Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE [166256]

Facility

$2,751.00

Service Code	HCPCS J0897
Hospital Revenue Code	250
Min. Negotiated Rate	$2,338.35
Max. Negotiated Rate	$2,668.47
Rate for Payer: Cash Price	$1,650.60
Rate for Payer: Health Management Network Commercial	$2,338.35
Rate for Payer: MDX Hawaii PPO	$2,668.47

DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE [166256]

Facility

$2,751.00

Service Code	HCPCS J0897
Hospital Revenue Code	636
Min. Negotiated Rate	$29.24
Max. Negotiated Rate	$2,668.47
Rate for Payer: AlohaCare Medicaid	$29.51
Rate for Payer: AlohaCare Medicare	$29.51
Rate for Payer: Cash Price	$1,650.60
Rate for Payer: Cash Price	$1,650.60
Rate for Payer: Devoted Health Medicare	$32.46
Rate for Payer: Hawaii Medical Service Association ABD	$29.24
Rate for Payer: Hawaii Medical Service Association Commercial	$36.89
Rate for Payer: Hawaii Medical Service Association Medicare	$29.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29.24
Rate for Payer: Hawaii Western Management Group Commercial	$2,613.45
Rate for Payer: Health Management Network Commercial	$2,338.35
Rate for Payer: Humana Medicare	$29.51
Rate for Payer: Kaiser Permanente Commercial	$1,733.13
Rate for Payer: Kaiser Permanente Medicaid	$1,403.01
Rate for Payer: Kaiser Permanente Medicare	$29.51
Rate for Payer: MDX Hawaii PPO	$2,668.47
Rate for Payer: Ohana Health Plan Medicaid	$32.46
Rate for Payer: Ohana Health Plan Medicare	$29.51
Rate for Payer: UnitedHealthcare Medicaid	$1,650.60
Rate for Payer: UnitedHealthcare Medicare	$29.51
Rate for Payer: University Health Alliance Commercial	$2,005.20

DENTAL AND ORAL DISEASES WITH CC

Facility

$20,407.71

Service Code	MSDRG 158
Min. Negotiated Rate	$10,348.31
Max. Negotiated Rate	$20,407.71
Rate for Payer: AlohaCare Medicare	$10,348.31
Rate for Payer: Devoted Health Medicare	$11,383.14
Rate for Payer: Hawaii Medical Service Association Commercial	$20,407.71
Rate for Payer: Hawaii Medical Service Association Medicare	$10,348.31
Rate for Payer: Humana Medicare	$10,348.31
Rate for Payer: Kaiser Permanente Commercial	$15,694.05
Rate for Payer: Kaiser Permanente Medicare	$10,348.31
Rate for Payer: Ohana Health Plan Medicare	$10,348.31
Rate for Payer: UnitedHealthcare Medicare	$10,348.31

DENTAL AND ORAL DISEASES WITH MCC

Facility

$29,614.80

Service Code	MSDRG 157
Min. Negotiated Rate	$19,527.32
Max. Negotiated Rate	$29,614.80
Rate for Payer: AlohaCare Medicare	$19,527.32
Rate for Payer: Devoted Health Medicare	$21,480.05
Rate for Payer: Hawaii Medical Service Association Commercial	$20,407.71
Rate for Payer: Hawaii Medical Service Association Medicare	$19,527.32
Rate for Payer: Humana Medicare	$19,527.32
Rate for Payer: Kaiser Permanente Commercial	$29,614.80
Rate for Payer: Kaiser Permanente Medicare	$19,527.32
Rate for Payer: Ohana Health Plan Medicare	$19,527.32
Rate for Payer: UnitedHealthcare Medicare	$19,527.32

DENTAL AND ORAL DISEASES WITHOUT CC/MCC

Facility

$20,407.71

Service Code	MSDRG 159
Min. Negotiated Rate	$8,058.66
Max. Negotiated Rate	$20,407.71
Rate for Payer: AlohaCare Medicare	$8,058.66
Rate for Payer: Devoted Health Medicare	$8,864.53
Rate for Payer: Hawaii Medical Service Association Commercial	$20,407.71
Rate for Payer: Hawaii Medical Service Association Medicare	$8,058.66
Rate for Payer: Humana Medicare	$8,058.66
Rate for Payer: Kaiser Permanente Commercial	$12,221.62
Rate for Payer: Kaiser Permanente Medicare	$8,058.66
Rate for Payer: Ohana Health Plan Medicare	$8,058.66
Rate for Payer: UnitedHealthcare Medicare	$8,058.66

