Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC

Facility

$25,940.35

Service Code	MSDRG 282
Min. Negotiated Rate	$8,224.73
Max. Negotiated Rate	$25,940.35
Rate for Payer: AlohaCare Medicare	$8,224.73
Rate for Payer: Devoted Health Medicare	$9,047.20
Rate for Payer: Hawaii Medical Service Association Commercial	$25,940.35
Rate for Payer: Hawaii Medical Service Association Medicare	$8,224.73
Rate for Payer: Humana Medicare	$8,224.73
Rate for Payer: Kaiser Permanente Commercial	$12,473.48
Rate for Payer: Kaiser Permanente Medicare	$8,224.73
Rate for Payer: Ohana Health Plan Medicare	$8,224.73
Rate for Payer: UnitedHealthcare Medicare	$8,224.73

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC

Facility

$57,243.49

Service Code	MSDRG 284
Min. Negotiated Rate	$7,873.24
Max. Negotiated Rate	$57,243.49
Rate for Payer: AlohaCare Medicare	$7,873.24
Rate for Payer: Devoted Health Medicare	$8,660.56
Rate for Payer: Hawaii Medical Service Association Commercial	$57,243.49
Rate for Payer: Hawaii Medical Service Association Medicare	$7,873.24
Rate for Payer: Humana Medicare	$7,873.24
Rate for Payer: Kaiser Permanente Commercial	$11,940.45
Rate for Payer: Kaiser Permanente Medicare	$7,873.24
Rate for Payer: Ohana Health Plan Medicare	$7,873.24
Rate for Payer: UnitedHealthcare Medicare	$7,873.24

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC

Facility

$57,243.49

Service Code	MSDRG 283
Min. Negotiated Rate	$22,530.13
Max. Negotiated Rate	$57,243.49
Rate for Payer: AlohaCare Medicare	$22,530.13
Rate for Payer: Devoted Health Medicare	$24,783.14
Rate for Payer: Hawaii Medical Service Association Commercial	$57,243.49
Rate for Payer: Hawaii Medical Service Association Medicare	$22,530.13
Rate for Payer: Humana Medicare	$22,530.13
Rate for Payer: Kaiser Permanente Commercial	$34,168.80
Rate for Payer: Kaiser Permanente Medicare	$22,530.13
Rate for Payer: Ohana Health Plan Medicare	$22,530.13
Rate for Payer: UnitedHealthcare Medicare	$22,530.13

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC

Facility

$57,243.49

Service Code	MSDRG 285
Min. Negotiated Rate	$6,812.04
Max. Negotiated Rate	$57,243.49
Rate for Payer: AlohaCare Medicare	$6,812.04
Rate for Payer: Devoted Health Medicare	$7,493.24
Rate for Payer: Hawaii Medical Service Association Commercial	$57,243.49
Rate for Payer: Hawaii Medical Service Association Medicare	$6,812.04
Rate for Payer: Humana Medicare	$6,812.04
Rate for Payer: Kaiser Permanente Commercial	$10,331.02
Rate for Payer: Kaiser Permanente Medicare	$6,812.04
Rate for Payer: Ohana Health Plan Medicare	$6,812.04
Rate for Payer: UnitedHealthcare Medicare	$6,812.04

ACUTE & SUBACUTE ENDOCARDITIS

Facility

$4,485.06

Service Code	APR-DRG 1931
Min. Negotiated Rate	$4,485.06
Max. Negotiated Rate	$4,485.06
Rate for Payer: AlohaCare Medicaid	$4,485.06
Rate for Payer: Hawaii Medical Service Association ABD	$4,485.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,485.06
Rate for Payer: Kaiser Permanente Medicaid	$4,485.06
Rate for Payer: Ohana Health Plan Medicaid	$4,485.06
Rate for Payer: UnitedHealthcare Medicaid	$4,485.06

ACUTE & SUBACUTE ENDOCARDITIS

Facility

$5,340.84

Service Code	APR-DRG 1932
Min. Negotiated Rate	$5,340.84
Max. Negotiated Rate	$5,340.84
Rate for Payer: AlohaCare Medicaid	$5,340.84
Rate for Payer: Hawaii Medical Service Association ABD	$5,340.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,340.84
Rate for Payer: Kaiser Permanente Medicaid	$5,340.84
Rate for Payer: Ohana Health Plan Medicaid	$5,340.84
Rate for Payer: UnitedHealthcare Medicaid	$5,340.84

