Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC IMMUNFIX E-PHORSIS/URINE/CSF - IMMUNOFIXATION/IFE URINE

Facility

$246.00

Service Code	HCPCS 86335
Hospital Charge Code	3028633501
Hospital Revenue Code	302
Min. Negotiated Rate	$209.10
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$147.60
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: MDX Hawaii PPO	$238.62

HC IMMUNIZ ADMIN,1 SINGLE/COMB VAC/TOXOID

Facility

$283.00

Service Code	HCPCS 90471
Hospital Charge Code	7719047101
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$274.51
Rate for Payer: AlohaCare Medicaid	$85.06
Rate for Payer: AlohaCare Medicare	$85.06
Rate for Payer: Cash Price	$169.80
Rate for Payer: Cash Price	$169.80
Rate for Payer: Devoted Health Medicare	$93.57
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Commercial	$106.33
Rate for Payer: Hawaii Medical Service Association Medicare	$85.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.56
Rate for Payer: Hawaii Western Management Group Commercial	$268.85
Rate for Payer: Health Management Network Commercial	$240.55
Rate for Payer: Humana Medicare	$85.06
Rate for Payer: Kaiser Permanente Commercial	$178.29
Rate for Payer: Kaiser Permanente Medicaid	$144.33
Rate for Payer: Kaiser Permanente Medicare	$85.06
Rate for Payer: MDX Hawaii PPO	$274.51
Rate for Payer: Ohana Health Plan Medicaid	$93.57
Rate for Payer: Ohana Health Plan Medicare	$85.06
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$85.06
Rate for Payer: University Health Alliance Commercial	$206.28

HC IMMUNIZ ADMIN,1 SINGLE/COMB VAC/TOXOID

Facility

$283.00

Service Code	HCPCS 90471
Hospital Charge Code	7719047101
Hospital Revenue Code	771
Min. Negotiated Rate	$240.55
Max. Negotiated Rate	$274.51
Rate for Payer: Cash Price	$169.80
Rate for Payer: Health Management Network Commercial	$240.55
Rate for Payer: MDX Hawaii PPO	$274.51

HC IMMUNIZ,ADMIN,EACH ADDL

Facility

$108.00

Service Code	HCPCS 90472
Hospital Charge Code	7719047201
Hospital Revenue Code	771
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$104.76
Rate for Payer: Cash Price	$64.80
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: MDX Hawaii PPO	$104.76

HC IMMUNIZ,ADMIN,EACH ADDL

Facility

$108.00

Service Code	HCPCS 90472
Hospital Charge Code	7719047201
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$104.76
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cash Price	$64.80
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.28
Rate for Payer: Hawaii Western Management Group Commercial	$102.60
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Kaiser Permanente Commercial	$68.04
Rate for Payer: Kaiser Permanente Medicaid	$55.08
Rate for Payer: MDX Hawaii PPO	$104.76
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: University Health Alliance Commercial	$78.72

HC IMMUNIZ ADMIN,INTRANASAL/ORAL,1 VAC/TOX

Facility

$277.00

Service Code	HCPCS 90473
Hospital Charge Code	7719047301
Hospital Revenue Code	771
Min. Negotiated Rate	$235.45
Max. Negotiated Rate	$268.69
Rate for Payer: Cash Price	$166.20
Rate for Payer: Health Management Network Commercial	$235.45
Rate for Payer: MDX Hawaii PPO	$268.69

HC IMMUNIZ ADMIN,INTRANASAL/ORAL,1 VAC/TOX

Facility

$277.00

Service Code	HCPCS 90473
Hospital Charge Code	7719047301
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$268.69
Rate for Payer: AlohaCare Medicaid	$85.06
Rate for Payer: AlohaCare Medicare	$85.06
Rate for Payer: Cash Price	$166.20
Rate for Payer: Cash Price	$166.20
Rate for Payer: Devoted Health Medicare	$93.57
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Commercial	$106.33
Rate for Payer: Hawaii Medical Service Association Medicare	$85.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.56
Rate for Payer: Hawaii Western Management Group Commercial	$263.15
Rate for Payer: Health Management Network Commercial	$235.45
Rate for Payer: Humana Medicare	$85.06
Rate for Payer: Kaiser Permanente Commercial	$174.51
Rate for Payer: Kaiser Permanente Medicaid	$141.27
Rate for Payer: Kaiser Permanente Medicare	$85.06
Rate for Payer: MDX Hawaii PPO	$268.69
Rate for Payer: Ohana Health Plan Medicaid	$93.57
Rate for Payer: Ohana Health Plan Medicare	$85.06
Rate for Payer: UnitedHealthcare Medicaid	$53.38
Rate for Payer: UnitedHealthcare Medicare	$85.06
Rate for Payer: University Health Alliance Commercial	$201.91

