Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC X-RAY EXAM OF SMALL BOWEL - FL SMALL BOWEL SERIES ENTEROCLYSIS TUBE

Facility

$885.00

Service Code	HCPCS 74251
Hospital Charge Code	3207425101
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 EYE FOR FOREIGN BODY - XR EYE FOREIGN BODY

Facility

$438.00

Service Code	HCPCS 70030
Hospital Charge Code	3207003001
Hospital Revenue Code	320
Min. Negotiated Rate	$13.91
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	$13.91
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	$15.15
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	$13.91
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$55.37

HC X-RAY EYE FOR FOREIGN BODY - XR EYE FOREIGN BODY

Facility

$438.00

Service Code	HCPCS 70030
Hospital Charge Code	3207003001
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 FACIAL BONES <3 VW - XR FACIAL BONES 1-2 VIEWS

Facility

$438.00

Service Code	HCPCS 70140
Hospital Charge Code	3207014001
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 FACIAL BONES <3 VW - XR FACIAL BONES 1-2 VIEWS

Facility

$438.00

Service Code	HCPCS 70140
Hospital Charge Code	3207014001
Hospital Revenue Code	320
Min. Negotiated Rate	$20.40
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	$20.40
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	$22.35
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	$20.40
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$64.21

HC X-RAY FACIAL BONES 3+ VW - XR FACIAL BONES 3+ VIEWS

Facility

$529.00

Service Code	HCPCS 70150
Hospital Charge Code	3207015001
Hospital Revenue Code	320
Min. Negotiated Rate	$25.96
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	$25.96
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	$28.19
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	$25.96
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$87.39

HC X-RAY FACIAL BONES 3+ VW - XR FACIAL BONES 3+ VIEWS

Facility

$529.00

Service Code	HCPCS 70150
Hospital Charge Code	3207015001
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 FISTULA,ABSCESS,SINUS TRACT - FL FISTULA SINUS TRACT

Facility

$2,728.00

Service Code	HCPCS 76080
Hospital Charge Code	3207608005
Hospital Revenue Code	320
Min. Negotiated Rate	$34.94
Max. Negotiated Rate	$2,646.16
Rate for Payer: AlohaCare Medicaid	$645.50
Rate for Payer: AlohaCare Medicare	$645.50
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Devoted Health Medicare	$710.05
Rate for Payer: Hawaii Medical Service Association ABD	$34.94
Rate for Payer: Hawaii Medical Service Association Commercial	$806.88
Rate for Payer: Hawaii Medical Service Association Medicare	$645.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.51
Rate for Payer: Hawaii Western Management Group Commercial	$645.50
Rate for Payer: Health Management Network Commercial	$2,318.80
Rate for Payer: Humana Medicare	$645.50
Rate for Payer: Kaiser Permanente Commercial	$1,718.64
Rate for Payer: Kaiser Permanente Medicaid	$1,391.28
Rate for Payer: Kaiser Permanente Medicare	$645.50
Rate for Payer: MDX Hawaii PPO	$2,646.16
Rate for Payer: Ohana Health Plan Medicaid	$710.05
Rate for Payer: Ohana Health Plan Medicare	$645.50
Rate for Payer: UnitedHealthcare Medicaid	$34.94
Rate for Payer: UnitedHealthcare Medicare	$645.50
Rate for Payer: University Health Alliance Commercial	$130.89

HC X-RAY FISTULA,ABSCESS,SINUS TRACT - FL FISTULA SINUS TRACT

Facility

$2,728.00

Service Code	HCPCS 76080
Hospital Charge Code	3207608005
Hospital Revenue Code	320
Min. Negotiated Rate	$2,318.80
Max. Negotiated Rate	$2,646.16
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Health Management Network Commercial	$2,318.80
Rate for Payer: MDX Hawaii PPO	$2,646.16

HC X-RAY FOOT 2 VW - XR FOOT 1-2 VIEWS

Facility

$438.00

Service Code	HCPCS 73620
Hospital Charge Code	3207362001
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
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	$16.41
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	$17.57
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	$16.41
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$54.67

HC X-RAY FOOT 2 VW - XR FOOT 1-2 VIEWS

Facility

$438.00

Service Code	HCPCS 73620
Hospital Charge Code	3207362001
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 FOOT 3+ VW - XR FOOT 3+ VIEWS BILATERAL

Facility

$438.00

Service Code	HCPCS 73630
Hospital Charge Code	3207363003
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 FOOT 3+ VW - XR FOOT 3+ VIEWS BILATERAL

Facility

$438.00

Service Code	HCPCS 73630
Hospital Charge Code	3207363003
Hospital Revenue Code	320
Min. Negotiated Rate	$19.08
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	$19.08
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	$20.03
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	$19.08
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$62.59

