Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC IV INFUSION, HYDRATION, EA ADD HOUR

Facility

$184.00

Service Code	HCPCS 96361
Hospital Charge Code	4509636101
Hospital Revenue Code	450
Min. Negotiated Rate	$55.32
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$55.32
Rate for Payer: AlohaCare Medicare	$55.32
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cash Price	$110.40
Rate for Payer: Devoted Health Medicare	$60.85
Rate for Payer: Hawaii Medical Service Association ABD	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$55.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$174.80
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Humana Medicare	$55.32
Rate for Payer: Kaiser Permanente Commercial	$115.92
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$55.32
Rate for Payer: MDX Hawaii PPO	$178.48
Rate for Payer: Ohana Health Plan Medicaid	$60.85
Rate for Payer: Ohana Health Plan Medicare	$55.32
Rate for Payer: UnitedHealthcare Medicare	$55.32
Rate for Payer: University Health Alliance Commercial	$134.12

HC IV INFUSION, HYDRATION, EA ADD HOUR

Facility

$184.00

Service Code	HCPCS 96361
Hospital Charge Code	4509636101
Hospital Revenue Code	450
Min. Negotiated Rate	$156.40
Max. Negotiated Rate	$178.48
Rate for Payer: Cash Price	$110.40
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: MDX Hawaii PPO	$178.48

HC IV INFUSION, THERAP/PROPH/DIAGNOST,ADD INFUSION,1ST HOUR

Facility

$368.00

Service Code	HCPCS 96367
Hospital Charge Code	9409636701
Hospital Revenue Code	940
Min. Negotiated Rate	$23.03
Max. Negotiated Rate	$356.96
Rate for Payer: AlohaCare Medicaid	$85.06
Rate for Payer: AlohaCare Medicare	$85.06
Rate for Payer: Cash Price	$220.80
Rate for Payer: Cash Price	$220.80
Rate for Payer: Devoted Health Medicare	$93.57
Rate for Payer: Hawaii Medical Service Association Commercial	$106.33
Rate for Payer: Hawaii Medical Service Association Medicare	$85.06
Rate for Payer: Hawaii Western Management Group Commercial	$349.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Humana Medicare	$85.06
Rate for Payer: Kaiser Permanente Commercial	$231.84
Rate for Payer: Kaiser Permanente Medicaid	$187.68
Rate for Payer: Kaiser Permanente Medicare	$85.06
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: Ohana Health Plan Medicaid	$93.57
Rate for Payer: Ohana Health Plan Medicare	$85.06
Rate for Payer: UnitedHealthcare Medicaid	$23.03
Rate for Payer: UnitedHealthcare Medicare	$85.06
Rate for Payer: University Health Alliance Commercial	$268.24

HC IV INFUSION, THERAP/PROPH/DIAGNOST,ADD INFUSION,1ST HOUR

Facility

$368.00

Service Code	HCPCS 96367
Hospital Charge Code	9409636701
Hospital Revenue Code	940
Min. Negotiated Rate	$312.80
Max. Negotiated Rate	$356.96
Rate for Payer: Cash Price	$220.80
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: MDX Hawaii PPO	$356.96

HC IV INFUSION, THERAP/PROPH/DIAGNOST,ADD INFUSION,1ST HOUR

Facility

$283.00

Service Code	HCPCS 96367
Hospital Charge Code	4509636701
Hospital Revenue Code	450
Min. Negotiated Rate	$85.06
Max. Negotiated Rate	$1,600.00
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: 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	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$85.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
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	$937.50
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 Medicare	$85.06
Rate for Payer: University Health Alliance Commercial	$206.28

HC IV INFUSION, THERAP/PROPH/DIAGNOST,ADD INFUSION,1ST HOUR

Facility

$283.00

Service Code	HCPCS 96367
Hospital Charge Code	4509636701
Hospital Revenue Code	450
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 IV INFUSION, THERAP/PROPH/DIAGNOST,CONCURRENT INFUSION

