Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [170336]

Facility

$15,308.00

Service Code	HCPCS J0896
Hospital Revenue Code	636
Min. Negotiated Rate	$41.96
Max. Negotiated Rate	$14,848.76
Rate for Payer: AlohaCare Medicaid	$42.75
Rate for Payer: AlohaCare Medicare	$42.75
Rate for Payer: Cash Price	$9,184.80
Rate for Payer: Cash Price	$9,184.80
Rate for Payer: Devoted Health Medicare	$47.02
Rate for Payer: Hawaii Medical Service Association ABD	$41.96
Rate for Payer: Hawaii Medical Service Association Commercial	$53.44
Rate for Payer: Hawaii Medical Service Association Medicare	$42.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$41.96
Rate for Payer: Hawaii Western Management Group Commercial	$14,542.60
Rate for Payer: Health Management Network Commercial	$13,011.80
Rate for Payer: Humana Medicare	$42.75
Rate for Payer: Kaiser Permanente Commercial	$9,644.04
Rate for Payer: Kaiser Permanente Medicaid	$7,807.08
Rate for Payer: Kaiser Permanente Medicare	$42.75
Rate for Payer: MDX Hawaii PPO	$14,848.76
Rate for Payer: Ohana Health Plan Medicaid	$47.02
Rate for Payer: Ohana Health Plan Medicare	$42.75
Rate for Payer: UnitedHealthcare Medicaid	$9,184.80
Rate for Payer: UnitedHealthcare Medicare	$42.75
Rate for Payer: University Health Alliance Commercial	$11,158.00

LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [170336]

Facility

$15,308.00

Service Code	HCPCS J0896
Hospital Revenue Code	250
Min. Negotiated Rate	$13,011.80
Max. Negotiated Rate	$14,848.76
Rate for Payer: Cash Price	$9,184.80
Rate for Payer: Health Management Network Commercial	$13,011.80
Rate for Payer: MDX Hawaii PPO	$14,848.76

LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [151258]

Facility

$310.00

Service Code	NDC 69488000301
Hospital Revenue Code	343
Min. Negotiated Rate	$158.10
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$186.00
Rate for Payer: Hawaii Western Management Group Commercial	$294.50
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Kaiser Permanente Commercial	$195.30
Rate for Payer: Kaiser Permanente Medicaid	$158.10
Rate for Payer: MDX Hawaii PPO	$300.70
Rate for Payer: University Health Alliance Commercial	$225.96

LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [151258]

Facility

$310.00

Service Code	NDC 69488000301
Hospital Revenue Code	343
Min. Negotiated Rate	$263.50
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$186.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: MDX Hawaii PPO	$300.70

LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [184179]

Facility

$445.00

Service Code	NDC 69488001061
Hospital Revenue Code	343
Min. Negotiated Rate	$226.95
Max. Negotiated Rate	$431.65
Rate for Payer: Cash Price	$267.00
Rate for Payer: Hawaii Western Management Group Commercial	$422.75
Rate for Payer: Health Management Network Commercial	$378.25
Rate for Payer: Kaiser Permanente Commercial	$280.35
Rate for Payer: Kaiser Permanente Medicaid	$226.95
Rate for Payer: MDX Hawaii PPO	$431.65
Rate for Payer: University Health Alliance Commercial	$324.36

LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [184179]

Facility

$445.00

Service Code	NDC 69488001061
Hospital Revenue Code	343
Min. Negotiated Rate	$378.25
Max. Negotiated Rate	$431.65
Rate for Payer: Cash Price	$267.00
Rate for Payer: Health Management Network Commercial	$378.25
Rate for Payer: MDX Hawaii PPO	$431.65

LUTONIX 018 DCB 5X300

Facility

$4,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,499.00
Max. Negotiated Rate	$4,753.00
Rate for Payer: Cash Price	$2,940.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,655.00
Rate for Payer: Health Management Network Commercial	$4,165.00
Rate for Payer: Kaiser Permanente Commercial	$3,087.00
Rate for Payer: Kaiser Permanente Medicaid	$2,499.00
Rate for Payer: MDX Hawaii PPO	$4,753.00
Rate for Payer: University Health Alliance Commercial	$3,571.61

