Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

DIPHENHYDRAMINE 50 MG CAPSULE [2510]

Facility

$1.00

Service Code	HCPCS Q0163
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

DIPHENHYDRAMINE 50 MG IN 50 MG NS IVPB-CNR (SIMPLE) [4080017]

Facility

$6.00

Service Code	HCPCS J1200
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
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: UnitedHealthcare Medicaid	$3.60
Rate for Payer: University Health Alliance Commercial	$4.37

DIPHENHYDRAMINE 50 MG IN 50 MG NS IVPB-CNR (SIMPLE) [4080017]

Facility

$6.00

Service Code	HCPCS J1200
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

DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]

Facility

$5.00

Service Code	HCPCS J1200
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: MDX Hawaii PPO	$4.85

DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]

Facility

$5.00

Service Code	HCPCS J1200
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Commercial	$4.41
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: UnitedHealthcare Medicaid	$3.00
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: University Health Alliance Commercial	$5.10
Rate for Payer: University Health Alliance Commercial	$3.64

DIPHENHYDRAMINE CAPSULES (BENADRYL) 25 MG (TAKE HOME) [4080356]

Facility

$15.00

Service Code	HCPCS Q0163
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

DIPHENHYDRAMINE CAPSULES (BENADRYL) 25 MG (TAKE HOME) [4080356]

Facility

$15.00

Service Code	HCPCS Q0163
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

DIPHENHYDRAMINE SOLUTION (BENADRYL) 12.5 MG/5 ML (118 ML) (TAKE HOME) [4080355]

Facility

$15.00

Service Code	NDC 00004080143
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

DIPHENHYDRAMINE SOLUTION (BENADRYL) 12.5 MG/5 ML (118 ML) (TAKE HOME) [4080355]

Facility

$15.00

Service Code	NDC 00004080143
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

DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]

Facility

$71.00

Service Code	HCPCS 90700
Hospital Revenue Code	250
Min. Negotiated Rate	$60.35
Max. Negotiated Rate	$68.87
Rate for Payer: Cash Price	$42.60
Rate for Payer: Health Management Network Commercial	$60.35
Rate for Payer: MDX Hawaii PPO	$68.87

DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]

Facility

$71.00

Service Code	HCPCS 90700
Hospital Revenue Code	636
Min. Negotiated Rate	$32.42
Max. Negotiated Rate	$68.87
Rate for Payer: Cash Price	$42.60
Rate for Payer: Cash Price	$42.60
Rate for Payer: Hawaii Medical Service Association ABD	$32.42
Rate for Payer: Hawaii Medical Service Association Non-ABD	$32.42
Rate for Payer: Hawaii Western Management Group Commercial	$67.45
Rate for Payer: Health Management Network Commercial	$60.35
Rate for Payer: Kaiser Permanente Commercial	$44.73
Rate for Payer: Kaiser Permanente Medicaid	$36.21
Rate for Payer: MDX Hawaii PPO	$68.87
Rate for Payer: UnitedHealthcare Medicaid	$42.60
Rate for Payer: University Health Alliance Commercial	$51.75

DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [180683]

Facility

$88.00

Service Code	HCPCS 90715
Hospital Revenue Code	636
Min. Negotiated Rate	$38.63
Max. Negotiated Rate	$85.36
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cash Price	$52.80
Rate for Payer: Hawaii Medical Service Association ABD	$38.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$38.63
Rate for Payer: Hawaii Western Management Group Commercial	$83.60
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Kaiser Permanente Commercial	$55.44
Rate for Payer: Kaiser Permanente Medicaid	$44.88
Rate for Payer: MDX Hawaii PPO	$85.36
Rate for Payer: UnitedHealthcare Medicaid	$52.80
Rate for Payer: University Health Alliance Commercial	$64.14

DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [180683]

Facility

$88.00

Service Code	HCPCS 90715
Hospital Revenue Code	250
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$85.36
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: MDX Hawaii PPO	$85.36