Facility

$209.00

Service Code	HCPCS 96368
Hospital Charge Code	9409636801
Hospital Revenue Code	940
Min. Negotiated Rate	$177.65
Max. Negotiated Rate	$202.73
Rate for Payer: Cash Price	$125.40
Rate for Payer: Health Management Network Commercial	$177.65
Rate for Payer: MDX Hawaii PPO	$202.73

HC IV INFUSION, THERAP/PROPH/DIAGNOST,CONCURRENT INFUSION

Facility

$209.00

Service Code	HCPCS 96368
Hospital Charge Code	9409636801
Hospital Revenue Code	940
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$202.73
Rate for Payer: Cash Price	$125.40
Rate for Payer: Cash Price	$125.40
Rate for Payer: Hawaii Western Management Group Commercial	$198.55
Rate for Payer: Health Management Network Commercial	$177.65
Rate for Payer: Kaiser Permanente Commercial	$131.67
Rate for Payer: Kaiser Permanente Medicaid	$106.59
Rate for Payer: MDX Hawaii PPO	$202.73
Rate for Payer: UnitedHealthcare Medicaid	$13.30
Rate for Payer: University Health Alliance Commercial	$152.34

HC IV INFUSION, THERAP/PROPH/DIAGNOST,CONCURRENT INFUSION

Facility

$161.00

Service Code	HCPCS 96368
Hospital Charge Code	4509636801
Hospital Revenue Code	450
Min. Negotiated Rate	$101.43
Max. Negotiated Rate	$1,600.00
Rate for Payer: Cash Price	$96.60
Rate for Payer: Cash Price	$96.60
Rate for Payer: Cash Price	$96.60
Rate for Payer: Hawaii Medical Service Association ABD	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$152.95
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: Kaiser Permanente Commercial	$101.43
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: MDX Hawaii PPO	$156.17
Rate for Payer: University Health Alliance Commercial	$117.35

HC IV INFUSION, THERAP/PROPH/DIAGNOST,CONCURRENT INFUSION

Facility

$161.00

Service Code	HCPCS 96368
Hospital Charge Code	4509636801
Hospital Revenue Code	450
Min. Negotiated Rate	$136.85
Max. Negotiated Rate	$156.17
Rate for Payer: Cash Price	$96.60
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: MDX Hawaii PPO	$156.17

HC IV INFUSION, THERAP/PROPH/DIAGNOST,INITIAL,1ST HOUR

Facility

$838.00

Service Code	HCPCS 96365
Hospital Charge Code	4509636501
Hospital Revenue Code	450
Min. Negotiated Rate	$251.28
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$251.28
Rate for Payer: AlohaCare Medicare	$251.28
Rate for Payer: Cash Price	$502.80
Rate for Payer: Cash Price	$502.80
Rate for Payer: Cash Price	$502.80
Rate for Payer: Cash Price	$502.80
Rate for Payer: Devoted Health Medicare	$276.41
Rate for Payer: Hawaii Medical Service Association ABD	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$251.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$796.10
Rate for Payer: Health Management Network Commercial	$712.30
Rate for Payer: Humana Medicare	$251.28
Rate for Payer: Kaiser Permanente Commercial	$527.94
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$251.28
Rate for Payer: MDX Hawaii PPO	$812.86
Rate for Payer: Ohana Health Plan Medicaid	$276.41
Rate for Payer: Ohana Health Plan Medicare	$251.28
Rate for Payer: UnitedHealthcare Medicare	$251.28
Rate for Payer: University Health Alliance Commercial	$610.82