HC IMMUNIZ ADMIN,INTRANASAL/ORAL,EACH ADDL

Facility

$74.00

Service Code	HCPCS 90474
Hospital Charge Code	7719047401
Hospital Revenue Code	771
Min. Negotiated Rate	$62.90
Max. Negotiated Rate	$71.78
Rate for Payer: Cash Price	$44.40
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: MDX Hawaii PPO	$71.78

HC IMMUNIZ ADMIN,INTRANASAL/ORAL,EACH ADDL

Facility

$74.00

Service Code	HCPCS 90474
Hospital Charge Code	7719047401
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$71.78
Rate for Payer: Cash Price	$44.40
Rate for Payer: Cash Price	$44.40
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.28
Rate for Payer: Hawaii Western Management Group Commercial	$70.30
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Kaiser Permanente Commercial	$46.62
Rate for Payer: Kaiser Permanente Medicaid	$37.74
Rate for Payer: MDX Hawaii PPO	$71.78
Rate for Payer: UnitedHealthcare Medicaid	$8.73
Rate for Payer: University Health Alliance Commercial	$53.94

HC IMMUNIZ ADMIN, THRU AGE 18, ANY ROUTE,W COUNSEL, 1ST VACCINE/TOXOID

Facility

$75.00

Service Code	HCPCS 90460
Hospital Charge Code	7719046001
Hospital Revenue Code	771
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$45.00
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: MDX Hawaii PPO	$72.75

HC IMMUNIZ ADMIN, THRU AGE 18, ANY ROUTE,W COUNSEL, 1ST VACCINE/TOXOID

Facility

$75.00

Service Code	HCPCS 90460
Hospital Charge Code	7719046001
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.56
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$47.25
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: UnitedHealthcare Medicaid	$16.74
Rate for Payer: University Health Alliance Commercial	$54.67

HC IMMUNIZ ADMIN, THRU AGE 18, ANY ROUTE,W COUNSEL, EA ADD VACCINE/TOXOID

Facility

$19.00

Service Code	HCPCS 90461
Hospital Charge Code	7719046101
Hospital Revenue Code	771
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: MDX Hawaii PPO	$18.43

HC IMMUNIZ ADMIN, THRU AGE 18, ANY ROUTE,W COUNSEL, EA ADD VACCINE/TOXOID

Facility

$19.00

Service Code	HCPCS 90461
Hospital Charge Code	7719046101
Hospital Revenue Code	771
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Cash Price	$11.40
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.14
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$11.97
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: UnitedHealthcare Medicaid	$6.31
Rate for Payer: University Health Alliance Commercial	$13.85

HC IMMUNOASSAY ANALYTE QUANTITATIVE NOS - TRYPTASE SO

Facility

$145.00

Service Code	HCPCS 83520
Hospital Charge Code	3018352005
Hospital Revenue Code	301
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$140.65
Rate for Payer: AlohaCare Medicaid	$17.27
Rate for Payer: AlohaCare Medicare	$17.27
Rate for Payer: Cash Price	$87.00
Rate for Payer: Cash Price	$87.00
Rate for Payer: Devoted Health Medicare	$19.00
Rate for Payer: Hawaii Medical Service Association ABD	$17.89
Rate for Payer: Hawaii Medical Service Association Commercial	$21.59
Rate for Payer: Hawaii Medical Service Association Medicare	$17.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.78
Rate for Payer: Hawaii Western Management Group Commercial	$17.27
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Humana Medicare	$17.27
Rate for Payer: Kaiser Permanente Commercial	$91.35
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: Kaiser Permanente Medicare	$17.27
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: Ohana Health Plan Medicaid	$19.00
Rate for Payer: Ohana Health Plan Medicare	$17.27
Rate for Payer: UnitedHealthcare Medicaid	$17.89
Rate for Payer: UnitedHealthcare Medicare	$17.27
Rate for Payer: University Health Alliance Commercial	$33.47

HC IMMUNOASSAY ANALYTE QUANTITATIVE NOS - TRYPTASE SO

Facility

$145.00

Service Code	HCPCS 83520
Hospital Charge Code	3018352005
Hospital Revenue Code	301
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$87.00
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: MDX Hawaii PPO	$140.65

