Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC X-RAY WRIST 2 VW - XR WRIST 1-2 VIEWS BILATERAL

Facility

$438.00

Service Code	HCPCS 73100
Hospital Charge Code	3207310003
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	$57.07

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

Facility

$438.00

Service Code	HCPCS 73110
Hospital Charge Code	3207311003
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	$66.60

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

Facility

$438.00

Service Code	HCPCS 73110
Hospital Charge Code	3207311003
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 XM ESOPHAGUS 2CNTRST

Facility

$885.00

Service Code	HCPCS 74221
Hospital Charge Code	3207422101
Hospital Revenue Code	320
Min. Negotiated Rate	$67.73
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	$102.34
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	$67.73
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	$72.83
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$225.92

HC X-RAY XM ESOPHAGUS 2CNTRST

Facility

$885.00

Service Code	HCPCS 74221
Hospital Charge Code	3207422101
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

HEADACHES WITH MCC

Facility

$19,335.53

Service Code	MSDRG 102
Min. Negotiated Rate	$12,749.40
Max. Negotiated Rate	$19,335.53
Rate for Payer: AlohaCare Medicare	$12,749.40
Rate for Payer: Devoted Health Medicare	$14,024.34
Rate for Payer: Hawaii Medical Service Association Commercial	$16,039.83
Rate for Payer: Hawaii Medical Service Association Medicare	$12,749.40
Rate for Payer: Humana Medicare	$12,749.40
Rate for Payer: Kaiser Permanente Commercial	$19,335.53
Rate for Payer: Kaiser Permanente Medicare	$12,749.40
Rate for Payer: Ohana Health Plan Medicare	$12,749.40
Rate for Payer: UnitedHealthcare Medicare	$12,749.40

HEADACHES WITHOUT MCC

Facility

$16,039.83

Service Code	MSDRG 103
Min. Negotiated Rate	$9,512.29
Max. Negotiated Rate	$16,039.83
Rate for Payer: AlohaCare Medicare	$9,512.29
Rate for Payer: Devoted Health Medicare	$10,463.52
Rate for Payer: Hawaii Medical Service Association Commercial	$16,039.83
Rate for Payer: Hawaii Medical Service Association Medicare	$9,512.29
Rate for Payer: Humana Medicare	$9,512.29
Rate for Payer: Kaiser Permanente Commercial	$14,426.17
Rate for Payer: Kaiser Permanente Medicare	$9,512.29
Rate for Payer: Ohana Health Plan Medicare	$9,512.29
Rate for Payer: UnitedHealthcare Medicare	$9,512.29

HEAD EVOLVE PROLINE 20 496H020

Facility

$4,452.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,270.52
Max. Negotiated Rate	$4,318.44
Rate for Payer: Cash Price	$2,671.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,116.40
Rate for Payer: Health Management Network Commercial	$3,784.20
Rate for Payer: Kaiser Permanente Commercial	$2,804.76
Rate for Payer: Kaiser Permanente Medicaid	$2,270.52
Rate for Payer: MDX Hawaii PPO	$4,318.44
Rate for Payer: University Health Alliance Commercial	$2,493.12

HEAD EVOLVE PROLINE 20 496H020

Facility

$4,452.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,493.12
Max. Negotiated Rate	$4,318.44
Rate for Payer: Cash Price	$2,671.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,116.40
Rate for Payer: Health Management Network Commercial	$3,784.20
Rate for Payer: MDX Hawaii PPO	$4,318.44
Rate for Payer: University Health Alliance Commercial	$2,493.12

HEAD FEMORAL 26MM 6260-9-226

Facility

$1,971.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,005.21
Max. Negotiated Rate	$1,911.87
Rate for Payer: Cash Price	$1,182.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,379.70
Rate for Payer: Health Management Network Commercial	$1,675.35
Rate for Payer: Kaiser Permanente Commercial	$1,241.73
Rate for Payer: Kaiser Permanente Medicaid	$1,005.21
Rate for Payer: MDX Hawaii PPO	$1,911.87
Rate for Payer: University Health Alliance Commercial	$1,103.76

HEAD FEMORAL 26MM 6260-9-226

Facility

$1,971.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,103.76
Max. Negotiated Rate	$1,911.87
Rate for Payer: Cash Price	$1,182.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,379.70
Rate for Payer: Health Management Network Commercial	$1,675.35
Rate for Payer: MDX Hawaii PPO	$1,911.87
Rate for Payer: University Health Alliance Commercial	$1,103.76

HEAD FEMORAL 28MM 6260-9-228

Facility

$1,971.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,005.21
Max. Negotiated Rate	$1,911.87
Rate for Payer: Cash Price	$1,182.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,379.70
Rate for Payer: Health Management Network Commercial	$1,675.35
Rate for Payer: Kaiser Permanente Commercial	$1,241.73
Rate for Payer: Kaiser Permanente Medicaid	$1,005.21
Rate for Payer: MDX Hawaii PPO	$1,911.87
Rate for Payer: University Health Alliance Commercial	$1,103.76

