Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

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

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

$5.00

Service Code	NDC 60687054011
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 60687085801
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

DIGOXIN 250 MCG (0.25 MG) TABLET [2445]

Facility

$6.00

Service Code	NDC 00904592261
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 250 MCG (0.25 MG) TABLET [2445]

Facility

$9.00

Service Code	NDC 00143124101
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: University Health Alliance Commercial	$6.56

DIGOXIN 250 MCG (0.25 MG) TABLET [2445]

Facility

$9.00

Service Code	NDC 00143124101
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

DIGOXIN 250 MCG (0.25 MG) TABLET [2445]

Facility

$6.00

Service Code	NDC 00904592261
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

DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION [2442]

Facility

$24.00

Service Code	HCPCS J1160
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: MDX Hawaii PPO	$23.28

DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION [2442]

Facility

$24.00

Service Code	HCPCS J1160
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cash Price	$14.40
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.00
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$15.12
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: UnitedHealthcare Medicaid	$14.40
Rate for Payer: University Health Alliance Commercial	$17.49

DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION [43556]

Facility

$224.00

Service Code	NDC 66689032702
Hospital Revenue Code	637
Min. Negotiated Rate	$114.24
Max. Negotiated Rate	$217.28
Rate for Payer: Cash Price	$134.40
Rate for Payer: Hawaii Western Management Group Commercial	$212.80
Rate for Payer: Health Management Network Commercial	$190.40
Rate for Payer: Kaiser Permanente Commercial	$141.12
Rate for Payer: Kaiser Permanente Medicaid	$114.24
Rate for Payer: MDX Hawaii PPO	$217.28
Rate for Payer: University Health Alliance Commercial	$163.27

DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION [43556]

Facility

$252.00

Service Code	NDC 00054005746
Hospital Revenue Code	250
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$244.44
Rate for Payer: Cash Price	$151.20
Rate for Payer: Health Management Network Commercial	$214.20
Rate for Payer: MDX Hawaii PPO	$244.44

DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION [43556]

Facility

$224.00

Service Code	NDC 66689032702
Hospital Revenue Code	250
Min. Negotiated Rate	$190.40
Max. Negotiated Rate	$217.28
Rate for Payer: Cash Price	$134.40
Rate for Payer: Health Management Network Commercial	$190.40
Rate for Payer: MDX Hawaii PPO	$217.28

DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION [43556]

Facility

$252.00

Service Code	NDC 00054005746
Hospital Revenue Code	637
Min. Negotiated Rate	$128.52
Max. Negotiated Rate	$244.44
Rate for Payer: Cash Price	$151.20
Rate for Payer: Hawaii Western Management Group Commercial	$239.40
Rate for Payer: Health Management Network Commercial	$214.20
Rate for Payer: Kaiser Permanente Commercial	$158.76
Rate for Payer: Kaiser Permanente Medicaid	$128.52
Rate for Payer: MDX Hawaii PPO	$244.44
Rate for Payer: University Health Alliance Commercial	$183.68

DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION [31432]

Facility

$6,469.00

Service Code	HCPCS J1162
Hospital Revenue Code	250
Min. Negotiated Rate	$5,498.65
Max. Negotiated Rate	$6,274.93
Rate for Payer: Cash Price	$3,881.40
Rate for Payer: Health Management Network Commercial	$5,498.65
Rate for Payer: MDX Hawaii PPO	$6,274.93

DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION [31432]

Facility

$6,469.00

Service Code	HCPCS J1162
Hospital Revenue Code	636
Min. Negotiated Rate	$3,299.19
Max. Negotiated Rate	$6,458.74
Rate for Payer: AlohaCare Medicaid	$5,166.99
Rate for Payer: AlohaCare Medicare	$5,166.99
Rate for Payer: Cash Price	$3,881.40
Rate for Payer: Cash Price	$3,881.40
Rate for Payer: Devoted Health Medicare	$5,683.69
Rate for Payer: Hawaii Medical Service Association ABD	$4,968.58
Rate for Payer: Hawaii Medical Service Association Commercial	$6,458.74
Rate for Payer: Hawaii Medical Service Association Medicare	$5,166.99
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,968.58
Rate for Payer: Hawaii Western Management Group Commercial	$6,145.55
Rate for Payer: Health Management Network Commercial	$5,498.65
Rate for Payer: Humana Medicare	$5,166.99
Rate for Payer: Kaiser Permanente Commercial	$4,075.47
Rate for Payer: Kaiser Permanente Medicaid	$3,299.19
Rate for Payer: Kaiser Permanente Medicare	$5,166.99
Rate for Payer: MDX Hawaii PPO	$6,274.93
Rate for Payer: Ohana Health Plan Medicaid	$5,683.69
Rate for Payer: Ohana Health Plan Medicare	$5,166.99
Rate for Payer: UnitedHealthcare Medicaid	$3,881.40
Rate for Payer: UnitedHealthcare Medicare	$5,166.99
Rate for Payer: University Health Alliance Commercial	$4,715.25

DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)

Facility

$5,509.00

Service Code	CPT 58120
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$3,824.16
Rate for Payer: AlohaCare Medicare	$3,824.16
Rate for Payer: Devoted Health Medicare	$4,206.58
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	$3,824.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,824.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,824.16
Rate for Payer: Ohana Health Plan Medicaid	$4,206.58
Rate for Payer: Ohana Health Plan Medicare	$3,824.16
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,824.16
Rate for Payer: University Health Alliance Commercial	$5,160.40

DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$7,492.71

Service Code	APR-DRG 5173
Min. Negotiated Rate	$7,492.71
Max. Negotiated Rate	$7,492.71
Rate for Payer: AlohaCare Medicaid	$7,492.71
Rate for Payer: Hawaii Medical Service Association ABD	$7,492.71
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,492.71
Rate for Payer: Kaiser Permanente Medicaid	$7,492.71
Rate for Payer: Ohana Health Plan Medicaid	$7,492.71
Rate for Payer: UnitedHealthcare Medicaid	$7,492.71

DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$15,980.13

Service Code	APR-DRG 5174
Min. Negotiated Rate	$15,980.13
Max. Negotiated Rate	$15,980.13
Rate for Payer: AlohaCare Medicaid	$15,980.13
Rate for Payer: Hawaii Medical Service Association ABD	$15,980.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15,980.13
Rate for Payer: Kaiser Permanente Medicaid	$15,980.13
Rate for Payer: Ohana Health Plan Medicaid	$15,980.13
Rate for Payer: UnitedHealthcare Medicaid	$15,980.13

DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$4,919.47

Service Code	APR-DRG 5172
Min. Negotiated Rate	$4,919.47
Max. Negotiated Rate	$4,919.47
Rate for Payer: AlohaCare Medicaid	$4,919.47
Rate for Payer: Hawaii Medical Service Association ABD	$4,919.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,919.47
Rate for Payer: Kaiser Permanente Medicaid	$4,919.47
Rate for Payer: Ohana Health Plan Medicaid	$4,919.47
Rate for Payer: UnitedHealthcare Medicaid	$4,919.47

DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES

Facility

$3,857.57

Service Code	APR-DRG 5171
Min. Negotiated Rate	$3,857.57
Max. Negotiated Rate	$3,857.57
Rate for Payer: AlohaCare Medicaid	$3,857.57
Rate for Payer: Hawaii Medical Service Association ABD	$3,857.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,857.57
Rate for Payer: Kaiser Permanente Medicaid	$3,857.57
Rate for Payer: Ohana Health Plan Medicaid	$3,857.57
Rate for Payer: UnitedHealthcare Medicaid	$3,857.57

DILATION OF CERVICAL CANAL, INSTRUMENTAL (SEPARATE PROCEDURE)

Facility

$4,780.20

Service Code	CPT 57800
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$4,780.20
Rate for Payer: AlohaCare Medicaid	$3,824.16
Rate for Payer: AlohaCare Medicare	$3,824.16
Rate for Payer: Devoted Health Medicare	$4,206.58
Rate for Payer: Hawaii Medical Service Association Commercial	$4,780.20
Rate for Payer: Hawaii Medical Service Association Medicare	$3,824.16
Rate for Payer: Humana Medicare	$3,824.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,824.16
Rate for Payer: Ohana Health Plan Medicaid	$4,206.58
Rate for Payer: Ohana Health Plan Medicare	$3,824.16
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,824.16

DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES

Facility

$2,837.00

Service Code	CPT 43450
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$1,071.46
Rate for Payer: AlohaCare Medicare	$1,071.46
Rate for Payer: Devoted Health Medicare	$1,178.61
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	$1,071.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$1,071.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,071.46
Rate for Payer: Ohana Health Plan Medicaid	$1,178.61
Rate for Payer: Ohana Health Plan Medicare	$1,071.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,071.46

DILATION OF EXISTING TRACT, PERCUTANEOUS, FOR AN ENDOUROLOGIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, WITH POSTPROCEDURE TUBE PLACEMENT, WHEN PERFORMED; INCLUDING NEW ACCESS INTO THE RENAL COLLECTING SYSTEM

Facility

$5,205.27

Service Code	CPT 50437
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,205.27
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
Rate for Payer: Hawaii Medical Service Association Commercial	$5,205.27
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22

DILATOR 28FR AMPLATZ

Facility

$207.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$105.57
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$124.20
Rate for Payer: Hawaii Western Management Group Commercial	$196.65
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$130.41
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: University Health Alliance Commercial	$150.88

Know your out-of-pocket cost for care.

All Charges