ACUTE & SUBACUTE ENDOCARDITIS

Facility

$11,762.51

Service Code	APR-DRG 1934
Min. Negotiated Rate	$11,762.51
Max. Negotiated Rate	$11,762.51
Rate for Payer: AlohaCare Medicaid	$11,762.51
Rate for Payer: Hawaii Medical Service Association ABD	$11,762.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,762.51
Rate for Payer: Kaiser Permanente Medicaid	$11,762.51
Rate for Payer: Ohana Health Plan Medicaid	$11,762.51
Rate for Payer: UnitedHealthcare Medicaid	$11,762.51

ACUTE & SUBACUTE ENDOCARDITIS

Facility

$7,747.09

Service Code	APR-DRG 1933
Min. Negotiated Rate	$7,747.09
Max. Negotiated Rate	$7,747.09
Rate for Payer: AlohaCare Medicaid	$7,747.09
Rate for Payer: Hawaii Medical Service Association ABD	$7,747.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,747.09
Rate for Payer: Kaiser Permanente Medicaid	$7,747.09
Rate for Payer: Ohana Health Plan Medicaid	$7,747.09
Rate for Payer: UnitedHealthcare Medicaid	$7,747.09

ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION [8970]

Facility

$659.00

Service Code	NDC 70954018810
Hospital Revenue Code	637
Min. Negotiated Rate	$336.09
Max. Negotiated Rate	$639.23
Rate for Payer: Cash Price	$395.40
Rate for Payer: Hawaii Western Management Group Commercial	$626.05
Rate for Payer: Health Management Network Commercial	$560.15
Rate for Payer: Kaiser Permanente Commercial	$415.17
Rate for Payer: Kaiser Permanente Medicaid	$336.09
Rate for Payer: MDX Hawaii PPO	$639.23
Rate for Payer: University Health Alliance Commercial	$480.35

ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION [8970]

Facility

$659.00

Service Code	NDC 70954018810
Hospital Revenue Code	250
Min. Negotiated Rate	$560.15
Max. Negotiated Rate	$639.23
Rate for Payer: Cash Price	$395.40
Rate for Payer: Health Management Network Commercial	$560.15
Rate for Payer: MDX Hawaii PPO	$639.23

ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION [8970]

Facility

$659.00

Service Code	NDC 31722068147
Hospital Revenue Code	637
Min. Negotiated Rate	$336.09
Max. Negotiated Rate	$639.23
Rate for Payer: Cash Price	$395.40
Rate for Payer: Hawaii Western Management Group Commercial	$626.05
Rate for Payer: Health Management Network Commercial	$560.15
Rate for Payer: Kaiser Permanente Commercial	$415.17
Rate for Payer: Kaiser Permanente Medicaid	$336.09
Rate for Payer: MDX Hawaii PPO	$639.23
Rate for Payer: University Health Alliance Commercial	$480.35

ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION [8970]

Facility

$659.00

Service Code	NDC 31722068147
Hospital Revenue Code	250
Min. Negotiated Rate	$560.15
Max. Negotiated Rate	$639.23
Rate for Payer: Cash Price	$395.40
Rate for Payer: Health Management Network Commercial	$560.15
Rate for Payer: MDX Hawaii PPO	$639.23

ACYCLOVIR 400 MG TABLET [8971]

Facility

$14.00

Service Code	NDC 50268006111
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: MDX Hawaii PPO	$13.58

ACYCLOVIR 400 MG TABLET [8971]

Facility

$14.00

Service Code	NDC 50268006115
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: MDX Hawaii PPO	$13.58

ACYCLOVIR 400 MG TABLET [8971]

Facility

$14.00

Service Code	NDC 50268006111
Hospital Revenue Code	637
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$8.82
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: University Health Alliance Commercial	$10.20

ACYCLOVIR 400 MG TABLET [8971]

Facility

$14.00

Service Code	NDC 50268006115
Hospital Revenue Code	637
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$8.82
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: University Health Alliance Commercial	$10.20

ACYCLOVIR 5 % TOPICAL OINTMENT [8968]