LUTONIX 018 DCB 5X300

Facility

$4,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$4,165.00
Max. Negotiated Rate	$4,753.00
Rate for Payer: Cash Price	$2,940.00
Rate for Payer: Health Management Network Commercial	$4,165.00
Rate for Payer: MDX Hawaii PPO	$4,753.00

LUTONIX 018 DCB 6X300

Facility

$4,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$4,165.00
Max. Negotiated Rate	$4,753.00
Rate for Payer: Cash Price	$2,940.00
Rate for Payer: Health Management Network Commercial	$4,165.00
Rate for Payer: MDX Hawaii PPO	$4,753.00

LUTONIX 018 DCB 6X300

Facility

$4,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,499.00
Max. Negotiated Rate	$4,753.00
Rate for Payer: Cash Price	$2,940.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,655.00
Rate for Payer: Health Management Network Commercial	$4,165.00
Rate for Payer: Kaiser Permanente Commercial	$3,087.00
Rate for Payer: Kaiser Permanente Medicaid	$2,499.00
Rate for Payer: MDX Hawaii PPO	$4,753.00
Rate for Payer: University Health Alliance Commercial	$3,571.61

LUTONIX 035 DCB 6X80

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,989.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,705.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Kaiser Permanente Commercial	$2,457.00
Rate for Payer: Kaiser Permanente Medicaid	$1,989.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: University Health Alliance Commercial	$2,842.71

LUTONIX 035 DCB 6X80

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,315.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: MDX Hawaii PPO	$3,783.00

LUTONIX 035 DCB 7X80

Facility

$3,300.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,805.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: MDX Hawaii PPO	$3,201.00

LUTONIX 035 DCB 7X80

Facility

$3,300.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,683.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,135.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Kaiser Permanente Commercial	$2,079.00
Rate for Payer: Kaiser Permanente Medicaid	$1,683.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$2,405.37

LUTONIX 035 DCB OTW 10X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,989.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,705.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Kaiser Permanente Commercial	$2,457.00
Rate for Payer: Kaiser Permanente Medicaid	$1,989.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: University Health Alliance Commercial	$2,842.71

LUTONIX 035 DCB OTW 10X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,315.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: MDX Hawaii PPO	$3,783.00

LUTONIX 035 DCB OTW 12X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,989.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,705.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Kaiser Permanente Commercial	$2,457.00
Rate for Payer: Kaiser Permanente Medicaid	$1,989.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: University Health Alliance Commercial	$2,842.71

LUTONIX 035 DCB OTW 12X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,315.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: MDX Hawaii PPO	$3,783.00

LUTONIX 035 DCB OTW 7X40

Facility

$3,300.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,683.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,135.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Kaiser Permanente Commercial	$2,079.00
Rate for Payer: Kaiser Permanente Medicaid	$1,683.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$2,405.37

LUTONIX 035 DCB OTW 7X40

Facility

$3,300.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,805.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: MDX Hawaii PPO	$3,201.00

LUTONIX 035 DCB OTW 8X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,315.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: MDX Hawaii PPO	$3,783.00

LUTONIX 035 DCB OTW 8X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,989.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,705.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Kaiser Permanente Commercial	$2,457.00
Rate for Payer: Kaiser Permanente Medicaid	$1,989.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: University Health Alliance Commercial	$2,842.71

LUTONIX 035 DCB OTW 9X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,315.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: MDX Hawaii PPO	$3,783.00

LUTONIX 035 DCB OTW 9X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,989.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,705.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Kaiser Permanente Commercial	$2,457.00
Rate for Payer: Kaiser Permanente Medicaid	$1,989.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: University Health Alliance Commercial	$2,842.71

LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$3,297.26

Service Code	APR-DRG 6941
Min. Negotiated Rate	$3,297.26
Max. Negotiated Rate	$3,297.26
Rate for Payer: AlohaCare Medicaid	$3,297.26
Rate for Payer: Hawaii Medical Service Association ABD	$3,297.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,297.26
Rate for Payer: Kaiser Permanente Medicaid	$3,297.26
Rate for Payer: Ohana Health Plan Medicaid	$3,297.26
Rate for Payer: UnitedHealthcare Medicaid	$3,297.26

Know your out-of-pocket cost for care.

All Charges