DIP-PERT-TET-POLIO-HIB(PF) 15 LF-20 MCG-5 LF-62 DU-10MCG/0.5 ML IM KIT [209491]

Facility

$215.00

Service Code	NDC 49281051105
Hospital Revenue Code	250
Min. Negotiated Rate	$182.75
Max. Negotiated Rate	$208.55
Rate for Payer: Cash Price	$129.00
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: MDX Hawaii PPO	$208.55

DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY

Facility

$24,500.00

Service Code	CPT 35045
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$6,573.58
Rate for Payer: AlohaCare Medicare	$6,573.58
Rate for Payer: Devoted Health Medicare	$7,230.94
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,573.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$6,573.58
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,573.58
Rate for Payer: Ohana Health Plan Medicaid	$7,230.94
Rate for Payer: Ohana Health Plan Medicare	$6,573.58
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,573.58
Rate for Payer: University Health Alliance Commercial	$24,500.00

DISORDERS OF GALLBLADDER & BILIARY TRACT

Facility

$3,515.77

Service Code	APR-DRG 2841
Min. Negotiated Rate	$3,515.77
Max. Negotiated Rate	$3,515.77
Rate for Payer: AlohaCare Medicaid	$3,515.77
Rate for Payer: Hawaii Medical Service Association ABD	$3,515.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,515.77
Rate for Payer: Kaiser Permanente Medicaid	$3,515.77
Rate for Payer: Ohana Health Plan Medicaid	$3,515.77
Rate for Payer: UnitedHealthcare Medicaid	$3,515.77

DISORDERS OF GALLBLADDER & BILIARY TRACT

Facility

$4,395.69

Service Code	APR-DRG 2842
Min. Negotiated Rate	$4,395.69
Max. Negotiated Rate	$4,395.69
Rate for Payer: AlohaCare Medicaid	$4,395.69
Rate for Payer: Hawaii Medical Service Association ABD	$4,395.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,395.69
Rate for Payer: Kaiser Permanente Medicaid	$4,395.69
Rate for Payer: Ohana Health Plan Medicaid	$4,395.69
Rate for Payer: UnitedHealthcare Medicaid	$4,395.69

DISORDERS OF GALLBLADDER & BILIARY TRACT

Facility

$10,538.84

Service Code	APR-DRG 2844
Min. Negotiated Rate	$10,538.84
Max. Negotiated Rate	$10,538.84
Rate for Payer: AlohaCare Medicaid	$10,538.84
Rate for Payer: Hawaii Medical Service Association ABD	$10,538.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,538.84
Rate for Payer: Kaiser Permanente Medicaid	$10,538.84
Rate for Payer: Ohana Health Plan Medicaid	$10,538.84
Rate for Payer: UnitedHealthcare Medicaid	$10,538.84

DISORDERS OF GALLBLADDER & BILIARY TRACT

Facility

$6,023.78

Service Code	APR-DRG 2843
Min. Negotiated Rate	$6,023.78
Max. Negotiated Rate	$6,023.78
Rate for Payer: AlohaCare Medicaid	$6,023.78
Rate for Payer: Hawaii Medical Service Association ABD	$6,023.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,023.78
Rate for Payer: Kaiser Permanente Medicaid	$6,023.78
Rate for Payer: Ohana Health Plan Medicaid	$6,023.78
Rate for Payer: UnitedHealthcare Medicaid	$6,023.78

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC

Facility

$32,686.30

Service Code	MSDRG 442
Min. Negotiated Rate	$10,979.56
Max. Negotiated Rate	$32,686.30
Rate for Payer: AlohaCare Medicare	$10,979.56
Rate for Payer: Devoted Health Medicare	$12,077.52
Rate for Payer: Hawaii Medical Service Association Commercial	$32,686.30
Rate for Payer: Hawaii Medical Service Association Medicare	$10,979.56
Rate for Payer: Humana Medicare	$10,979.56
Rate for Payer: Kaiser Permanente Commercial	$16,651.42
Rate for Payer: Kaiser Permanente Medicare	$10,979.56
Rate for Payer: Ohana Health Plan Medicare	$10,979.56
Rate for Payer: UnitedHealthcare Medicare	$10,979.56

