Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [39918]

Facility

$20.00

Service Code	HCPCS J3260
Hospital Revenue Code	250
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cash Price	$55.80
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: MDX Hawaii PPO	$90.21
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: MDX Hawaii PPO	$89.24

TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]

Facility

$626.00

Service Code	NDC 00078087601
Hospital Revenue Code	637
Min. Negotiated Rate	$319.26
Max. Negotiated Rate	$607.22
Rate for Payer: Cash Price	$375.60
Rate for Payer: Hawaii Western Management Group Commercial	$594.70
Rate for Payer: Health Management Network Commercial	$532.10
Rate for Payer: Kaiser Permanente Commercial	$394.38
Rate for Payer: Kaiser Permanente Medicaid	$319.26
Rate for Payer: MDX Hawaii PPO	$607.22
Rate for Payer: University Health Alliance Commercial	$456.29

TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]

Facility

$626.00

Service Code	NDC 00078087601
Hospital Revenue Code	250
Min. Negotiated Rate	$532.10
Max. Negotiated Rate	$607.22
Rate for Payer: Cash Price	$375.60
Rate for Payer: Health Management Network Commercial	$532.10
Rate for Payer: MDX Hawaii PPO	$607.22

TOLNAFTATE 1 % TOPICAL POWDER [8021]

Facility

$9.00

Service Code	NDC 00536132926
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]

Facility

$33.00

Service Code	NDC 27241019230
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: MDX Hawaii PPO	$32.01

TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]

Facility

$33.00

Service Code	NDC 27241019230
Hospital Revenue Code	637
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$20.79
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: University Health Alliance Commercial	$24.05

TOLVAPTAN 15 MG TABLET [97893]

Facility

$843.00

Service Code	NDC 49884076852
Hospital Revenue Code	637
Min. Negotiated Rate	$429.93
Max. Negotiated Rate	$817.71
Rate for Payer: Cash Price	$505.80
Rate for Payer: Hawaii Western Management Group Commercial	$800.85
Rate for Payer: Health Management Network Commercial	$716.55
Rate for Payer: Kaiser Permanente Commercial	$531.09
Rate for Payer: Kaiser Permanente Medicaid	$429.93
Rate for Payer: MDX Hawaii PPO	$817.71
Rate for Payer: University Health Alliance Commercial	$614.46

TOLVAPTAN 15 MG TABLET [97893]

Facility

$843.00

Service Code	NDC 49884076852
Hospital Revenue Code	250
Min. Negotiated Rate	$716.55
Max. Negotiated Rate	$817.71
Rate for Payer: Cash Price	$505.80
Rate for Payer: Health Management Network Commercial	$716.55
Rate for Payer: MDX Hawaii PPO	$817.71

TOLVAPTAN 15 MG TABLET [97893]

Facility

$843.00

Service Code	NDC 31722086803
Hospital Revenue Code	250
Min. Negotiated Rate	$716.55
Max. Negotiated Rate	$817.71
Rate for Payer: Cash Price	$505.80
Rate for Payer: Health Management Network Commercial	$716.55
Rate for Payer: MDX Hawaii PPO	$817.71

TOLVAPTAN 15 MG TABLET [97893]

Facility

$843.00

Service Code	NDC 31722086803
Hospital Revenue Code	637
Min. Negotiated Rate	$429.93
Max. Negotiated Rate	$817.71
Rate for Payer: Cash Price	$505.80
Rate for Payer: Hawaii Western Management Group Commercial	$800.85
Rate for Payer: Health Management Network Commercial	$716.55
Rate for Payer: Kaiser Permanente Commercial	$531.09
Rate for Payer: Kaiser Permanente Medicaid	$429.93
Rate for Payer: MDX Hawaii PPO	$817.71
Rate for Payer: University Health Alliance Commercial	$614.46

TONSIL & ADENOID PROCEDURES

Facility

$2,872.63

Service Code	APR-DRG 0971
Min. Negotiated Rate	$2,872.63
Max. Negotiated Rate	$2,872.63
Rate for Payer: AlohaCare Medicaid	$2,872.63
Rate for Payer: Hawaii Medical Service Association ABD	$2,872.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,872.63
Rate for Payer: Kaiser Permanente Medicaid	$2,872.63
Rate for Payer: Ohana Health Plan Medicaid	$2,872.63
Rate for Payer: UnitedHealthcare Medicaid	$2,872.63