HC IV INFUSION, THERAP/PROPH/DIAGNOST,INITIAL,1ST HOUR

Facility

$1,089.00

Service Code	HCPCS 96365
Hospital Charge Code	9409636501
Hospital Revenue Code	940
Min. Negotiated Rate	$46.51
Max. Negotiated Rate	$1,056.33
Rate for Payer: AlohaCare Medicaid	$251.28
Rate for Payer: AlohaCare Medicare	$251.28
Rate for Payer: Cash Price	$653.40
Rate for Payer: Cash Price	$653.40
Rate for Payer: Devoted Health Medicare	$276.41
Rate for Payer: Hawaii Medical Service Association Commercial	$314.10
Rate for Payer: Hawaii Medical Service Association Medicare	$251.28
Rate for Payer: Hawaii Western Management Group Commercial	$1,034.55
Rate for Payer: Health Management Network Commercial	$925.65
Rate for Payer: Humana Medicare	$251.28
Rate for Payer: Kaiser Permanente Commercial	$686.07
Rate for Payer: Kaiser Permanente Medicaid	$555.39
Rate for Payer: Kaiser Permanente Medicare	$251.28
Rate for Payer: MDX Hawaii PPO	$1,056.33
Rate for Payer: Ohana Health Plan Medicaid	$276.41
Rate for Payer: Ohana Health Plan Medicare	$251.28
Rate for Payer: UnitedHealthcare Medicaid	$46.51
Rate for Payer: UnitedHealthcare Medicare	$251.28
Rate for Payer: University Health Alliance Commercial	$793.77

HC IV INFUSION, THERAP/PROPH/DIAGNOST,INITIAL,1ST HOUR

Facility

$1,089.00

Service Code	HCPCS 96365
Hospital Charge Code	9409636501
Hospital Revenue Code	940
Min. Negotiated Rate	$925.65
Max. Negotiated Rate	$1,056.33
Rate for Payer: Cash Price	$653.40
Rate for Payer: Health Management Network Commercial	$925.65
Rate for Payer: MDX Hawaii PPO	$1,056.33

HC IV INFUSION, THERAP/PROPH/DIAGNOST,INITIAL,1ST HOUR

Facility

$838.00

Service Code	HCPCS 96365
Hospital Charge Code	4509636501
Hospital Revenue Code	450
Min. Negotiated Rate	$712.30
Max. Negotiated Rate	$812.86
Rate for Payer: Cash Price	$502.80
Rate for Payer: Health Management Network Commercial	$712.30
Rate for Payer: MDX Hawaii PPO	$812.86

HC IV INFUSION, THERAP/PROPH/DIAGNOST,INITIAL,EA ADD HOUR

Facility

$239.00

Service Code	HCPCS 96366
Hospital Charge Code	9409636601
Hospital Revenue Code	940
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$231.83
Rate for Payer: AlohaCare Medicaid	$55.32
Rate for Payer: AlohaCare Medicare	$55.32
Rate for Payer: Cash Price	$143.40
Rate for Payer: Cash Price	$143.40
Rate for Payer: Devoted Health Medicare	$60.85
Rate for Payer: Hawaii Medical Service Association Commercial	$69.15
Rate for Payer: Hawaii Medical Service Association Medicare	$55.32
Rate for Payer: Hawaii Western Management Group Commercial	$227.05
Rate for Payer: Health Management Network Commercial	$203.15
Rate for Payer: Humana Medicare	$55.32
Rate for Payer: Kaiser Permanente Commercial	$150.57
Rate for Payer: Kaiser Permanente Medicaid	$121.89
Rate for Payer: Kaiser Permanente Medicare	$55.32
Rate for Payer: MDX Hawaii PPO	$231.83
Rate for Payer: Ohana Health Plan Medicaid	$60.85
Rate for Payer: Ohana Health Plan Medicare	$55.32
Rate for Payer: UnitedHealthcare Medicaid	$14.27
Rate for Payer: UnitedHealthcare Medicare	$55.32
Rate for Payer: University Health Alliance Commercial	$174.21

