Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION [31577]

Facility

$6.00

Service Code	HCPCS J7613
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [31578]

Facility

$7.00

Service Code	HCPCS J7613
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: MDX Hawaii PPO	$6.79

ALBUTEROL SULFATE 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [31578]

Facility

$7.00

Service Code	HCPCS J7613
Hospital Revenue Code	636
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$4.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.08
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$4.41
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: University Health Alliance Commercial	$5.10

ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250]

Facility

$5.00

Service Code	HCPCS J7613
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: MDX Hawaii PPO	$1.94

ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION [250]

Facility

$2.00

Service Code	HCPCS J7613
Hospital Revenue Code	636
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Cash Price	$1.20
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.08
Rate for Payer: Hawaii Medical Service Association ABD	$0.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.08
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: UnitedHealthcare Medicaid	$3.00
Rate for Payer: University Health Alliance Commercial	$1.46
Rate for Payer: University Health Alliance Commercial	$3.64

ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP [252]

Facility

$209.00

Service Code	NDC 70752010212
Hospital Revenue Code	250
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

ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP [252]

Facility

$209.00

Service Code	NDC 70752010212
Hospital Revenue Code	637
Min. Negotiated Rate	$106.59
Max. Negotiated Rate	$202.73
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: University Health Alliance Commercial	$152.34

ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION [170439]

Facility

$4.00

Service Code	HCPCS J7611
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: UnitedHealthcare Medicaid	$2.40
Rate for Payer: University Health Alliance Commercial	$2.92

ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION [170439]

Facility

$4.00

Service Code	HCPCS J7611
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

ALBUTEROL SULFATE CONCENTRATE 5 MG/ML(0.5 %) SOLUTION FOR NEBULIZATION [251]

Facility

$18.00

Service Code	HCPCS J7611
Hospital Revenue Code	250
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$17.46

ALBUTEROL SULFATE CONCENTRATE 5 MG/ML(0.5 %) SOLUTION FOR NEBULIZATION [251]

Facility

$18.00

Service Code	HCPCS J7611
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$10.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$11.34
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: University Health Alliance Commercial	$13.12

ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]

Facility

$135.00

Service Code	NDC 00781729685
Hospital Revenue Code	637
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$130.95
Rate for Payer: Cash Price	$81.00
Rate for Payer: Hawaii Western Management Group Commercial	$128.25
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Kaiser Permanente Commercial	$85.05
Rate for Payer: Kaiser Permanente Medicaid	$68.85
Rate for Payer: MDX Hawaii PPO	$130.95
Rate for Payer: University Health Alliance Commercial	$98.40

ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17837]

Facility

$135.00

Service Code	NDC 00781729685
Hospital Revenue Code	250
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$130.95
Rate for Payer: Cash Price	$81.00
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: MDX Hawaii PPO	$130.95

ALCOHOL ABUSE & DEPENDENCE

Facility

$3,383.03

Service Code	APR-DRG 7752
Min. Negotiated Rate	$3,383.03
Max. Negotiated Rate	$3,383.03
Rate for Payer: AlohaCare Medicaid	$3,383.03
Rate for Payer: Hawaii Medical Service Association ABD	$3,383.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,383.03
Rate for Payer: Kaiser Permanente Medicaid	$3,383.03
Rate for Payer: Ohana Health Plan Medicaid	$3,383.03
Rate for Payer: UnitedHealthcare Medicaid	$3,383.03

ALCOHOL ABUSE & DEPENDENCE

Facility

$5,457.11

Service Code	APR-DRG 7753
Min. Negotiated Rate	$5,457.11
Max. Negotiated Rate	$5,457.11
Rate for Payer: AlohaCare Medicaid	$5,457.11
Rate for Payer: Hawaii Medical Service Association ABD	$5,457.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,457.11
Rate for Payer: Kaiser Permanente Medicaid	$5,457.11
Rate for Payer: Ohana Health Plan Medicaid	$5,457.11
Rate for Payer: UnitedHealthcare Medicaid	$5,457.11

ALCOHOL ABUSE & DEPENDENCE

Facility

$2,462.64

Service Code	APR-DRG 7751
Min. Negotiated Rate	$2,462.64
Max. Negotiated Rate	$2,462.64
Rate for Payer: AlohaCare Medicaid	$2,462.64
Rate for Payer: Hawaii Medical Service Association ABD	$2,462.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,462.64
Rate for Payer: Kaiser Permanente Medicaid	$2,462.64
Rate for Payer: Ohana Health Plan Medicaid	$2,462.64
Rate for Payer: UnitedHealthcare Medicaid	$2,462.64

ALCOHOL ABUSE & DEPENDENCE

Facility

$12,819.53

Service Code	APR-DRG 7754
Min. Negotiated Rate	$12,819.53
Max. Negotiated Rate	$12,819.53
Rate for Payer: AlohaCare Medicaid	$12,819.53
Rate for Payer: Hawaii Medical Service Association ABD	$12,819.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12,819.53
Rate for Payer: Kaiser Permanente Medicaid	$12,819.53
Rate for Payer: Ohana Health Plan Medicaid	$12,819.53
Rate for Payer: UnitedHealthcare Medicaid	$12,819.53

ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA

Facility

$10,641.52

Service Code	MSDRG 894
Min. Negotiated Rate	$7,016.77
Max. Negotiated Rate	$10,641.52
Rate for Payer: AlohaCare Medicare	$7,016.77
Rate for Payer: Devoted Health Medicare	$7,718.45
Rate for Payer: Hawaii Medical Service Association Commercial	$8,662.96
Rate for Payer: Hawaii Medical Service Association Medicare	$7,016.77
Rate for Payer: Humana Medicare	$7,016.77
Rate for Payer: Kaiser Permanente Commercial	$10,641.52
Rate for Payer: Kaiser Permanente Medicare	$7,016.77
Rate for Payer: Ohana Health Plan Medicare	$7,016.77
Rate for Payer: UnitedHealthcare Medicare	$7,016.77

ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC

Facility

$30,102.97

Service Code	MSDRG 896
Min. Negotiated Rate	$19,849.21
Max. Negotiated Rate	$30,102.97
Rate for Payer: AlohaCare Medicare	$19,849.21
Rate for Payer: Devoted Health Medicare	$21,834.13
Rate for Payer: Hawaii Medical Service Association Commercial	$23,125.50
Rate for Payer: Hawaii Medical Service Association Medicare	$19,849.21
Rate for Payer: Humana Medicare	$19,849.21
Rate for Payer: Kaiser Permanente Commercial	$30,102.97
Rate for Payer: Kaiser Permanente Medicare	$19,849.21
Rate for Payer: Ohana Health Plan Medicare	$19,849.21
Rate for Payer: UnitedHealthcare Medicare	$19,849.21

ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC

Facility

$15,228.30

Service Code	MSDRG 897
Min. Negotiated Rate	$10,041.20
Max. Negotiated Rate	$15,228.30
Rate for Payer: AlohaCare Medicare	$10,041.20
Rate for Payer: Devoted Health Medicare	$11,045.32
Rate for Payer: Hawaii Medical Service Association Commercial	$14,753.73
Rate for Payer: Hawaii Medical Service Association Medicare	$10,041.20
Rate for Payer: Humana Medicare	$10,041.20
Rate for Payer: Kaiser Permanente Commercial	$15,228.30
Rate for Payer: Kaiser Permanente Medicare	$10,041.20
Rate for Payer: Ohana Health Plan Medicare	$10,041.20
Rate for Payer: UnitedHealthcare Medicare	$10,041.20

ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY

Facility

$24,419.10

Service Code	MSDRG 895
Min. Negotiated Rate	$16,101.39
Max. Negotiated Rate	$24,419.10
Rate for Payer: AlohaCare Medicare	$16,101.39
Rate for Payer: Devoted Health Medicare	$17,711.53
Rate for Payer: Hawaii Medical Service Association Commercial	$23,125.50
Rate for Payer: Hawaii Medical Service Association Medicare	$16,101.39
Rate for Payer: Humana Medicare	$16,101.39
Rate for Payer: Kaiser Permanente Commercial	$24,419.10
Rate for Payer: Kaiser Permanente Medicare	$16,101.39
Rate for Payer: Ohana Health Plan Medicare	$16,101.39
Rate for Payer: UnitedHealthcare Medicare	$16,101.39

ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY

Facility

$14,176.49

Service Code	APR-DRG 7724
Min. Negotiated Rate	$14,176.49
Max. Negotiated Rate	$14,176.49
Rate for Payer: AlohaCare Medicaid	$14,176.49
Rate for Payer: Hawaii Medical Service Association ABD	$14,176.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14,176.49
Rate for Payer: Kaiser Permanente Medicaid	$14,176.49
Rate for Payer: Ohana Health Plan Medicaid	$14,176.49
Rate for Payer: UnitedHealthcare Medicaid	$14,176.49

ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY

Facility

$3,018.48

Service Code	APR-DRG 7721
Min. Negotiated Rate	$3,018.48
Max. Negotiated Rate	$3,018.48
Rate for Payer: AlohaCare Medicaid	$3,018.48
Rate for Payer: Hawaii Medical Service Association ABD	$3,018.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,018.48
Rate for Payer: Kaiser Permanente Medicaid	$3,018.48
Rate for Payer: Ohana Health Plan Medicaid	$3,018.48
Rate for Payer: UnitedHealthcare Medicaid	$3,018.48

ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY

Facility

$3,948.62

Service Code	APR-DRG 7722
Min. Negotiated Rate	$3,948.62
Max. Negotiated Rate	$3,948.62
Rate for Payer: AlohaCare Medicaid	$3,948.62
Rate for Payer: Hawaii Medical Service Association ABD	$3,948.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,948.62
Rate for Payer: Kaiser Permanente Medicaid	$3,948.62
Rate for Payer: Ohana Health Plan Medicaid	$3,948.62
Rate for Payer: UnitedHealthcare Medicaid	$3,948.62

ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY

Facility

$5,186.32

Service Code	APR-DRG 7723
Min. Negotiated Rate	$5,186.32
Max. Negotiated Rate	$5,186.32
Rate for Payer: AlohaCare Medicaid	$5,186.32
Rate for Payer: Hawaii Medical Service Association ABD	$5,186.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,186.32
Rate for Payer: Kaiser Permanente Medicaid	$5,186.32
Rate for Payer: Ohana Health Plan Medicaid	$5,186.32
Rate for Payer: UnitedHealthcare Medicaid	$5,186.32

Know your out-of-pocket cost for care.

All Charges