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

Facility

$438.00

Service Code	HCPCS 73090
Hospital Charge Code	3207309001
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 FOREARM 2 VW - XR FOREARM 2 VIEWS

Facility

$438.00

Service Code	HCPCS 73090
Hospital Charge Code	3207309001
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 GUIDE FOR GI TUBE - FL FEEDING TUBE PLACEMENT

Facility

$575.00

Service Code	HCPCS 74340
Hospital Charge Code	3207434002
Hospital Revenue Code	320
Min. Negotiated Rate	$86.28
Max. Negotiated Rate	$557.75
Rate for Payer: Cash Price	$345.00
Rate for Payer: Cash Price	$345.00
Rate for Payer: Hawaii Medical Service Association ABD	$86.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$93.99
Rate for Payer: Hawaii Western Management Group Commercial	$546.25
Rate for Payer: Health Management Network Commercial	$488.75
Rate for Payer: Kaiser Permanente Commercial	$362.25
Rate for Payer: Kaiser Permanente Medicaid	$293.25
Rate for Payer: MDX Hawaii PPO	$557.75
Rate for Payer: UnitedHealthcare Medicaid	$86.28
Rate for Payer: University Health Alliance Commercial	$419.12

HC X-RAY GUIDE FOR GI TUBE - FL FEEDING TUBE PLACEMENT

Facility

$575.00

Service Code	HCPCS 74340
Hospital Charge Code	3207434002
Hospital Revenue Code	320
Min. Negotiated Rate	$488.75
Max. Negotiated Rate	$557.75
Rate for Payer: Cash Price	$345.00
Rate for Payer: Health Management Network Commercial	$488.75
Rate for Payer: MDX Hawaii PPO	$557.75

HC X-RAY GUIDE FOR GI TUBE - FL FEEDING TUBE PLACEMENT LONG

Facility

$575.00

Service Code	HCPCS 74340
Hospital Charge Code	3207434001
Hospital Revenue Code	320
Min. Negotiated Rate	$86.28
Max. Negotiated Rate	$557.75
Rate for Payer: Cash Price	$345.00
Rate for Payer: Cash Price	$345.00
Rate for Payer: Hawaii Medical Service Association ABD	$86.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$93.99
Rate for Payer: Hawaii Western Management Group Commercial	$546.25
Rate for Payer: Health Management Network Commercial	$488.75
Rate for Payer: Kaiser Permanente Commercial	$362.25
Rate for Payer: Kaiser Permanente Medicaid	$293.25
Rate for Payer: MDX Hawaii PPO	$557.75
Rate for Payer: UnitedHealthcare Medicaid	$86.28
Rate for Payer: University Health Alliance Commercial	$419.12

HC X-RAY GUIDE FOR GI TUBE - FL FEEDING TUBE PLACEMENT LONG

Facility

$575.00

Service Code	HCPCS 74340
Hospital Charge Code	3207434001
Hospital Revenue Code	320
Min. Negotiated Rate	$488.75
Max. Negotiated Rate	$557.75
Rate for Payer: Cash Price	$345.00
Rate for Payer: Health Management Network Commercial	$488.75
Rate for Payer: MDX Hawaii PPO	$557.75

HC X-RAY HAND 2 VW - XR HAND 1-2 VIEWS

Facility

$529.00

Service Code	HCPCS 73120
Hospital Charge Code	3207312001
Hospital Revenue Code	320
Min. Negotiated Rate	$17.55
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	$17.55
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	$18.43
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	$17.55
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$55.46

HC X-RAY HAND 2 VW - XR HAND 1-2 VIEWS

Facility

$529.00

Service Code	HCPCS 73120
Hospital Charge Code	3207312001
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 HAND 3+ VW - XR HAND 3+ VIEWS BILATERAL

Facility

$438.00

Service Code	HCPCS 73130
Hospital Charge Code	3207313003
Hospital Revenue Code	320
Min. Negotiated Rate	$19.08
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	$19.08
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	$20.03
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	$19.08
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$62.59

HC X-RAY HAND 3+ VW - XR HAND 3+ VIEWS BILATERAL

Facility

$438.00

Service Code	HCPCS 73130
Hospital Charge Code	3207313003
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 HEEL - XR CALCANEUS 1 VIEW

Facility

$438.00

Service Code	HCPCS 73650
Hospital Charge Code	3207365003
Hospital Revenue Code	320
Min. Negotiated Rate	$17.03
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	$17.03
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	$17.88
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	$17.03
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$53.87

HC X-RAY HEEL - XR CALCANEUS 1 VIEW

Facility

$438.00

Service Code	HCPCS 73650
Hospital Charge Code	3207365003
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

Know your out-of-pocket cost for care.

All Charges