Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

VIRAL MENINGITIS

Facility

$2,316.24

Service Code	APR-DRG 0511
Min. Negotiated Rate	$2,316.24
Max. Negotiated Rate	$2,316.24
Rate for Payer: AlohaCare Medicaid	$2,316.24
Rate for Payer: Hawaii Medical Service Association ABD	$2,316.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,316.24
Rate for Payer: Kaiser Permanente Medicaid	$2,316.24
Rate for Payer: Ohana Health Plan Medicaid	$2,316.24
Rate for Payer: UnitedHealthcare Medicaid	$2,316.24

VIRAL MENINGITIS

Facility

$13,050.11

Service Code	APR-DRG 0514
Min. Negotiated Rate	$13,050.11
Max. Negotiated Rate	$13,050.11
Rate for Payer: AlohaCare Medicaid	$13,050.11
Rate for Payer: Hawaii Medical Service Association ABD	$13,050.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,050.11
Rate for Payer: Kaiser Permanente Medicaid	$13,050.11
Rate for Payer: Ohana Health Plan Medicaid	$13,050.11
Rate for Payer: UnitedHealthcare Medicaid	$13,050.11

VIRAL MENINGITIS WITH CC/MCC

Facility

$33,076.88

Service Code	MSDRG 075
Min. Negotiated Rate	$14,438.27
Max. Negotiated Rate	$33,076.88
Rate for Payer: AlohaCare Medicare	$21,810.14
Rate for Payer: Devoted Health Medicare	$23,991.15
Rate for Payer: Hawaii Medical Service Association Commercial	$14,438.27
Rate for Payer: Hawaii Medical Service Association Medicare	$21,810.14
Rate for Payer: Humana Medicare	$21,810.14
Rate for Payer: Kaiser Permanente Commercial	$33,076.88
Rate for Payer: Kaiser Permanente Medicare	$21,810.14
Rate for Payer: Ohana Health Plan Medicare	$21,810.14
Rate for Payer: UnitedHealthcare Medicare	$21,810.14

VIRAL MENINGITIS WITHOUT CC/MCC

Facility

$14,438.27

Service Code	MSDRG 076
Min. Negotiated Rate	$9,386.04
Max. Negotiated Rate	$14,438.27
Rate for Payer: AlohaCare Medicare	$9,386.04
Rate for Payer: Devoted Health Medicare	$10,324.64
Rate for Payer: Hawaii Medical Service Association Commercial	$14,438.27
Rate for Payer: Hawaii Medical Service Association Medicare	$9,386.04
Rate for Payer: Humana Medicare	$9,386.04
Rate for Payer: Kaiser Permanente Commercial	$12,916.80
Rate for Payer: Kaiser Permanente Medicare	$9,386.04
Rate for Payer: Ohana Health Plan Medicare	$9,386.04
Rate for Payer: UnitedHealthcare Medicare	$9,386.04

VISIONIST X4

Facility

$11,512.00

Service Code	HCPCS C2621
Hospital Revenue Code	275
Min. Negotiated Rate	$5,871.12
Max. Negotiated Rate	$11,166.64
Rate for Payer: Cash Price	$6,907.20
Rate for Payer: Hawaii Western Management Group Commercial	$8,058.40
Rate for Payer: Health Management Network Commercial	$9,785.20
Rate for Payer: Kaiser Permanente Commercial	$7,252.56
Rate for Payer: Kaiser Permanente Medicaid	$5,871.12
Rate for Payer: MDX Hawaii PPO	$11,166.64
Rate for Payer: University Health Alliance Commercial	$6,446.72

VISIONIST X4

Facility

$11,512.00

Service Code	HCPCS C2621
Hospital Revenue Code	275
Min. Negotiated Rate	$6,446.72
Max. Negotiated Rate	$11,166.64
Rate for Payer: Cash Price	$6,907.20
Rate for Payer: Hawaii Western Management Group Commercial	$8,058.40
Rate for Payer: Health Management Network Commercial	$9,785.20
Rate for Payer: MDX Hawaii PPO	$11,166.64
Rate for Payer: University Health Alliance Commercial	$6,446.72

VISTA COLLAR, ADULT 79-83370

Facility

$201.00

Service Code	HCPCS L0172
Hospital Revenue Code	274
Min. Negotiated Rate	$78.38
Max. Negotiated Rate	$194.97
Rate for Payer: Cash Price	$120.60
Rate for Payer: Cash Price	$120.60
Rate for Payer: Hawaii Western Management Group Commercial	$140.70
Rate for Payer: Health Management Network Commercial	$170.85
Rate for Payer: Kaiser Permanente Commercial	$126.63
Rate for Payer: Kaiser Permanente Medicaid	$102.51
Rate for Payer: MDX Hawaii PPO	$194.97
Rate for Payer: UnitedHealthcare Medicaid	$78.38
Rate for Payer: University Health Alliance Commercial	$112.56