HC IV INFUSION, THERAP/PROPH/DIAGNOST,INITIAL,EA ADD HOUR

Facility

$239.00

Service Code	HCPCS 96366
Hospital Charge Code	9409636601
Hospital Revenue Code	940
Min. Negotiated Rate	$203.15
Max. Negotiated Rate	$231.83
Rate for Payer: Cash Price	$143.40
Rate for Payer: Health Management Network Commercial	$203.15
Rate for Payer: MDX Hawaii PPO	$231.83

HC IV INFUSION, THERAP/PROPH/DIAGNOST,INITIAL,EA ADD HOUR

Facility

$184.00

Service Code	HCPCS 96366
Hospital Charge Code	4509636601
Hospital Revenue Code	450
Min. Negotiated Rate	$55.32
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$55.32
Rate for Payer: AlohaCare Medicare	$55.32
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cash Price	$110.40
Rate for Payer: Devoted Health Medicare	$60.85
Rate for Payer: Hawaii Medical Service Association ABD	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$55.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$174.80
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Humana Medicare	$55.32
Rate for Payer: Kaiser Permanente Commercial	$115.92
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$55.32
Rate for Payer: MDX Hawaii PPO	$178.48
Rate for Payer: Ohana Health Plan Medicaid	$60.85
Rate for Payer: Ohana Health Plan Medicare	$55.32
Rate for Payer: UnitedHealthcare Medicare	$55.32
Rate for Payer: University Health Alliance Commercial	$134.12

HC IV INFUSION, THERAP/PROPH/DIAGNOST,INITIAL,EA ADD HOUR

Facility

$184.00

Service Code	HCPCS 96366
Hospital Charge Code	4509636601
Hospital Revenue Code	450
Min. Negotiated Rate	$156.40
Max. Negotiated Rate	$178.48
Rate for Payer: Cash Price	$110.40
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: MDX Hawaii PPO	$178.48

HC JAK2 EXON 12 ANALYSIS SO

Facility

$1,554.00

Service Code	HCPCS 81279
Hospital Charge Code	3108127901
Hospital Revenue Code	310
Min. Negotiated Rate	$111.12
Max. Negotiated Rate	$1,507.38
Rate for Payer: AlohaCare Medicaid	$185.20
Rate for Payer: AlohaCare Medicare	$185.20
Rate for Payer: Cash Price	$932.40
Rate for Payer: Cash Price	$932.40
Rate for Payer: Devoted Health Medicare	$203.72
Rate for Payer: Hawaii Medical Service Association ABD	$185.20
Rate for Payer: Hawaii Medical Service Association Commercial	$231.50
Rate for Payer: Hawaii Medical Service Association Medicare	$185.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$185.20
Rate for Payer: Hawaii Western Management Group Commercial	$185.20
Rate for Payer: Health Management Network Commercial	$1,320.90
Rate for Payer: Humana Medicare	$185.20
Rate for Payer: Kaiser Permanente Commercial	$979.02
Rate for Payer: Kaiser Permanente Medicaid	$792.54
Rate for Payer: Kaiser Permanente Medicare	$185.20
Rate for Payer: MDX Hawaii PPO	$1,507.38
Rate for Payer: Ohana Health Plan Medicaid	$203.72
Rate for Payer: Ohana Health Plan Medicare	$185.20
Rate for Payer: UnitedHealthcare Medicaid	$111.12
Rate for Payer: UnitedHealthcare Medicare	$185.20
Rate for Payer: University Health Alliance Commercial	$1,132.71

HC JAK2 EXON 12 ANALYSIS SO

Facility

$1,554.00

Service Code	HCPCS 81279
Hospital Charge Code	3108127901
Hospital Revenue Code	310
Min. Negotiated Rate	$1,320.90
Max. Negotiated Rate	$1,507.38
Rate for Payer: Cash Price	$932.40
Rate for Payer: Health Management Network Commercial	$1,320.90
Rate for Payer: MDX Hawaii PPO	$1,507.38