DENTAL DISEASES & DISORDERS

Facility

$3,083.97

Service Code	APR-DRG 1142
Min. Negotiated Rate	$3,083.97
Max. Negotiated Rate	$3,083.97
Rate for Payer: AlohaCare Medicaid	$3,083.97
Rate for Payer: Hawaii Medical Service Association ABD	$3,083.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,083.97
Rate for Payer: Kaiser Permanente Medicaid	$3,083.97
Rate for Payer: Ohana Health Plan Medicaid	$3,083.97
Rate for Payer: UnitedHealthcare Medicaid	$3,083.97

DENTAL DISEASES & DISORDERS

Facility

$4,750.53

Service Code	APR-DRG 1143
Min. Negotiated Rate	$4,750.53
Max. Negotiated Rate	$4,750.53
Rate for Payer: AlohaCare Medicaid	$4,750.53
Rate for Payer: Hawaii Medical Service Association ABD	$4,750.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,750.53
Rate for Payer: Kaiser Permanente Medicaid	$4,750.53
Rate for Payer: Ohana Health Plan Medicaid	$4,750.53
Rate for Payer: UnitedHealthcare Medicaid	$4,750.53

DENTAL DISEASES & DISORDERS

Facility

$2,194.26

Service Code	APR-DRG 1141
Min. Negotiated Rate	$2,194.26
Max. Negotiated Rate	$2,194.26
Rate for Payer: AlohaCare Medicaid	$2,194.26
Rate for Payer: Hawaii Medical Service Association ABD	$2,194.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,194.26
Rate for Payer: Kaiser Permanente Medicaid	$2,194.26
Rate for Payer: Ohana Health Plan Medicaid	$2,194.26
Rate for Payer: UnitedHealthcare Medicaid	$2,194.26

DENTAL DISEASES & DISORDERS

Facility

$10,602.76

Service Code	APR-DRG 1144
Min. Negotiated Rate	$10,602.76
Max. Negotiated Rate	$10,602.76
Rate for Payer: AlohaCare Medicaid	$10,602.76
Rate for Payer: Hawaii Medical Service Association ABD	$10,602.76
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,602.76
Rate for Payer: Kaiser Permanente Medicaid	$10,602.76
Rate for Payer: Ohana Health Plan Medicaid	$10,602.76
Rate for Payer: UnitedHealthcare Medicaid	$10,602.76

DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER

Facility

$9,336.73

Service Code	APR-DRG 7544
Min. Negotiated Rate	$9,336.73
Max. Negotiated Rate	$9,336.73
Rate for Payer: AlohaCare Medicaid	$9,336.73
Rate for Payer: Hawaii Medical Service Association ABD	$9,336.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,336.73
Rate for Payer: Kaiser Permanente Medicaid	$9,336.73
Rate for Payer: Ohana Health Plan Medicaid	$9,336.73
Rate for Payer: UnitedHealthcare Medicaid	$9,336.73

DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER

Facility

$4,091.90

Service Code	APR-DRG 7543
Min. Negotiated Rate	$4,091.90
Max. Negotiated Rate	$4,091.90
Rate for Payer: AlohaCare Medicaid	$4,091.90
Rate for Payer: Hawaii Medical Service Association ABD	$4,091.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,091.90
Rate for Payer: Kaiser Permanente Medicaid	$4,091.90
Rate for Payer: Ohana Health Plan Medicaid	$4,091.90
Rate for Payer: UnitedHealthcare Medicaid	$4,091.90

DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER

Facility

$2,530.90

Service Code	APR-DRG 7541
Min. Negotiated Rate	$2,530.90
Max. Negotiated Rate	$2,530.90
Rate for Payer: AlohaCare Medicaid	$2,530.90
Rate for Payer: Hawaii Medical Service Association ABD	$2,530.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,530.90
Rate for Payer: Kaiser Permanente Medicaid	$2,530.90
Rate for Payer: Ohana Health Plan Medicaid	$2,530.90
Rate for Payer: UnitedHealthcare Medicaid	$2,530.90

DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER

Facility

$2,938.96

Service Code	APR-DRG 7542
Min. Negotiated Rate	$2,938.96
Max. Negotiated Rate	$2,938.96
Rate for Payer: AlohaCare Medicaid	$2,938.96
Rate for Payer: Hawaii Medical Service Association ABD	$2,938.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,938.96
Rate for Payer: Kaiser Permanente Medicaid	$2,938.96
Rate for Payer: Ohana Health Plan Medicaid	$2,938.96
Rate for Payer: UnitedHealthcare Medicaid	$2,938.96