HC IMMUNOASSAY,INFECT AGENT,QUANT - IMMUNOASSAY INF AGT AB SO

Facility

$126.00

Service Code	HCPCS 86317
Hospital Charge Code	3028631701
Hospital Revenue Code	302
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: MDX Hawaii PPO	$122.22

HC IMMUNOASSAY,INFECT AGENT,QUANT - IMMUNOASSAY INF AGT AB SO

Facility

$126.00

Service Code	HCPCS 86317
Hospital Charge Code	3028631701
Hospital Revenue Code	302
Min. Negotiated Rate	$14.99
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$14.99
Rate for Payer: AlohaCare Medicare	$14.99
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cash Price	$75.60
Rate for Payer: Devoted Health Medicare	$16.49
Rate for Payer: Hawaii Medical Service Association ABD	$20.72
Rate for Payer: Hawaii Medical Service Association Commercial	$18.74
Rate for Payer: Hawaii Medical Service Association Medicare	$14.99
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.76
Rate for Payer: Hawaii Western Management Group Commercial	$14.99
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$14.99
Rate for Payer: Kaiser Permanente Commercial	$79.38
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$14.99
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$16.49
Rate for Payer: Ohana Health Plan Medicare	$14.99
Rate for Payer: UnitedHealthcare Medicaid	$20.72
Rate for Payer: UnitedHealthcare Medicare	$14.99
Rate for Payer: University Health Alliance Commercial	$38.76

HC IMMUNOASSAY NONANTIBODY - GLOMERULAR BASE MEM AB SO

Facility

$97.00

Service Code	HCPCS 83516
Hospital Charge Code	3018351603
Hospital Revenue Code	301
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$94.09
Rate for Payer: AlohaCare Medicaid	$11.53
Rate for Payer: AlohaCare Medicare	$11.53
Rate for Payer: Cash Price	$58.20
Rate for Payer: Cash Price	$58.20
Rate for Payer: Devoted Health Medicare	$12.68
Rate for Payer: Hawaii Medical Service Association ABD	$15.95
Rate for Payer: Hawaii Medical Service Association Commercial	$14.41
Rate for Payer: Hawaii Medical Service Association Medicare	$11.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.75
Rate for Payer: Hawaii Western Management Group Commercial	$11.53
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Humana Medicare	$11.53
Rate for Payer: Kaiser Permanente Commercial	$61.11
Rate for Payer: Kaiser Permanente Medicaid	$49.47
Rate for Payer: Kaiser Permanente Medicare	$11.53
Rate for Payer: MDX Hawaii PPO	$94.09
Rate for Payer: Ohana Health Plan Medicaid	$12.68
Rate for Payer: Ohana Health Plan Medicare	$11.53
Rate for Payer: UnitedHealthcare Medicaid	$15.95
Rate for Payer: UnitedHealthcare Medicare	$11.53
Rate for Payer: University Health Alliance Commercial	$29.82

HC IMMUNOASSAY NONANTIBODY - GLOMERULAR BASE MEM AB SO

Facility

$97.00

Service Code	HCPCS 83516
Hospital Charge Code	3018351603
Hospital Revenue Code	301
Min. Negotiated Rate	$82.45
Max. Negotiated Rate	$94.09
Rate for Payer: Cash Price	$58.20
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: MDX Hawaii PPO	$94.09

HC IMMUNOASSAY NONANTIBODY - IMMUNOASSAY ANAL MULT SO

Facility

$97.00

Service Code	HCPCS 83516
Hospital Charge Code	3018351601
Hospital Revenue Code	301
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$94.09
Rate for Payer: AlohaCare Medicaid	$11.53
Rate for Payer: AlohaCare Medicare	$11.53
Rate for Payer: Cash Price	$58.20
Rate for Payer: Cash Price	$58.20
Rate for Payer: Devoted Health Medicare	$12.68
Rate for Payer: Hawaii Medical Service Association ABD	$15.95
Rate for Payer: Hawaii Medical Service Association Commercial	$14.41
Rate for Payer: Hawaii Medical Service Association Medicare	$11.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.75
Rate for Payer: Hawaii Western Management Group Commercial	$11.53
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Humana Medicare	$11.53
Rate for Payer: Kaiser Permanente Commercial	$61.11
Rate for Payer: Kaiser Permanente Medicaid	$49.47
Rate for Payer: Kaiser Permanente Medicare	$11.53
Rate for Payer: MDX Hawaii PPO	$94.09
Rate for Payer: Ohana Health Plan Medicaid	$12.68
Rate for Payer: Ohana Health Plan Medicare	$11.53
Rate for Payer: UnitedHealthcare Medicaid	$15.95
Rate for Payer: UnitedHealthcare Medicare	$11.53
Rate for Payer: University Health Alliance Commercial	$29.82