TONSIL & ADENOID PROCEDURES

Facility

$4,008.24

Service Code	APR-DRG 0972
Min. Negotiated Rate	$4,008.24
Max. Negotiated Rate	$4,008.24
Rate for Payer: AlohaCare Medicaid	$4,008.24
Rate for Payer: Hawaii Medical Service Association ABD	$4,008.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,008.24
Rate for Payer: Kaiser Permanente Medicaid	$4,008.24
Rate for Payer: Ohana Health Plan Medicaid	$4,008.24
Rate for Payer: UnitedHealthcare Medicaid	$4,008.24

TONSIL & ADENOID PROCEDURES

Facility

$6,434.06

Service Code	APR-DRG 0973
Min. Negotiated Rate	$6,434.06
Max. Negotiated Rate	$6,434.06
Rate for Payer: AlohaCare Medicaid	$6,434.06
Rate for Payer: Hawaii Medical Service Association ABD	$6,434.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,434.06
Rate for Payer: Kaiser Permanente Medicaid	$6,434.06
Rate for Payer: Ohana Health Plan Medicaid	$6,434.06
Rate for Payer: UnitedHealthcare Medicaid	$6,434.06

TONSIL & ADENOID PROCEDURES

Facility

$15,032.38

Service Code	APR-DRG 0974
Min. Negotiated Rate	$15,032.38
Max. Negotiated Rate	$15,032.38
Rate for Payer: AlohaCare Medicaid	$15,032.38
Rate for Payer: Hawaii Medical Service Association ABD	$15,032.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15,032.38
Rate for Payer: Kaiser Permanente Medicaid	$15,032.38
Rate for Payer: Ohana Health Plan Medicaid	$15,032.38
Rate for Payer: UnitedHealthcare Medicaid	$15,032.38

TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER

Facility

$11,157.19

Service Code	CPT 42821
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$11,157.19
Rate for Payer: AlohaCare Medicaid	$3,916.70
Rate for Payer: AlohaCare Medicare	$3,916.70
Rate for Payer: Devoted Health Medicare	$4,308.37
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,916.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,916.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,916.70
Rate for Payer: Ohana Health Plan Medicaid	$4,308.37
Rate for Payer: Ohana Health Plan Medicare	$3,916.70
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,916.70
Rate for Payer: University Health Alliance Commercial	$11,157.19

TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12

Facility

$7,692.70

Service Code	CPT 42820
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,692.70
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Devoted Health Medicare	$7,692.70
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$6,993.36
Rate for Payer: University Health Alliance Commercial	$6,743.44

TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER

Facility

$10,679.55

Service Code	CPT 42826
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$3,916.70
Rate for Payer: AlohaCare Medicare	$3,916.70
Rate for Payer: Devoted Health Medicare	$4,308.37
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,916.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,916.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,916.70
Rate for Payer: Ohana Health Plan Medicaid	$4,308.37
Rate for Payer: Ohana Health Plan Medicare	$3,916.70
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,916.70
Rate for Payer: University Health Alliance Commercial	$10,679.55

TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12

Facility

$10,679.55

Service Code	CPT 42825
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$6,993.36
Rate for Payer: AlohaCare Medicare	$6,993.36
Rate for Payer: Devoted Health Medicare	$7,692.70
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,993.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$6,993.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,993.36
Rate for Payer: Ohana Health Plan Medicaid	$7,692.70
Rate for Payer: Ohana Health Plan Medicare	$6,993.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$6,993.36
Rate for Payer: University Health Alliance Commercial	$10,679.55

TOPIRAMATE 100 MG TABLET [18922]

Facility

$19.00

Service Code	NDC 68084034411
Hospital Revenue Code	250
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

TOPIRAMATE 100 MG TABLET [18922]

Facility

$19.00

Service Code	NDC 68084034411
Hospital Revenue Code	637
Min. Negotiated Rate	$9.69
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
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: University Health Alliance Commercial	$13.85

TOPIRAMATE 100 MG TABLET [18922]

Facility

$19.00

Service Code	NDC 68084034401
Hospital Revenue Code	637
Min. Negotiated Rate	$9.69
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
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: University Health Alliance Commercial	$13.85

TOPIRAMATE 100 MG TABLET [18922]

Facility

$19.00

Service Code	NDC 68084034401
Hospital Revenue Code	250
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

TOPIRAMATE 25 MG TABLET [18920]

Facility

$8.00

Service Code	NDC 68084034211
Hospital Revenue Code	637
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: University Health Alliance Commercial	$5.83

TOPIRAMATE 25 MG TABLET [18920]

Facility

$9.00

Service Code	NDC 68382013814
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: University Health Alliance Commercial	$6.56

TOPIRAMATE 25 MG TABLET [18920]

Facility

$9.00

Service Code	NDC 68382013814
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

Know your out-of-pocket cost for care.

All Charges