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC

Facility

$32,686.30

Service Code	MSDRG 441
Min. Negotiated Rate	$20,413.38
Max. Negotiated Rate	$32,686.30
Rate for Payer: AlohaCare Medicare	$20,413.38
Rate for Payer: Devoted Health Medicare	$22,454.72
Rate for Payer: Hawaii Medical Service Association Commercial	$32,686.30
Rate for Payer: Hawaii Medical Service Association Medicare	$20,413.38
Rate for Payer: Humana Medicare	$20,413.38
Rate for Payer: Kaiser Permanente Commercial	$30,958.58
Rate for Payer: Kaiser Permanente Medicare	$20,413.38
Rate for Payer: Ohana Health Plan Medicare	$20,413.38
Rate for Payer: UnitedHealthcare Medicare	$20,413.38

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC

Facility

$23,635.08

Service Code	MSDRG 443
Min. Negotiated Rate	$7,958.56
Max. Negotiated Rate	$23,635.08
Rate for Payer: AlohaCare Medicare	$7,958.56
Rate for Payer: Devoted Health Medicare	$8,754.42
Rate for Payer: Hawaii Medical Service Association Commercial	$23,635.08
Rate for Payer: Hawaii Medical Service Association Medicare	$7,958.56
Rate for Payer: Humana Medicare	$7,958.56
Rate for Payer: Kaiser Permanente Commercial	$12,069.83
Rate for Payer: Kaiser Permanente Medicare	$7,958.56
Rate for Payer: Ohana Health Plan Medicare	$7,958.56
Rate for Payer: UnitedHealthcare Medicare	$7,958.56

DISORDERS OF PANCREAS EXCEPT MALIGNANCY

Facility

$5,552.18

Service Code	APR-DRG 2823
Min. Negotiated Rate	$5,552.18
Max. Negotiated Rate	$5,552.18
Rate for Payer: AlohaCare Medicaid	$5,552.18
Rate for Payer: Hawaii Medical Service Association ABD	$5,552.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,552.18
Rate for Payer: Kaiser Permanente Medicaid	$5,552.18
Rate for Payer: Ohana Health Plan Medicaid	$5,552.18
Rate for Payer: UnitedHealthcare Medicaid	$5,552.18

DISORDERS OF PANCREAS EXCEPT MALIGNANCY

Facility

$12,282.38

Service Code	APR-DRG 2824
Min. Negotiated Rate	$12,282.38
Max. Negotiated Rate	$12,282.38
Rate for Payer: AlohaCare Medicaid	$12,282.38
Rate for Payer: Hawaii Medical Service Association ABD	$12,282.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12,282.38
Rate for Payer: Kaiser Permanente Medicaid	$12,282.38
Rate for Payer: Ohana Health Plan Medicaid	$12,282.38
Rate for Payer: UnitedHealthcare Medicaid	$12,282.38

DISORDERS OF PANCREAS EXCEPT MALIGNANCY

Facility

$2,828.27

Service Code	APR-DRG 2821
Min. Negotiated Rate	$2,828.27
Max. Negotiated Rate	$2,828.27
Rate for Payer: AlohaCare Medicaid	$2,828.27
Rate for Payer: Hawaii Medical Service Association ABD	$2,828.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,828.27
Rate for Payer: Kaiser Permanente Medicaid	$2,828.27
Rate for Payer: Ohana Health Plan Medicaid	$2,828.27
Rate for Payer: UnitedHealthcare Medicaid	$2,828.27

Know your out-of-pocket cost for care.

All Charges