Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9814]

Facility

$14.00

Service Code	NDC 00264761200
Hospital Revenue Code	258
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

DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9815]

Facility

$18.00

Service Code	HCPCS J7042
Hospital Revenue Code	258
Min. Negotiated Rate	$1.02
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	$1.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.36
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	$1.02
Rate for Payer: University Health Alliance Commercial	$13.12

DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9815]

Facility

$18.00

Service Code	HCPCS J7042
Hospital Revenue Code	258
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

DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION [9788]

Facility

$14.00

Service Code	NDC 00264775100
Hospital Revenue Code	258
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

DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION [9788]

Facility

$14.00

Service Code	NDC 00264775100
Hospital Revenue Code	258
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

DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]

Facility

$2.00

Service Code	HCPCS J7060
Hospital Revenue Code	636
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$2.03
Rate for Payer: Cash Price	$1.20
Rate for Payer: Cash Price	$1.20
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Medical Service Association ABD	$2.03
Rate for Payer: Hawaii Medical Service Association ABD	$2.03
Rate for Payer: Hawaii Medical Service Association ABD	$2.03
Rate for Payer: Hawaii Medical Service Association ABD	$2.03
Rate for Payer: Hawaii Medical Service Association ABD	$2.03
Rate for Payer: Hawaii Medical Service Association ABD	$2.03
Rate for Payer: Hawaii Medical Service Association ABD	$2.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.03
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Hawaii Western Management Group Commercial	$15.20
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Commercial	$11.34
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Commercial	$10.08
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicaid	$8.16
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: UnitedHealthcare Medicaid	$5.40
Rate for Payer: UnitedHealthcare Medicaid	$9.60
Rate for Payer: UnitedHealthcare Medicaid	$0.60
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: UnitedHealthcare Medicaid	$3.00
Rate for Payer: UnitedHealthcare Medicaid	$6.60
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: University Health Alliance Commercial	$3.64
Rate for Payer: University Health Alliance Commercial	$11.66
Rate for Payer: University Health Alliance Commercial	$13.12
Rate for Payer: University Health Alliance Commercial	$0.73
Rate for Payer: University Health Alliance Commercial	$8.02
Rate for Payer: University Health Alliance Commercial	$1.46
Rate for Payer: University Health Alliance Commercial	$6.56

DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]

Facility

$2.00

Service Code	HCPCS J7060
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: MDX Hawaii PPO	$4.85

DIABETES

Facility

$8,625.06

Service Code	APR-DRG 4204
Min. Negotiated Rate	$8,625.06
Max. Negotiated Rate	$8,625.06
Rate for Payer: AlohaCare Medicaid	$8,625.06
Rate for Payer: Hawaii Medical Service Association ABD	$8,625.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,625.06
Rate for Payer: Kaiser Permanente Medicaid	$8,625.06
Rate for Payer: Ohana Health Plan Medicaid	$8,625.06
Rate for Payer: UnitedHealthcare Medicaid	$8,625.06

DIABETES

Facility

$4,300.46

Service Code	APR-DRG 4203
Min. Negotiated Rate	$4,300.46
Max. Negotiated Rate	$4,300.46
Rate for Payer: AlohaCare Medicaid	$4,300.46
Rate for Payer: Hawaii Medical Service Association ABD	$4,300.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,300.46
Rate for Payer: Kaiser Permanente Medicaid	$4,300.46
Rate for Payer: Ohana Health Plan Medicaid	$4,300.46
Rate for Payer: UnitedHealthcare Medicaid	$4,300.46

DIABETES

Facility

$3,047.44

Service Code	APR-DRG 4202
Min. Negotiated Rate	$3,047.44
Max. Negotiated Rate	$3,047.44
Rate for Payer: AlohaCare Medicaid	$3,047.44
Rate for Payer: Hawaii Medical Service Association ABD	$3,047.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,047.44
Rate for Payer: Kaiser Permanente Medicaid	$3,047.44
Rate for Payer: Ohana Health Plan Medicaid	$3,047.44
Rate for Payer: UnitedHealthcare Medicaid	$3,047.44

DIABETES

Facility

$2,356.68

Service Code	APR-DRG 4201
Min. Negotiated Rate	$2,356.68
Max. Negotiated Rate	$2,356.68
Rate for Payer: AlohaCare Medicaid	$2,356.68
Rate for Payer: Hawaii Medical Service Association ABD	$2,356.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,356.68
Rate for Payer: Kaiser Permanente Medicaid	$2,356.68
Rate for Payer: Ohana Health Plan Medicaid	$2,356.68
Rate for Payer: UnitedHealthcare Medicaid	$2,356.68