HC JAK2 V617F MUT QUAL SO

Facility

$769.00

Service Code	HCPCS 81270
Hospital Charge Code	3108127001
Hospital Revenue Code	310
Min. Negotiated Rate	$49.73
Max. Negotiated Rate	$745.93
Rate for Payer: AlohaCare Medicaid	$91.66
Rate for Payer: AlohaCare Medicare	$91.66
Rate for Payer: Cash Price	$461.40
Rate for Payer: Cash Price	$461.40
Rate for Payer: Devoted Health Medicare	$100.83
Rate for Payer: Hawaii Medical Service Association ABD	$122.70
Rate for Payer: Hawaii Medical Service Association Commercial	$114.58
Rate for Payer: Hawaii Medical Service Association Medicare	$91.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$122.70
Rate for Payer: Hawaii Western Management Group Commercial	$91.66
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Humana Medicare	$91.66
Rate for Payer: Kaiser Permanente Commercial	$484.47
Rate for Payer: Kaiser Permanente Medicaid	$392.19
Rate for Payer: Kaiser Permanente Medicare	$91.66
Rate for Payer: MDX Hawaii PPO	$745.93
Rate for Payer: Ohana Health Plan Medicaid	$100.83
Rate for Payer: Ohana Health Plan Medicare	$91.66
Rate for Payer: UnitedHealthcare Medicaid	$49.73
Rate for Payer: UnitedHealthcare Medicare	$91.66
Rate for Payer: University Health Alliance Commercial	$230.79

HC JAK2 V617F MUT QUAL SO

Facility

$769.00

Service Code	HCPCS 81270
Hospital Charge Code	3108127001
Hospital Revenue Code	310
Min. Negotiated Rate	$653.65
Max. Negotiated Rate	$745.93
Rate for Payer: Cash Price	$461.40
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: MDX Hawaii PPO	$745.93

HC JAK2 V617F RF EXON 12 SO

Facility

$769.00

Service Code	HCPCS 81270
Hospital Charge Code	3108127002
Hospital Revenue Code	310
Min. Negotiated Rate	$49.73
Max. Negotiated Rate	$745.93
Rate for Payer: AlohaCare Medicaid	$91.66
Rate for Payer: AlohaCare Medicare	$91.66
Rate for Payer: Cash Price	$461.40
Rate for Payer: Cash Price	$461.40
Rate for Payer: Devoted Health Medicare	$100.83
Rate for Payer: Hawaii Medical Service Association ABD	$122.70
Rate for Payer: Hawaii Medical Service Association Commercial	$114.58
Rate for Payer: Hawaii Medical Service Association Medicare	$91.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$122.70
Rate for Payer: Hawaii Western Management Group Commercial	$91.66
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Humana Medicare	$91.66
Rate for Payer: Kaiser Permanente Commercial	$484.47
Rate for Payer: Kaiser Permanente Medicaid	$392.19
Rate for Payer: Kaiser Permanente Medicare	$91.66
Rate for Payer: MDX Hawaii PPO	$745.93
Rate for Payer: Ohana Health Plan Medicaid	$100.83
Rate for Payer: Ohana Health Plan Medicare	$91.66
Rate for Payer: UnitedHealthcare Medicaid	$49.73
Rate for Payer: UnitedHealthcare Medicare	$91.66
Rate for Payer: University Health Alliance Commercial	$230.79

HC JAK2 V617F RF EXON 12 SO

Facility

$769.00

Service Code	HCPCS 81270
Hospital Charge Code	3108127002
Hospital Revenue Code	310
Min. Negotiated Rate	$653.65
Max. Negotiated Rate	$745.93
Rate for Payer: Cash Price	$461.40
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: MDX Hawaii PPO	$745.93

HC JOINT SURVEY, SINGLE VIEW - XR JOINT ANTEROPOSTERIOR 2+ JOINTS

Facility

$529.00

Service Code	HCPCS 77077
Hospital Charge Code	3207707701
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

Know your out-of-pocket cost for care.

All Charges