Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

DICYCLOMINE 10 MG CAPSULE [2418]

Facility

$3.00

Service Code	NDC 60687036911
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: University Health Alliance Commercial	$2.19

DICYCLOMINE 10 MG CAPSULE [2418]

Facility

$3.00

Service Code	NDC 60687036901
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: University Health Alliance Commercial	$2.19

DICYCLOMINE 10 MG CAPSULE [2418]

Facility

$3.00

Service Code	NDC 60687036901
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

DICYCLOMINE 10 MG CAPSULE [2418]

Facility

$3.00

Service Code	NDC 60687036911
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION [2417]

Facility

$122.00

Service Code	HCPCS J0500
Hospital Revenue Code	636
Min. Negotiated Rate	$11.68
Max. Negotiated Rate	$118.34
Rate for Payer: Cash Price	$73.20
Rate for Payer: Cash Price	$44.40
Rate for Payer: Cash Price	$44.40
Rate for Payer: Cash Price	$73.20
Rate for Payer: Hawaii Medical Service Association ABD	$11.68
Rate for Payer: Hawaii Medical Service Association ABD	$11.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.68
Rate for Payer: Hawaii Western Management Group Commercial	$115.90
Rate for Payer: Hawaii Western Management Group Commercial	$70.30
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: Kaiser Permanente Commercial	$46.62
Rate for Payer: Kaiser Permanente Commercial	$76.86
Rate for Payer: Kaiser Permanente Medicaid	$62.22
Rate for Payer: Kaiser Permanente Medicaid	$37.74
Rate for Payer: MDX Hawaii PPO	$118.34
Rate for Payer: MDX Hawaii PPO	$71.78
Rate for Payer: UnitedHealthcare Medicaid	$44.40
Rate for Payer: UnitedHealthcare Medicaid	$73.20
Rate for Payer: University Health Alliance Commercial	$88.93
Rate for Payer: University Health Alliance Commercial	$53.94

DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION [2417]

Facility

$122.00

Service Code	HCPCS J0500
Hospital Revenue Code	250
Min. Negotiated Rate	$103.70
Max. Negotiated Rate	$118.34
Rate for Payer: Cash Price	$73.20
Rate for Payer: Cash Price	$44.40
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: MDX Hawaii PPO	$71.78
Rate for Payer: MDX Hawaii PPO	$118.34

DICYCLOMINE 20 MG TABLET [2420]

Facility

$2.00

Service Code	NDC 60687038011
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

DICYCLOMINE 20 MG TABLET [2420]

Facility

$2.00

Service Code	NDC 60687038001
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

DICYCLOMINE 20 MG TABLET [2420]

Facility

$2.00

Service Code	NDC 60687038011
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

DICYCLOMINE 20 MG TABLET [2420]

Facility

$2.00

Service Code	NDC 60687038001
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

DICYCLOMINE TABLETS (BENTYL) 20 MG (TAKE HOME) [4080354]

Facility

$15.00

Service Code	NDC 00004080142
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: MDX Hawaii PPO	$14.55

DICYCLOMINE TABLETS (BENTYL) 20 MG (TAKE HOME) [4080354]

Facility

$15.00

Service Code	NDC 00004080142
Hospital Revenue Code	253
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$9.45
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: University Health Alliance Commercial	$10.93

DIGESTIVE MALIGNANCY

Facility

$5,972.25

Service Code	APR-DRG 2403
Min. Negotiated Rate	$5,972.25
Max. Negotiated Rate	$5,972.25
Rate for Payer: AlohaCare Medicaid	$5,972.25
Rate for Payer: Hawaii Medical Service Association ABD	$5,972.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,972.25
Rate for Payer: Kaiser Permanente Medicaid	$5,972.25
Rate for Payer: Ohana Health Plan Medicaid	$5,972.25
Rate for Payer: UnitedHealthcare Medicaid	$5,972.25

DIGESTIVE MALIGNANCY

Facility

$4,348.73

Service Code	APR-DRG 2402
Min. Negotiated Rate	$4,348.73
Max. Negotiated Rate	$4,348.73
Rate for Payer: AlohaCare Medicaid	$4,348.73
Rate for Payer: Hawaii Medical Service Association ABD	$4,348.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,348.73
Rate for Payer: Kaiser Permanente Medicaid	$4,348.73
Rate for Payer: Ohana Health Plan Medicaid	$4,348.73
Rate for Payer: UnitedHealthcare Medicaid	$4,348.73