HEAD FEMORAL 28MM 6260-9-228

Facility

$1,971.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,103.76
Max. Negotiated Rate	$1,911.87
Rate for Payer: Cash Price	$1,182.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,379.70
Rate for Payer: Health Management Network Commercial	$1,675.35
Rate for Payer: MDX Hawaii PPO	$1,911.87
Rate for Payer: University Health Alliance Commercial	$1,103.76

HEAD FEMORAL 28MM 6570-0-028

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

HEAD FEMORAL 28MM 6570-0-028

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.76
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$1,685.88
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

HEAD FEMORAL 36+5MM 6570-0-236

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.76
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$1,685.88
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

HEAD FEMORAL 36+5MM 6570-0-236

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

HEAD FEMORAL 36MM 6260-9-136

Facility

$1,990.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,014.90
Max. Negotiated Rate	$1,930.30
Rate for Payer: Cash Price	$1,194.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,393.00
Rate for Payer: Health Management Network Commercial	$1,691.50
Rate for Payer: Kaiser Permanente Commercial	$1,253.70
Rate for Payer: Kaiser Permanente Medicaid	$1,014.90
Rate for Payer: MDX Hawaii PPO	$1,930.30
Rate for Payer: University Health Alliance Commercial	$1,114.40

HEAD FEMORAL 36MM 6260-9-136

Facility

$1,990.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,114.40
Max. Negotiated Rate	$1,930.30
Rate for Payer: Cash Price	$1,194.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,393.00
Rate for Payer: Health Management Network Commercial	$1,691.50
Rate for Payer: MDX Hawaii PPO	$1,930.30
Rate for Payer: University Health Alliance Commercial	$1,114.40

HEAD FEMOR LFIT V40 6260-9-328

Facility

$1,971.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,005.21
Max. Negotiated Rate	$1,911.87
Rate for Payer: Cash Price	$1,182.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,379.70
Rate for Payer: Health Management Network Commercial	$1,675.35
Rate for Payer: Kaiser Permanente Commercial	$1,241.73
Rate for Payer: Kaiser Permanente Medicaid	$1,005.21
Rate for Payer: MDX Hawaii PPO	$1,911.87
Rate for Payer: University Health Alliance Commercial	$1,103.76

HEAD FEMOR LFIT V40 6260-9-328

Facility

$1,971.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,103.76
Max. Negotiated Rate	$1,911.87
Rate for Payer: Cash Price	$1,182.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,379.70
Rate for Payer: Health Management Network Commercial	$1,675.35
Rate for Payer: MDX Hawaii PPO	$1,911.87
Rate for Payer: University Health Alliance Commercial	$1,103.76

HEAD HUM 48X15MM 5552-S-4815

Facility

$4,067.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,277.52
Max. Negotiated Rate	$3,944.99
Rate for Payer: Cash Price	$2,440.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,846.90
Rate for Payer: Health Management Network Commercial	$3,456.95
Rate for Payer: MDX Hawaii PPO	$3,944.99
Rate for Payer: University Health Alliance Commercial	$2,277.52

HEAD HUM 48X15MM 5552-S-4815

Facility

$4,067.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,074.17
Max. Negotiated Rate	$3,944.99
Rate for Payer: Cash Price	$2,440.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,846.90
Rate for Payer: Health Management Network Commercial	$3,456.95
Rate for Payer: Kaiser Permanente Commercial	$2,562.21
Rate for Payer: Kaiser Permanente Medicaid	$2,074.17
Rate for Payer: MDX Hawaii PPO	$3,944.99
Rate for Payer: University Health Alliance Commercial	$2,277.52

HEAD HUM 48X18MM 5552-S-4818

Facility

$4,067.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,074.17
Max. Negotiated Rate	$3,944.99
Rate for Payer: Cash Price	$2,440.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,846.90
Rate for Payer: Health Management Network Commercial	$3,456.95
Rate for Payer: Kaiser Permanente Commercial	$2,562.21
Rate for Payer: Kaiser Permanente Medicaid	$2,074.17
Rate for Payer: MDX Hawaii PPO	$3,944.99
Rate for Payer: University Health Alliance Commercial	$2,277.52

HEAD HUM 48X18MM 5552-S-4818

Facility

$4,067.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,277.52
Max. Negotiated Rate	$3,944.99
Rate for Payer: Cash Price	$2,440.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,846.90
Rate for Payer: Health Management Network Commercial	$3,456.95
Rate for Payer: MDX Hawaii PPO	$3,944.99
Rate for Payer: University Health Alliance Commercial	$2,277.52

Know your out-of-pocket cost for care.

All Charges