Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

DESMOPRESSIN 0.1 MG TABLET [16052]

Facility

$11.00

Service Code	NDC 68001057400
Hospital Revenue Code	637
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: University Health Alliance Commercial	$8.02

DESMOPRESSIN 0.1 MG TABLET [16052]

Facility

$11.00

Service Code	NDC 68001057400
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: MDX Hawaii PPO	$10.67

DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY [27770]

Facility

$616.00

Service Code	NDC 24208034205
Hospital Revenue Code	637
Min. Negotiated Rate	$314.16
Max. Negotiated Rate	$597.52
Rate for Payer: Cash Price	$369.60
Rate for Payer: Hawaii Western Management Group Commercial	$585.20
Rate for Payer: Health Management Network Commercial	$523.60
Rate for Payer: Kaiser Permanente Commercial	$388.08
Rate for Payer: Kaiser Permanente Medicaid	$314.16
Rate for Payer: MDX Hawaii PPO	$597.52
Rate for Payer: University Health Alliance Commercial	$449.00

DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY [27770]

Facility

$616.00

Service Code	NDC 24208034205
Hospital Revenue Code	250
Min. Negotiated Rate	$523.60
Max. Negotiated Rate	$597.52
Rate for Payer: Cash Price	$369.60
Rate for Payer: Health Management Network Commercial	$523.60
Rate for Payer: MDX Hawaii PPO	$597.52

DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]

Facility

$1,185.00

Service Code	HCPCS J2597
Hospital Revenue Code	250
Min. Negotiated Rate	$1,007.25
Max. Negotiated Rate	$1,149.45
Rate for Payer: Cash Price	$711.00
Rate for Payer: Cash Price	$68.40
Rate for Payer: Cash Price	$220.80
Rate for Payer: Cash Price	$270.00
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Health Management Network Commercial	$1,007.25
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: MDX Hawaii PPO	$1,149.45
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: MDX Hawaii PPO	$436.50

DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]

Facility

$1,185.00

Service Code	HCPCS J2597
Hospital Revenue Code	636
Min. Negotiated Rate	$3.89
Max. Negotiated Rate	$1,149.45
Rate for Payer: Cash Price	$711.00
Rate for Payer: Cash Price	$711.00
Rate for Payer: Cash Price	$68.40
Rate for Payer: Cash Price	$220.80
Rate for Payer: Cash Price	$68.40
Rate for Payer: Cash Price	$220.80
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Hawaii Medical Service Association ABD	$3.89
Rate for Payer: Hawaii Medical Service Association ABD	$3.89
Rate for Payer: Hawaii Medical Service Association ABD	$3.89
Rate for Payer: Hawaii Medical Service Association ABD	$3.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.89
Rate for Payer: Hawaii Western Management Group Commercial	$1,125.75
Rate for Payer: Hawaii Western Management Group Commercial	$349.60
Rate for Payer: Hawaii Western Management Group Commercial	$427.50
Rate for Payer: Hawaii Western Management Group Commercial	$108.30
Rate for Payer: Health Management Network Commercial	$1,007.25
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Kaiser Permanente Commercial	$746.55
Rate for Payer: Kaiser Permanente Commercial	$283.50
Rate for Payer: Kaiser Permanente Commercial	$231.84
Rate for Payer: Kaiser Permanente Commercial	$71.82
Rate for Payer: Kaiser Permanente Medicaid	$229.50
Rate for Payer: Kaiser Permanente Medicaid	$187.68
Rate for Payer: Kaiser Permanente Medicaid	$604.35
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: MDX Hawaii PPO	$1,149.45
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: UnitedHealthcare Medicaid	$711.00
Rate for Payer: UnitedHealthcare Medicaid	$270.00
Rate for Payer: UnitedHealthcare Medicaid	$220.80
Rate for Payer: UnitedHealthcare Medicaid	$68.40
Rate for Payer: University Health Alliance Commercial	$328.00
Rate for Payer: University Health Alliance Commercial	$83.09
Rate for Payer: University Health Alliance Commercial	$863.75
Rate for Payer: University Health Alliance Commercial	$268.24

DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]

Facility

$204.00

Service Code	NDC 45802049535
Hospital Revenue Code	637
Min. Negotiated Rate	$104.04
Max. Negotiated Rate	$197.88
Rate for Payer: Cash Price	$122.40
Rate for Payer: Hawaii Western Management Group Commercial	$193.80
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Kaiser Permanente Commercial	$128.52
Rate for Payer: Kaiser Permanente Medicaid	$104.04
Rate for Payer: MDX Hawaii PPO	$197.88
Rate for Payer: University Health Alliance Commercial	$148.70

DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]

Facility

$304.00

Service Code	NDC 51672127001
Hospital Revenue Code	637
Min. Negotiated Rate	$155.04
Max. Negotiated Rate	$294.88
Rate for Payer: Cash Price	$182.40
Rate for Payer: Hawaii Western Management Group Commercial	$288.80
Rate for Payer: Health Management Network Commercial	$258.40
Rate for Payer: Kaiser Permanente Commercial	$191.52
Rate for Payer: Kaiser Permanente Medicaid	$155.04
Rate for Payer: MDX Hawaii PPO	$294.88
Rate for Payer: University Health Alliance Commercial	$221.59

DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]

Facility

$204.00

Service Code	NDC 45802049535
Hospital Revenue Code	250
Min. Negotiated Rate	$173.40
Max. Negotiated Rate	$197.88
Rate for Payer: Cash Price	$122.40
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: MDX Hawaii PPO	$197.88

DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]

Facility

$304.00

Service Code	NDC 51672127001
Hospital Revenue Code	250
Min. Negotiated Rate	$258.40
Max. Negotiated Rate	$294.88
Rate for Payer: Cash Price	$182.40
Rate for Payer: Health Management Network Commercial	$258.40
Rate for Payer: MDX Hawaii PPO	$294.88

DESOXIMETASONE 0.25 % TOPICAL OINTMENT [9753]

Facility

$210.00

Service Code	NDC 45802049696
Hospital Revenue Code	637
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$203.70
Rate for Payer: Cash Price	$126.00
Rate for Payer: Hawaii Western Management Group Commercial	$199.50
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: Kaiser Permanente Medicaid	$107.10
Rate for Payer: MDX Hawaii PPO	$203.70
Rate for Payer: University Health Alliance Commercial	$153.07

DESOXIMETASONE 0.25 % TOPICAL OINTMENT [9753]

Facility

$210.00

Service Code	NDC 45802049696
Hospital Revenue Code	250
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$203.70
Rate for Payer: Cash Price	$126.00
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: MDX Hawaii PPO	$203.70

DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED

Facility

$2,837.00

Service Code	CPT 64624
Hospital Revenue Code	361
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$2,306.84
Rate for Payer: AlohaCare Medicare	$2,306.84
Rate for Payer: Devoted Health Medicare	$2,537.52
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,306.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$2,306.84
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,306.84
Rate for Payer: Ohana Health Plan Medicaid	$2,537.52
Rate for Payer: Ohana Health Plan Medicare	$2,306.84
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,306.84

DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION

Facility

$5,509.00

Service Code	CPT 46922
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$3,279.01
Rate for Payer: AlohaCare Medicare	$3,279.01
Rate for Payer: Devoted Health Medicare	$3,606.91
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	$3,279.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,279.01
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,279.01
Rate for Payer: Ohana Health Plan Medicaid	$3,606.91
Rate for Payer: Ohana Health Plan Medicare	$3,279.01
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,279.01

DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH

Facility

$24,500.00

Service Code	CPT 45190
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$3,279.01
Rate for Payer: AlohaCare Medicare	$3,279.01
Rate for Payer: Devoted Health Medicare	$3,606.91
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	$3,279.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,279.01
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,279.01
Rate for Payer: Ohana Health Plan Medicaid	$3,606.91
Rate for Payer: Ohana Health Plan Medicare	$3,279.01
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,279.01
Rate for Payer: University Health Alliance Commercial	$24,500.00

DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR [2319]

Facility

$126.00

Service Code	HCPCS J8540
Hospital Revenue Code	637
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cash Price	$75.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Western Management Group Commercial	$119.70
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$79.38
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: UnitedHealthcare Medicaid	$0.02
Rate for Payer: University Health Alliance Commercial	$91.84

DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR [2319]

Facility

$126.00

Service Code	HCPCS J8540
Hospital Revenue Code	250
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: MDX Hawaii PPO	$122.22

DEXAMETHASONE 0.5 MG TABLET [2322]

Facility

$1.00

Service Code	NDC 00054817925
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

DEXAMETHASONE 0.5 MG TABLET [2322]

Facility

$1.00

Service Code	NDC 60505624901
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

DEXAMETHASONE 40 MG IN 50 ML NS IVPB (SIMPLE) [4080503]

Facility

$36.00

Service Code	HCPCS J1100
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.12
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$22.68
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: UnitedHealthcare Medicaid	$21.60
Rate for Payer: University Health Alliance Commercial	$26.24

DEXAMETHASONE 40 MG IN 50 ML NS IVPB (SIMPLE) [4080503]

Facility

$36.00

Service Code	HCPCS J1100
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$34.92

DEXAMETHASONE 4 MG TABLET [2327]

Facility

$5.00

Service Code	HCPCS J8540
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.02
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: UnitedHealthcare Medicaid	$3.00
Rate for Payer: University Health Alliance Commercial	$3.64

DEXAMETHASONE 4 MG TABLET [2327]

Facility

$5.00

Service Code	HCPCS J8540
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$4.85

DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS [2335]

Facility

$162.00

Service Code	NDC 24208072002
Hospital Revenue Code	250
Min. Negotiated Rate	$137.70
Max. Negotiated Rate	$157.14
Rate for Payer: Cash Price	$97.20
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: MDX Hawaii PPO	$157.14

DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS [2335]

Facility

$162.00

Service Code	NDC 24208072002
Hospital Revenue Code	637
Min. Negotiated Rate	$82.62
Max. Negotiated Rate	$157.14
Rate for Payer: Cash Price	$97.20
Rate for Payer: Hawaii Western Management Group Commercial	$153.90
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$102.06
Rate for Payer: Kaiser Permanente Medicaid	$82.62
Rate for Payer: MDX Hawaii PPO	$157.14
Rate for Payer: University Health Alliance Commercial	$118.08

Know your out-of-pocket cost for care.

All Charges