DIGESTIVE MALIGNANCY

Facility

$9,679.79

Service Code	APR-DRG 2404
Min. Negotiated Rate	$9,679.79
Max. Negotiated Rate	$9,679.79
Rate for Payer: AlohaCare Medicaid	$9,679.79
Rate for Payer: Hawaii Medical Service Association ABD	$9,679.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,679.79
Rate for Payer: Kaiser Permanente Medicaid	$9,679.79
Rate for Payer: Ohana Health Plan Medicaid	$9,679.79
Rate for Payer: UnitedHealthcare Medicaid	$9,679.79

DIGESTIVE MALIGNANCY

Facility

$3,922.79

Service Code	APR-DRG 2401
Min. Negotiated Rate	$3,922.79
Max. Negotiated Rate	$3,922.79
Rate for Payer: AlohaCare Medicaid	$3,922.79
Rate for Payer: Hawaii Medical Service Association ABD	$3,922.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,922.79
Rate for Payer: Kaiser Permanente Medicaid	$3,922.79
Rate for Payer: Ohana Health Plan Medicaid	$3,922.79
Rate for Payer: UnitedHealthcare Medicaid	$3,922.79

DIGESTIVE MALIGNANCY WITH CC

Facility

$55,933.13

Service Code	MSDRG 375
Min. Negotiated Rate	$13,758.31
Max. Negotiated Rate	$55,933.13
Rate for Payer: AlohaCare Medicare	$13,758.31
Rate for Payer: Devoted Health Medicare	$15,134.14
Rate for Payer: Hawaii Medical Service Association Commercial	$55,933.13
Rate for Payer: Hawaii Medical Service Association Medicare	$13,758.31
Rate for Payer: Humana Medicare	$13,758.31
Rate for Payer: Kaiser Permanente Commercial	$20,865.60
Rate for Payer: Kaiser Permanente Medicare	$13,758.31
Rate for Payer: Ohana Health Plan Medicare	$13,758.31
Rate for Payer: UnitedHealthcare Medicare	$13,758.31

DIGESTIVE MALIGNANCY WITH MCC

Facility

$57,267.76

Service Code	MSDRG 374
Min. Negotiated Rate	$24,326.12
Max. Negotiated Rate	$57,267.76
Rate for Payer: AlohaCare Medicare	$24,326.12
Rate for Payer: Devoted Health Medicare	$26,758.73
Rate for Payer: Hawaii Medical Service Association Commercial	$57,267.76
Rate for Payer: Hawaii Medical Service Association Medicare	$24,326.12
Rate for Payer: Humana Medicare	$24,326.12
Rate for Payer: Kaiser Permanente Commercial	$36,892.57
Rate for Payer: Kaiser Permanente Medicare	$24,326.12
Rate for Payer: Ohana Health Plan Medicare	$24,326.12
Rate for Payer: UnitedHealthcare Medicare	$24,326.12

DIGESTIVE MALIGNANCY WITHOUT CC/MCC

Facility

$29,167.73

Service Code	MSDRG 376
Min. Negotiated Rate	$10,513.22
Max. Negotiated Rate	$29,167.73
Rate for Payer: AlohaCare Medicare	$10,513.22
Rate for Payer: Devoted Health Medicare	$11,564.54
Rate for Payer: Hawaii Medical Service Association Commercial	$29,167.73
Rate for Payer: Hawaii Medical Service Association Medicare	$10,513.22
Rate for Payer: Humana Medicare	$10,513.22
Rate for Payer: Kaiser Permanente Commercial	$15,944.17
Rate for Payer: Kaiser Permanente Medicare	$10,513.22
Rate for Payer: Ohana Health Plan Medicare	$10,513.22
Rate for Payer: UnitedHealthcare Medicare	$10,513.22

DIGIT WIDGET EXTL FIX DWD-232

Facility

$3,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,683.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Kaiser Permanente Commercial	$2,079.00
Rate for Payer: Kaiser Permanente Medicaid	$1,683.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

DIGIT WIDGET EXTL FIX DWD-232

Facility

$3,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,848.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$5.00

Service Code	NDC 60687054001
Hospital Revenue Code	637
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
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: University Health Alliance Commercial	$3.64

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$5.00

Service Code	NDC 60687054001
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

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$6.00

Service Code	NDC 60687085811
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$6.00

Service Code	NDC 60687085801
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

Know your out-of-pocket cost for care.

All Charges