Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC X-RAY SCAPULA - XR SCAPULA

Facility

$529.00

Service Code	HCPCS 73010
Hospital Charge Code	3207301001
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-RAYS FOR BONE AGE

Facility

$529.00

Service Code	HCPCS 77072
Hospital Charge Code	3207707201
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-RAYS FOR BONE AGE

Facility

$529.00

Service Code	HCPCS 77072
Hospital Charge Code	3207707201
Hospital Revenue Code	320
Min. Negotiated Rate	$10.46
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	$10.46
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	$18.60
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	$10.46
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$47.17

HC X-RAY SHOULDER 1 VW - XR SHOULDER 1 VIEW

Facility

$438.00

Service Code	HCPCS 73020
Hospital Charge Code	3207302002
Hospital Revenue Code	320
Min. Negotiated Rate	$15.78
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	$15.78
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	$16.87
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	$15.78
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$49.15

HC X-RAY SHOULDER 1 VW - XR SHOULDER 1 VIEW

Facility

$438.00

Service Code	HCPCS 73020
Hospital Charge Code	3207302002
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 SHOULDER 2+ VW - XR SHOULDER 2+ VIEWS BILATERAL

Facility

$438.00

Service Code	HCPCS 73030
Hospital Charge Code	3207303001
Hospital Revenue Code	320
Min. Negotiated Rate	$18.84
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	$18.84
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	$20.64
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	$18.84
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$61.92

HC X-RAY SHOULDER 2+ VW - XR SHOULDER 2+ VIEWS BILATERAL

Facility

$438.00

Service Code	HCPCS 73030
Hospital Charge Code	3207303001
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 SINUSES 3+ VW - XR PARANASAL SINUSES 3+ VIEWS

Facility

$438.00

Service Code	HCPCS 70220
Hospital Charge Code	3207022001
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 SINUSES 3+ VW - XR PARANASAL SINUSES 3+ VIEWS

Facility

$438.00

Service Code	HCPCS 70220
Hospital Charge Code	3207022001
Hospital Revenue Code	320
Min. Negotiated Rate	$25.96
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	$25.96
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	$28.19
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	$25.96
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$82.68

HC X-RAY SKULL <4 VW - XR SKULL 1-3 VIEWS

Facility

$529.00

Service Code	HCPCS 70250
Hospital Charge Code	3207025001
Hospital Revenue Code	320
Min. Negotiated Rate	$20.40
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	$20.40
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	$22.35
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	$20.40
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$72.65

HC X-RAY SKULL <4 VW - XR SKULL 1-3 VIEWS

Facility

$529.00

Service Code	HCPCS 70250
Hospital Charge Code	3207025001
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 SKULL 4+ VW - XR SKULL COMPLETE 4+ VIEWS

Facility

$529.00

Service Code	HCPCS 70260
Hospital Charge Code	3207026001
Hospital Revenue Code	320
Min. Negotiated Rate	$29.64
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	$29.64
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	$32.30
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	$29.64
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$100.57

HC X-RAY SKULL 4+ VW - XR SKULL COMPLETE 4+ VIEWS

Facility

$529.00

Service Code	HCPCS 70260
Hospital Charge Code	3207026001
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 SPINE ONE VIEW - XR SPINE

Facility

$438.00

Service Code	HCPCS 72020
Hospital Charge Code	3207202001
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 SPINE ONE VIEW - XR SPINE

Facility

$438.00

Service Code	HCPCS 72020
Hospital Charge Code	3207202001
Hospital Revenue Code	320
Min. Negotiated Rate	$14.98
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	$14.98
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	$15.73
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	$14.98
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$48.36

HC X-RAY STERNUM 2+ VW - XR STERNUM 2+ VIEWS

Facility

$438.00

Service Code	HCPCS 71120
Hospital Charge Code	3207112001
Hospital Revenue Code	320
Min. Negotiated Rate	$21.34
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	$21.34
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	$23.43
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	$21.34
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$69.73

HC X-RAY STERNUM 2+ VW - XR STERNUM 2+ VIEWS

Facility

$438.00

Service Code	HCPCS 71120
Hospital Charge Code	3207112001
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-RAYS TRANSCATH THERAPY - US TRANSCATHETER THERAPY EMBOLIZATION