HC IMMUNOASSAY NONANTIBODY - IMMUNOASSAY ANAL MULT SO

Facility

$97.00

Service Code	HCPCS 83516
Hospital Charge Code	3018351601
Hospital Revenue Code	301
Min. Negotiated Rate	$82.45
Max. Negotiated Rate	$94.09
Rate for Payer: Cash Price	$58.20
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: MDX Hawaii PPO	$94.09

HC IMMUNOASSAY NONANTIBODY - MYELOPEROXIDASE AB (MPOAB)

Facility

$97.00

Service Code	HCPCS 83516
Hospital Charge Code	3018351604
Hospital Revenue Code	301
Min. Negotiated Rate	$82.45
Max. Negotiated Rate	$94.09
Rate for Payer: Cash Price	$58.20
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: MDX Hawaii PPO	$94.09

HC IMMUNOASSAY NONANTIBODY - MYELOPEROXIDASE AB (MPOAB)

Facility

$97.00

Service Code	HCPCS 83516
Hospital Charge Code	3018351604
Hospital Revenue Code	301
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$94.09
Rate for Payer: AlohaCare Medicaid	$11.53
Rate for Payer: AlohaCare Medicare	$11.53
Rate for Payer: Cash Price	$58.20
Rate for Payer: Cash Price	$58.20
Rate for Payer: Devoted Health Medicare	$12.68
Rate for Payer: Hawaii Medical Service Association ABD	$15.95
Rate for Payer: Hawaii Medical Service Association Commercial	$14.41
Rate for Payer: Hawaii Medical Service Association Medicare	$11.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.75
Rate for Payer: Hawaii Western Management Group Commercial	$11.53
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Humana Medicare	$11.53
Rate for Payer: Kaiser Permanente Commercial	$61.11
Rate for Payer: Kaiser Permanente Medicaid	$49.47
Rate for Payer: Kaiser Permanente Medicare	$11.53
Rate for Payer: MDX Hawaii PPO	$94.09
Rate for Payer: Ohana Health Plan Medicaid	$12.68
Rate for Payer: Ohana Health Plan Medicare	$11.53
Rate for Payer: UnitedHealthcare Medicaid	$15.95
Rate for Payer: UnitedHealthcare Medicare	$11.53
Rate for Payer: University Health Alliance Commercial	$29.82

HC IMMUNOASSAY NONANTIBODY - PROTEIN-3 AB (PR3AB) IA

Facility

$97.00

Service Code	HCPCS 83516
Hospital Charge Code	3018351605
Hospital Revenue Code	301
Min. Negotiated Rate	$82.45
Max. Negotiated Rate	$94.09
Rate for Payer: Cash Price	$58.20
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: MDX Hawaii PPO	$94.09

HC IMMUNOASSAY NONANTIBODY - PROTEIN-3 AB (PR3AB) IA

Facility

$97.00

Service Code	HCPCS 83516
Hospital Charge Code	3018351605
Hospital Revenue Code	301
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$94.09
Rate for Payer: AlohaCare Medicaid	$11.53
Rate for Payer: AlohaCare Medicare	$11.53
Rate for Payer: Cash Price	$58.20
Rate for Payer: Cash Price	$58.20
Rate for Payer: Devoted Health Medicare	$12.68
Rate for Payer: Hawaii Medical Service Association ABD	$15.95
Rate for Payer: Hawaii Medical Service Association Commercial	$14.41
Rate for Payer: Hawaii Medical Service Association Medicare	$11.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.75
Rate for Payer: Hawaii Western Management Group Commercial	$11.53
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Humana Medicare	$11.53
Rate for Payer: Kaiser Permanente Commercial	$61.11
Rate for Payer: Kaiser Permanente Medicaid	$49.47
Rate for Payer: Kaiser Permanente Medicare	$11.53
Rate for Payer: MDX Hawaii PPO	$94.09
Rate for Payer: Ohana Health Plan Medicaid	$12.68
Rate for Payer: Ohana Health Plan Medicare	$11.53
Rate for Payer: UnitedHealthcare Medicaid	$15.95
Rate for Payer: UnitedHealthcare Medicare	$11.53
Rate for Payer: University Health Alliance Commercial	$29.82

Know your out-of-pocket cost for care.

All Charges