DEPRESSIVE NEUROSES

Facility

$16,230.52

Service Code	MSDRG 881
Min. Negotiated Rate	$10,240.25
Max. Negotiated Rate	$16,230.52
Rate for Payer: AlohaCare Medicare	$10,702.05
Rate for Payer: Devoted Health Medicare	$11,772.25
Rate for Payer: Hawaii Medical Service Association Commercial	$10,240.25
Rate for Payer: Hawaii Medical Service Association Medicare	$10,702.05
Rate for Payer: Humana Medicare	$10,702.05
Rate for Payer: Kaiser Permanente Commercial	$16,230.52
Rate for Payer: Kaiser Permanente Medicare	$10,702.05
Rate for Payer: Ohana Health Plan Medicare	$10,702.05
Rate for Payer: UnitedHealthcare Medicare	$10,702.05

DERMACLOSE RC KIT 204010-K

Facility

$2,997.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,547.45
Max. Negotiated Rate	$2,907.09
Rate for Payer: Cash Price	$1,798.20
Rate for Payer: Health Management Network Commercial	$2,547.45
Rate for Payer: MDX Hawaii PPO	$2,907.09

DERMACLOSE RC KIT 204010-K

Facility

$2,997.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,528.47
Max. Negotiated Rate	$2,907.09
Rate for Payer: Cash Price	$1,798.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,847.15
Rate for Payer: Health Management Network Commercial	$2,547.45
Rate for Payer: Kaiser Permanente Commercial	$1,888.11
Rate for Payer: Kaiser Permanente Medicaid	$1,528.47
Rate for Payer: MDX Hawaii PPO	$2,907.09
Rate for Payer: University Health Alliance Commercial	$2,184.51

DERMATOME BLADE 00-8800-000-10

Facility

$244.00

Hospital Revenue Code	272
Min. Negotiated Rate	$124.44
Max. Negotiated Rate	$236.68
Rate for Payer: Cash Price	$146.40
Rate for Payer: Hawaii Western Management Group Commercial	$231.80
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Kaiser Permanente Commercial	$153.72
Rate for Payer: Kaiser Permanente Medicaid	$124.44
Rate for Payer: MDX Hawaii PPO	$236.68
Rate for Payer: University Health Alliance Commercial	$177.85

DERMATOME BLADE 00-8800-000-10

Facility

$244.00

Hospital Revenue Code	272
Min. Negotiated Rate	$207.40
Max. Negotiated Rate	$236.68
Rate for Payer: Cash Price	$146.40
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: MDX Hawaii PPO	$236.68

DESFLURANE 100 % INHALATION LIQUID [9747]

Facility

$289.00

Service Code	NDC 10019064134
Hospital Revenue Code	250
Min. Negotiated Rate	$245.65
Max. Negotiated Rate	$280.33
Rate for Payer: Cash Price	$173.40
Rate for Payer: Health Management Network Commercial	$245.65
Rate for Payer: MDX Hawaii PPO	$280.33

DESFLURANE 100 % INHALATION LIQUID [9747]

Facility

$271.00

Service Code	NDC 00781617286
Hospital Revenue Code	250
Min. Negotiated Rate	$230.35
Max. Negotiated Rate	$262.87
Rate for Payer: Cash Price	$162.60
Rate for Payer: Health Management Network Commercial	$230.35
Rate for Payer: MDX Hawaii PPO	$262.87

DESFLURANE 100 % INHALATION LIQUID [9747]

Facility

$289.00

Service Code	NDC 10019064164
Hospital Revenue Code	250
Min. Negotiated Rate	$245.65
Max. Negotiated Rate	$280.33
Rate for Payer: Cash Price	$173.40
Rate for Payer: Health Management Network Commercial	$245.65
Rate for Payer: MDX Hawaii PPO	$280.33

DESIPRAMINE 25 MG TABLET [2286]

Facility

$8.00

Service Code	NDC 50742011301
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$7.76

DESIPRAMINE 25 MG TABLET [2286]

Facility

$8.00

Service Code	NDC 69238105501
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$7.76

DESIPRAMINE 25 MG TABLET [2286]

Facility

$8.00

Service Code	NDC 50742011301
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

DESIPRAMINE 25 MG TABLET [2286]

Facility

$8.00

Service Code	NDC 69238105501
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

Know your out-of-pocket cost for care.

All Charges