VISTA COLLAR, ADULT 79-83370

Facility

$201.00

Service Code	HCPCS L0172
Hospital Revenue Code	274
Min. Negotiated Rate	$112.56
Max. Negotiated Rate	$194.97
Rate for Payer: Cash Price	$120.60
Rate for Payer: Hawaii Western Management Group Commercial	$140.70
Rate for Payer: Health Management Network Commercial	$170.85
Rate for Payer: MDX Hawaii PPO	$194.97
Rate for Payer: University Health Alliance Commercial	$112.56

VITAMIN A PALMITATE 3,000 MCG (10,000 UNIT) CAPSULE [201407]

Facility

$1.00

Service Code	NDC 40725000000
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: MDX Hawaii PPO	$0.97

VITAMIN A PALMITATE 3,000 MCG (10,000 UNIT) CAPSULE [201407]

Facility

$1.00

Service Code	NDC 40725000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: University Health Alliance Commercial	$0.73

VITAMIN B COMPLEX CAPSULE [804]

Facility

$1.00

Service Code	NDC 37801000000
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: MDX Hawaii PPO	$0.97

VITAMIN B COMPLEX CAPSULE [804]

Facility

$1.00

Service Code	NDC 37801000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: University Health Alliance Commercial	$0.73

VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID 0.8 MG TABLET [5495]

Facility

$1.00

Service Code	NDC 16001000000
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: MDX Hawaii PPO	$0.97

VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID 0.8 MG TABLET [5495]

Facility

$1.00

Service Code	NDC 16001000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: University Health Alliance Commercial	$0.73

VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE [180774]

Facility

$1.00

Service Code	NDC 40754000000
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: MDX Hawaii PPO	$0.97

VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE [180774]

Facility

$1.00

Service Code	NDC 40754000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: University Health Alliance Commercial	$0.73

VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE [180774]

Facility

$1.00

Service Code	NDC 95125000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: University Health Alliance Commercial	$0.73

VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE [180774]

Facility

$1.00

Service Code	NDC 95125000000
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: MDX Hawaii PPO	$0.97

VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT [8723]

Facility

$17.00

Service Code	NDC 65197040101
Hospital Revenue Code	637
Min. Negotiated Rate	$8.67
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$10.71
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: University Health Alliance Commercial	$12.39

VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT [8723]

Facility

$16.00

Service Code	NDC 71399012204
Hospital Revenue Code	637
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Hawaii Western Management Group Commercial	$15.20
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Kaiser Permanente Commercial	$10.08
Rate for Payer: Kaiser Permanente Medicaid	$8.16
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: University Health Alliance Commercial	$11.66

VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT [8723]

Facility

$17.00

Service Code	NDC 65197040101
Hospital Revenue Code	250
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: MDX Hawaii PPO	$16.49

VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT [8723]

Facility

$16.00

Service Code	NDC 71399012204
Hospital Revenue Code	250
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: MDX Hawaii PPO	$15.52

VITOSS 2.5CC 2102-2202

Facility

$2,444.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,368.64
Max. Negotiated Rate	$2,370.68
Rate for Payer: Cash Price	$1,466.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,710.80
Rate for Payer: Health Management Network Commercial	$2,077.40
Rate for Payer: MDX Hawaii PPO	$2,370.68
Rate for Payer: University Health Alliance Commercial	$1,368.64

VITOSS 2.5CC 2102-2202

Facility

$2,444.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,246.44
Max. Negotiated Rate	$2,370.68
Rate for Payer: Cash Price	$1,466.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,710.80
Rate for Payer: Health Management Network Commercial	$2,077.40
Rate for Payer: Kaiser Permanente Commercial	$1,539.72
Rate for Payer: Kaiser Permanente Medicaid	$1,246.44
Rate for Payer: MDX Hawaii PPO	$2,370.68
Rate for Payer: University Health Alliance Commercial	$1,368.64

VITOSS BONE GRAFT 2102-2205

Facility

$7,048.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,946.88
Max. Negotiated Rate	$6,836.56
Rate for Payer: Cash Price	$4,228.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,933.60
Rate for Payer: Health Management Network Commercial	$5,990.80
Rate for Payer: MDX Hawaii PPO	$6,836.56
Rate for Payer: University Health Alliance Commercial	$3,946.88

Know your out-of-pocket cost for care.

All Charges