Facility

$998.00

Service Code	NDC 72578008201
Hospital Revenue Code	250
Min. Negotiated Rate	$848.30
Max. Negotiated Rate	$968.06
Rate for Payer: Cash Price	$598.80
Rate for Payer: Health Management Network Commercial	$848.30
Rate for Payer: MDX Hawaii PPO	$968.06

ACYCLOVIR 5 % TOPICAL OINTMENT [8968]

Facility

$998.00

Service Code	NDC 72578008201
Hospital Revenue Code	637
Min. Negotiated Rate	$508.98
Max. Negotiated Rate	$968.06
Rate for Payer: Cash Price	$598.80
Rate for Payer: Hawaii Western Management Group Commercial	$948.10
Rate for Payer: Health Management Network Commercial	$848.30
Rate for Payer: Kaiser Permanente Commercial	$628.74
Rate for Payer: Kaiser Permanente Medicaid	$508.98
Rate for Payer: MDX Hawaii PPO	$968.06
Rate for Payer: University Health Alliance Commercial	$727.44

ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]

Facility

$28.00

Service Code	HCPCS J0133
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cash Price	$37.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Hawaii Western Management Group Commercial	$53.20
Rate for Payer: Hawaii Western Management Group Commercial	$59.85
Rate for Payer: Hawaii Western Management Group Commercial	$139.65
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$17.64
Rate for Payer: Kaiser Permanente Commercial	$39.69
Rate for Payer: Kaiser Permanente Commercial	$35.28
Rate for Payer: Kaiser Permanente Commercial	$92.61
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: UnitedHealthcare Medicaid	$16.80
Rate for Payer: UnitedHealthcare Medicaid	$37.80
Rate for Payer: UnitedHealthcare Medicaid	$33.60
Rate for Payer: UnitedHealthcare Medicaid	$88.20
Rate for Payer: University Health Alliance Commercial	$45.92
Rate for Payer: University Health Alliance Commercial	$107.15
Rate for Payer: University Health Alliance Commercial	$20.41
Rate for Payer: University Health Alliance Commercial	$40.82

ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]

Facility

$28.00

Service Code	HCPCS J0133
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cash Price	$37.80
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: MDX Hawaii PPO	$61.11

ADAPTER CARTRIDGE 110030166

Facility

$225.00

Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: MDX Hawaii PPO	$218.25

ADAPTER CARTRIDGE 110030166

Facility

$225.00

Hospital Revenue Code	272
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$141.75
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: University Health Alliance Commercial	$164.00

ADAPTER FOR ELLIK EVACU 3664

Facility

$348.00

Hospital Revenue Code	272
Min. Negotiated Rate	$295.80
Max. Negotiated Rate	$337.56
Rate for Payer: Cash Price	$208.80
Rate for Payer: Health Management Network Commercial	$295.80
Rate for Payer: MDX Hawaii PPO	$337.56

ADAPTER FOR ELLIK EVACU 3664

Facility

$348.00

Hospital Revenue Code	272
Min. Negotiated Rate	$177.48
Max. Negotiated Rate	$337.56
Rate for Payer: Cash Price	$208.80
Rate for Payer: Hawaii Western Management Group Commercial	$330.60
Rate for Payer: Health Management Network Commercial	$295.80
Rate for Payer: Kaiser Permanente Commercial	$219.24
Rate for Payer: Kaiser Permanente Medicaid	$177.48
Rate for Payer: MDX Hawaii PPO	$337.56
Rate for Payer: University Health Alliance Commercial	$253.66

ADAPTER LATITUDE 3G USB 6295

Facility

$746.00

Hospital Revenue Code	271
Min. Negotiated Rate	$380.46
Max. Negotiated Rate	$723.62
Rate for Payer: Cash Price	$447.60
Rate for Payer: Hawaii Western Management Group Commercial	$708.70
Rate for Payer: Health Management Network Commercial	$634.10
Rate for Payer: Kaiser Permanente Commercial	$469.98
Rate for Payer: Kaiser Permanente Medicaid	$380.46
Rate for Payer: MDX Hawaii PPO	$723.62
Rate for Payer: University Health Alliance Commercial	$543.76

Know your out-of-pocket cost for care.

All Charges