 72285
Hospital Charge Code	3207228503
Hospital Revenue Code	320
Min. Negotiated Rate	$6,467.65
Max. Negotiated Rate	$7,380.73
Rate for Payer: Cash Price	$4,565.40
Rate for Payer: Health Management Network Commercial	$6,467.65
Rate for Payer: MDX Hawaii PPO	$7,380.73

HC X-RAY,C/T,DISK,SUPERV/INTERPRET - FL THORACIC SPINE DISCOGRAM

Facility

$7,609.00

Service Code	HCPCS 72285
Hospital Charge Code	3207228503
Hospital Revenue Code	320
Min. Negotiated Rate	$275.95
Max. Negotiated Rate	$7,380.73
Rate for Payer: AlohaCare Medicaid	$2,306.84
Rate for Payer: AlohaCare Medicare	$2,306.84
Rate for Payer: Cash Price	$4,565.40
Rate for Payer: Cash Price	$4,565.40
Rate for Payer: Devoted Health Medicare	$2,537.52
Rate for Payer: Hawaii Medical Service Association ABD	$275.95
Rate for Payer: Hawaii Medical Service Association Commercial	$2,883.55
Rate for Payer: Hawaii Medical Service Association Medicare	$2,306.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$289.75
Rate for Payer: Hawaii Western Management Group Commercial	$2,306.84
Rate for Payer: Health Management Network Commercial	$6,467.65
Rate for Payer: Humana Medicare	$2,306.84
Rate for Payer: Kaiser Permanente Commercial	$4,793.67
Rate for Payer: Kaiser Permanente Medicaid	$3,880.59
Rate for Payer: Kaiser Permanente Medicare	$2,306.84
Rate for Payer: MDX Hawaii PPO	$7,380.73
Rate for Payer: Ohana Health Plan Medicaid	$2,537.52
Rate for Payer: Ohana Health Plan Medicare	$2,306.84
Rate for Payer: UnitedHealthcare Medicaid	$275.95
Rate for Payer: UnitedHealthcare Medicare	$2,306.84
Rate for Payer: University Health Alliance Commercial	$505.31

HC X-RAY CYSTOGRAM, MIN 3 VIEW - FL CYSTOGRAM 3V

Facility

$1,776.00

Service Code	HCPCS 74430
Hospital Charge Code	3207443001
Hospital Revenue Code	320
Min. Negotiated Rate	$34.94
Max. Negotiated Rate	$1,722.72
Rate for Payer: AlohaCare Medicaid	$412.14
Rate for Payer: AlohaCare Medicare	$412.14
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Devoted Health Medicare	$453.35
Rate for Payer: Hawaii Medical Service Association ABD	$34.94
Rate for Payer: Hawaii Medical Service Association Commercial	$515.17
Rate for Payer: Hawaii Medical Service Association Medicare	$412.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.51
Rate for Payer: Hawaii Western Management Group Commercial	$412.14
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: Humana Medicare	$412.14
Rate for Payer: Kaiser Permanente Commercial	$1,118.88
Rate for Payer: Kaiser Permanente Medicaid	$905.76
Rate for Payer: Kaiser Permanente Medicare	$412.14
Rate for Payer: MDX Hawaii PPO	$1,722.72
Rate for Payer: Ohana Health Plan Medicaid	$453.35
Rate for Payer: Ohana Health Plan Medicare	$412.14
Rate for Payer: UnitedHealthcare Medicaid	$34.94
Rate for Payer: UnitedHealthcare Medicare	$412.14
Rate for Payer: University Health Alliance Commercial	$148.81

HC X-RAY CYSTOGRAM, MIN 3 VIEW - FL CYSTOGRAM 3V

Facility

$1,776.00

Service Code	HCPCS 74430
Hospital Charge Code	3207443001
Hospital Revenue Code	320
Min. Negotiated Rate	$1,509.60
Max. Negotiated Rate	$1,722.72
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: MDX Hawaii PPO	$1,722.72

Know your out-of-pocket cost for care.

All Charges