Facility

$9,561.00

Service Code	HCPCS 75894
Hospital Charge Code	4027589401
Hospital Revenue Code	402
Min. Negotiated Rate	$794.65
Max. Negotiated Rate	$9,274.17
Rate for Payer: Cash Price	$5,736.60
Rate for Payer: Cash Price	$5,736.60
Rate for Payer: Hawaii Medical Service Association ABD	$794.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$863.71
Rate for Payer: Hawaii Western Management Group Commercial	$9,082.95
Rate for Payer: Health Management Network Commercial	$8,126.85
Rate for Payer: Kaiser Permanente Commercial	$6,023.43
Rate for Payer: Kaiser Permanente Medicaid	$4,876.11
Rate for Payer: MDX Hawaii PPO	$9,274.17
Rate for Payer: UnitedHealthcare Medicaid	$794.65
Rate for Payer: University Health Alliance Commercial	$6,969.01

HC X-RAYS TRANSCATH THERAPY - US TRANSCATHETER THERAPY EMBOLIZATION

Facility

$9,561.00

Service Code	HCPCS 75894
Hospital Charge Code	4027589401
Hospital Revenue Code	402
Min. Negotiated Rate	$8,126.85
Max. Negotiated Rate	$9,274.17
Rate for Payer: Cash Price	$5,736.60
Rate for Payer: Health Management Network Commercial	$8,126.85
Rate for Payer: MDX Hawaii PPO	$9,274.17

HC X-RAY STRESS VIEW - XR ANKLE STRESS W CONTRALATERAL JOINT

Facility

$343.00

Service Code	HCPCS 77071
Hospital Charge Code	3207707121
Hospital Revenue Code	320
Min. Negotiated Rate	$291.55
Max. Negotiated Rate	$332.71
Rate for Payer: Cash Price	$205.80
Rate for Payer: Health Management Network Commercial	$291.55
Rate for Payer: MDX Hawaii PPO	$332.71

HC X-RAY STRESS VIEW - XR ANKLE STRESS W CONTRALATERAL JOINT

Facility

$343.00

Service Code	HCPCS 77071
Hospital Charge Code	3207707121
Hospital Revenue Code	320
Min. Negotiated Rate	$19.76
Max. Negotiated Rate	$332.71
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$205.80
Rate for Payer: Cash Price	$205.80
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$291.55
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$216.09
Rate for Payer: Kaiser Permanente Medicaid	$174.93
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$332.71
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$19.76
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$66.91

HC X-RAY STRESS VIEW - XR ANKLE STRESS WO CONTRALATERAL JOINT

Facility

$343.00

Service Code	HCPCS 77071
Hospital Charge Code	3207707123
Hospital Revenue Code	320
Min. Negotiated Rate	$19.76
Max. Negotiated Rate	$332.71
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$205.80
Rate for Payer: Cash Price	$205.80
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$291.55
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$216.09
Rate for Payer: Kaiser Permanente Medicaid	$174.93
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$332.71
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$19.76
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$66.91

HC X-RAY STRESS VIEW - XR ANKLE STRESS WO CONTRALATERAL JOINT

Facility

$343.00

Service Code	HCPCS 77071
Hospital Charge Code	3207707123
Hospital Revenue Code	320
Min. Negotiated Rate	$291.55
Max. Negotiated Rate	$332.71
Rate for Payer: Cash Price	$205.80
Rate for Payer: Health Management Network Commercial	$291.55
Rate for Payer: MDX Hawaii PPO	$332.71

HC X-RAY STRESS VIEW - XR HIP STRESS W CONTRALATERAL JOINT

Facility

$343.00

Service Code	HCPCS 77071
Hospital Charge Code	3207707113
Hospital Revenue Code	320
Min. Negotiated Rate	$291.55
Max. Negotiated Rate	$332.71
Rate for Payer: Cash Price	$205.80
Rate for Payer: Health Management Network Commercial	$291.55
Rate for Payer: MDX Hawaii PPO	$332.71

HC X-RAY STRESS VIEW - XR HIP STRESS W CONTRALATERAL JOINT

Facility

$343.00

Service Code	HCPCS 77071
Hospital Charge Code	3207707113
Hospital Revenue Code	320
Min. Negotiated Rate	$19.76
Max. Negotiated Rate	$332.71
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$205.80
Rate for Payer: Cash Price	$205.80
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$291.55
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$216.09
Rate for Payer: Kaiser Permanente Medicaid	$174.93
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$332.71
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$19.76
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$66.91

Know your out-of-pocket cost for care.

All Charges