Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14845]

Facility

$63.00

Service Code	HCPCS J1265
Hospital Revenue Code	636
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cash Price	$42.00
Rate for Payer: Cash Price	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.66
Rate for Payer: Hawaii Medical Service Association ABD	$0.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.66
Rate for Payer: Hawaii Western Management Group Commercial	$59.85
Rate for Payer: Hawaii Western Management Group Commercial	$66.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: Kaiser Permanente Commercial	$39.69
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: Kaiser Permanente Medicaid	$35.70
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: MDX Hawaii PPO	$67.90
Rate for Payer: UnitedHealthcare Medicaid	$42.00
Rate for Payer: UnitedHealthcare Medicaid	$37.80
Rate for Payer: University Health Alliance Commercial	$45.92
Rate for Payer: University Health Alliance Commercial	$51.02

DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK

Facility

$36,025.91

Service Code	APR-DRG 3044
Min. Negotiated Rate	$36,025.91
Max. Negotiated Rate	$36,025.91
Rate for Payer: AlohaCare Medicaid	$36,025.91
Rate for Payer: Hawaii Medical Service Association ABD	$36,025.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$36,025.91
Rate for Payer: Kaiser Permanente Medicaid	$36,025.91
Rate for Payer: Ohana Health Plan Medicaid	$36,025.91
Rate for Payer: UnitedHealthcare Medicaid	$36,025.91

DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK

Facility

$17,409.27

Service Code	APR-DRG 3042
Min. Negotiated Rate	$17,409.27
Max. Negotiated Rate	$17,409.27
Rate for Payer: AlohaCare Medicaid	$17,409.27
Rate for Payer: Hawaii Medical Service Association ABD	$17,409.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17,409.27
Rate for Payer: Kaiser Permanente Medicaid	$17,409.27
Rate for Payer: Ohana Health Plan Medicaid	$17,409.27
Rate for Payer: UnitedHealthcare Medicaid	$17,409.27

DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK

Facility

$14,820.39

Service Code	APR-DRG 3041
Min. Negotiated Rate	$14,820.39
Max. Negotiated Rate	$14,820.39
Rate for Payer: AlohaCare Medicaid	$14,820.39
Rate for Payer: Hawaii Medical Service Association ABD	$14,820.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14,820.39
Rate for Payer: Kaiser Permanente Medicaid	$14,820.39
Rate for Payer: Ohana Health Plan Medicaid	$14,820.39
Rate for Payer: UnitedHealthcare Medicaid	$14,820.39

DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK

Facility

$24,896.11

Service Code	APR-DRG 3043
Min. Negotiated Rate	$24,896.11
Max. Negotiated Rate	$24,896.11
Rate for Payer: AlohaCare Medicaid	$24,896.11
Rate for Payer: Hawaii Medical Service Association ABD	$24,896.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24,896.11
Rate for Payer: Kaiser Permanente Medicaid	$24,896.11
Rate for Payer: Ohana Health Plan Medicaid	$24,896.11
Rate for Payer: UnitedHealthcare Medicaid	$24,896.11

DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK

Facility

$38,480.43

Service Code	APR-DRG 3033
Min. Negotiated Rate	$38,480.43
Max. Negotiated Rate	$38,480.43
Rate for Payer: AlohaCare Medicaid	$38,480.43
Rate for Payer: Hawaii Medical Service Association ABD	$38,480.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$38,480.43
Rate for Payer: Kaiser Permanente Medicaid	$38,480.43
Rate for Payer: Ohana Health Plan Medicaid	$38,480.43
Rate for Payer: UnitedHealthcare Medicaid	$38,480.43

DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK

Facility

$24,316.23

Service Code	APR-DRG 3031
Min. Negotiated Rate	$24,316.23
Max. Negotiated Rate	$24,316.23
Rate for Payer: AlohaCare Medicaid	$24,316.23
Rate for Payer: Hawaii Medical Service Association ABD	$24,316.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24,316.23
Rate for Payer: Kaiser Permanente Medicaid	$24,316.23
Rate for Payer: Ohana Health Plan Medicaid	$24,316.23
Rate for Payer: UnitedHealthcare Medicaid	$24,316.23

DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK

Facility

$28,479.07

Service Code	APR-DRG 3032
Min. Negotiated Rate	$28,479.07
Max. Negotiated Rate	$28,479.07
Rate for Payer: AlohaCare Medicaid	$28,479.07
Rate for Payer: Hawaii Medical Service Association ABD	$28,479.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28,479.07
Rate for Payer: Kaiser Permanente Medicaid	$28,479.07
Rate for Payer: Ohana Health Plan Medicaid	$28,479.07
Rate for Payer: UnitedHealthcare Medicaid	$28,479.07

DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK

Facility

$50,251.42

Service Code	APR-DRG 3034
Min. Negotiated Rate	$50,251.42
Max. Negotiated Rate	$50,251.42
Rate for Payer: AlohaCare Medicaid	$50,251.42
Rate for Payer: Hawaii Medical Service Association ABD	$50,251.42
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50,251.42
Rate for Payer: Kaiser Permanente Medicaid	$50,251.42
Rate for Payer: Ohana Health Plan Medicaid	$50,251.42
Rate for Payer: UnitedHealthcare Medicaid	$50,251.42

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

$161.00

Service Code	NDC 24208048510
Hospital Revenue Code	637
Min. Negotiated Rate	$82.11
Max. Negotiated Rate	$156.17
Rate for Payer: Cash Price	$96.60
Rate for Payer: Hawaii Western Management Group Commercial	$152.95
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: Kaiser Permanente Commercial	$101.43
Rate for Payer: Kaiser Permanente Medicaid	$82.11
Rate for Payer: MDX Hawaii PPO	$156.17
Rate for Payer: University Health Alliance Commercial	$117.35

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

$161.00

Service Code	NDC 24208048510
Hospital Revenue Code	250
Min. Negotiated Rate	$136.85
Max. Negotiated Rate	$156.17
Rate for Payer: Cash Price	$96.60
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: MDX Hawaii PPO	$156.17

DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION [179013]

Facility

$14,937.00

Service Code	HCPCS J9272
Hospital Revenue Code	250
Min. Negotiated Rate	$12,696.45
Max. Negotiated Rate	$14,488.89
Rate for Payer: Cash Price	$8,962.20
Rate for Payer: Health Management Network Commercial	$12,696.45
Rate for Payer: MDX Hawaii PPO	$14,488.89

DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION [179013]

Facility

$14,937.00

Service Code	HCPCS J9272
Hospital Revenue Code	636
Min. Negotiated Rate	$243.82
Max. Negotiated Rate	$14,488.89
Rate for Payer: AlohaCare Medicaid	$247.08
Rate for Payer: AlohaCare Medicare	$247.08
Rate for Payer: Cash Price	$8,962.20
Rate for Payer: Cash Price	$8,962.20
Rate for Payer: Devoted Health Medicare	$271.79
Rate for Payer: Hawaii Medical Service Association ABD	$243.82
Rate for Payer: Hawaii Medical Service Association Commercial	$308.85
Rate for Payer: Hawaii Medical Service Association Medicare	$247.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$243.82
Rate for Payer: Hawaii Western Management Group Commercial	$14,190.15
Rate for Payer: Health Management Network Commercial	$12,696.45
Rate for Payer: Humana Medicare	$247.08
Rate for Payer: Kaiser Permanente Commercial	$9,410.31
Rate for Payer: Kaiser Permanente Medicaid	$7,617.87
Rate for Payer: Kaiser Permanente Medicare	$247.08
Rate for Payer: MDX Hawaii PPO	$14,488.89
Rate for Payer: Ohana Health Plan Medicaid	$271.79
Rate for Payer: Ohana Health Plan Medicare	$247.08
Rate for Payer: UnitedHealthcare Medicaid	$8,962.20
Rate for Payer: UnitedHealthcare Medicare	$247.08
Rate for Payer: University Health Alliance Commercial	$10,887.58

DOXEPIN 10 MG CAPSULE [2608]

Facility

$3.00

Service Code	NDC 51079043620
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

DOXEPIN 10 MG CAPSULE [2608]

Facility

$3.00

Service Code	NDC 27241016701
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

DOXEPIN 10 MG CAPSULE [2608]

Facility

$3.00

Service Code	NDC 27241016701
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

DOXEPIN 10 MG CAPSULE [2608]

Facility

$3.00

Service Code	NDC 51079043601
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

DOXEPIN 10 MG CAPSULE [2608]

Facility

$3.00

Service Code	NDC 51079043601
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

DOXEPIN 10 MG CAPSULE [2608]

Facility

$3.00

Service Code	NDC 51079043620
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

DOXEPIN 25 MG CAPSULE [2611]

Facility

$3.00

Service Code	NDC 51079043701
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

DOXEPIN 25 MG CAPSULE [2611]

Facility

$3.00

Service Code	NDC 27241016801
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

DOXEPIN 25 MG CAPSULE [2611]

Facility

$3.00

Service Code	NDC 27241016801
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

DOXEPIN 25 MG CAPSULE [2611]

Facility

$3.00

Service Code	NDC 51079043701
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

DOXEPIN 50 MG CAPSULE [2612]

Facility

$5.00

Service Code	NDC 27241016901
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

DOXEPIN 50 MG CAPSULE [2612]

Facility

$5.00

Service Code	NDC 27241016901
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

Know your out-of-pocket cost for care.

All Charges