DIABETES WITH CC

Facility

$15,459.45

Service Code	MSDRG 638
Min. Negotiated Rate	$10,193.60
Max. Negotiated Rate	$15,459.45
Rate for Payer: AlohaCare Medicare	$10,193.60
Rate for Payer: Devoted Health Medicare	$11,212.96
Rate for Payer: Hawaii Medical Service Association Commercial	$15,287.58
Rate for Payer: Hawaii Medical Service Association Medicare	$10,193.60
Rate for Payer: Humana Medicare	$10,193.60
Rate for Payer: Kaiser Permanente Commercial	$15,459.45
Rate for Payer: Kaiser Permanente Medicare	$10,193.60
Rate for Payer: Ohana Health Plan Medicare	$10,193.60
Rate for Payer: UnitedHealthcare Medicare	$10,193.60

DIABETES WITH MCC

Facility

$24,783.08

Service Code	MSDRG 637
Min. Negotiated Rate	$15,433.18
Max. Negotiated Rate	$24,783.08
Rate for Payer: AlohaCare Medicare	$16,341.39
Rate for Payer: Devoted Health Medicare	$17,975.53
Rate for Payer: Hawaii Medical Service Association Commercial	$15,433.18
Rate for Payer: Hawaii Medical Service Association Medicare	$16,341.39
Rate for Payer: Humana Medicare	$16,341.39
Rate for Payer: Kaiser Permanente Commercial	$24,783.08
Rate for Payer: Kaiser Permanente Medicare	$16,341.39
Rate for Payer: Ohana Health Plan Medicare	$16,341.39
Rate for Payer: UnitedHealthcare Medicare	$16,341.39

DIABETES WITHOUT CC/MCC

Facility

$15,166.25

Service Code	MSDRG 639
Min. Negotiated Rate	$7,065.68
Max. Negotiated Rate	$15,166.25
Rate for Payer: AlohaCare Medicare	$7,065.68
Rate for Payer: Devoted Health Medicare	$7,772.25
Rate for Payer: Hawaii Medical Service Association Commercial	$15,166.25
Rate for Payer: Hawaii Medical Service Association Medicare	$7,065.68
Rate for Payer: Humana Medicare	$7,065.68
Rate for Payer: Kaiser Permanente Commercial	$10,715.70
Rate for Payer: Kaiser Permanente Medicare	$7,065.68
Rate for Payer: Ohana Health Plan Medicare	$7,065.68
Rate for Payer: UnitedHealthcare Medicare	$7,065.68

DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [9828]

Facility

$168.00

Service Code	HCPCS Q9963
Hospital Revenue Code	255
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$43.80
Rate for Payer: Cash Price	$37.20
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: MDX Hawaii PPO	$70.81
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: MDX Hawaii PPO	$60.14

DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [9828]

Facility

$73.00

Service Code	HCPCS Q9963
Hospital Revenue Code	255
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$43.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$37.20
Rate for Payer: Cash Price	$37.20
Rate for Payer: Cash Price	$43.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Western Management Group Commercial	$159.60
Rate for Payer: Hawaii Western Management Group Commercial	$58.90
Rate for Payer: Hawaii Western Management Group Commercial	$69.35
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Kaiser Permanente Commercial	$45.99
Rate for Payer: Kaiser Permanente Commercial	$105.84
Rate for Payer: Kaiser Permanente Commercial	$39.06
Rate for Payer: Kaiser Permanente Medicaid	$37.23
Rate for Payer: Kaiser Permanente Medicaid	$85.68
Rate for Payer: Kaiser Permanente Medicaid	$31.62
Rate for Payer: MDX Hawaii PPO	$60.14
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: MDX Hawaii PPO	$70.81
Rate for Payer: UnitedHealthcare Medicaid	$0.17
Rate for Payer: UnitedHealthcare Medicaid	$0.17
Rate for Payer: UnitedHealthcare Medicaid	$0.17
Rate for Payer: University Health Alliance Commercial	$45.19
Rate for Payer: University Health Alliance Commercial	$122.46
Rate for Payer: University Health Alliance Commercial	$53.21

DIAZEPAM 10 MG TABLET [2403]

Facility

$2.00

Service Code	NDC 00378047701
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

DIAZEPAM 10 MG TABLET [2403]

Facility

$2.00

Service Code	NDC 51079028601
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

DIAZEPAM 10 MG TABLET [2403]

Facility

$2.00

Service Code	NDC 00378047701
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

DIAZEPAM 10 MG TABLET [2403]

Facility

$2.00

Service Code	NDC 51079028601
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

DIAZEPAM 10 MG TABLET [2403]

Facility

$2.00

Service Code	NDC 51079028620
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

DIAZEPAM 10 MG TABLET [2403]

Facility

$2.00

Service Code	NDC 51079028620
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

DIAZEPAM 2 MG TABLET [2404]

Facility

$1.00

Service Code	NDC 51079028420
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

DIAZEPAM 2 MG TABLET [2404]

Facility

$1.00

Service Code	NDC 00378027101
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

DIAZEPAM 2 MG TABLET [2404]

Facility

$1.00

Service Code	NDC 00172392560
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

Know your out-of-pocket cost for care.

All Charges