Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Facility

$26,428.96

Service Code	APR-DRG 0092
Min. Negotiated Rate	$26,428.96
Max. Negotiated Rate	$26,428.96
Rate for Payer: AlohaCare Medicaid	$26,428.96
Rate for Payer: Hawaii Medical Service Association ABD	$26,428.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26,428.96
Rate for Payer: Kaiser Permanente Medicaid	$26,428.96
Rate for Payer: Ohana Health Plan Medicaid	$26,428.96
Rate for Payer: UnitedHealthcare Medicaid	$26,428.96

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Facility

$38,348.02

Service Code	APR-DRG 0093
Min. Negotiated Rate	$38,348.02
Max. Negotiated Rate	$38,348.02
Rate for Payer: AlohaCare Medicaid	$38,348.02
Rate for Payer: Hawaii Medical Service Association ABD	$38,348.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$38,348.02
Rate for Payer: Kaiser Permanente Medicaid	$38,348.02
Rate for Payer: Ohana Health Plan Medicaid	$38,348.02
Rate for Payer: UnitedHealthcare Medicaid	$38,348.02

EXTRACRANIAL PROCEDURES WITH CC

Facility

$55,423.54

Service Code	MSDRG 038
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$55,423.54
Rate for Payer: AlohaCare Medicare	$18,455.87
Rate for Payer: Devoted Health Medicare	$20,301.46
Rate for Payer: Hawaii Medical Service Association Commercial	$55,423.54
Rate for Payer: Hawaii Medical Service Association Medicare	$18,455.87
Rate for Payer: Humana Medicare	$18,455.87
Rate for Payer: Kaiser Permanente Commercial	$27,989.85
Rate for Payer: Kaiser Permanente Medicare	$18,455.87
Rate for Payer: Ohana Health Plan Medicare	$18,455.87
Rate for Payer: UnitedHealthcare Medicare	$18,455.87
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRACRANIAL PROCEDURES WITH MCC

Facility

$66,585.90

Service Code	MSDRG 037
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$66,585.90
Rate for Payer: AlohaCare Medicare	$37,445.18
Rate for Payer: Devoted Health Medicare	$41,189.70
Rate for Payer: Hawaii Medical Service Association Commercial	$66,585.90
Rate for Payer: Hawaii Medical Service Association Medicare	$37,445.18
Rate for Payer: Humana Medicare	$37,445.18
Rate for Payer: Kaiser Permanente Commercial	$56,788.72
Rate for Payer: Kaiser Permanente Medicare	$37,445.18
Rate for Payer: Ohana Health Plan Medicare	$37,445.18
Rate for Payer: UnitedHealthcare Medicare	$37,445.18
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRACRANIAL PROCEDURES WITHOUT CC/MCC

Facility

$43,144.95

Service Code	MSDRG 039
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$43,144.95
Rate for Payer: AlohaCare Medicare	$13,370.42
Rate for Payer: Devoted Health Medicare	$14,707.46
Rate for Payer: Hawaii Medical Service Association Commercial	$43,144.95
Rate for Payer: Hawaii Medical Service Association Medicare	$13,370.42
Rate for Payer: Humana Medicare	$13,370.42
Rate for Payer: Kaiser Permanente Commercial	$20,277.38
Rate for Payer: Kaiser Permanente Medicare	$13,370.42
Rate for Payer: Ohana Health Plan Medicare	$13,370.42
Rate for Payer: UnitedHealthcare Medicare	$13,370.42
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRAOCULAR PROCEDURES EXCEPT ORBIT

Facility

$26,477.03

Service Code	MSDRG 115
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$26,477.03
Rate for Payer: AlohaCare Medicare	$17,458.34
Rate for Payer: Devoted Health Medicare	$19,204.17
Rate for Payer: Hawaii Medical Service Association Commercial	$18,223.77
Rate for Payer: Hawaii Medical Service Association Medicare	$17,458.34
Rate for Payer: Humana Medicare	$17,458.34
Rate for Payer: Kaiser Permanente Commercial	$26,477.03
Rate for Payer: Kaiser Permanente Medicare	$17,458.34
Rate for Payer: Ohana Health Plan Medicare	$17,458.34
Rate for Payer: UnitedHealthcare Medicare	$17,458.34
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE

Facility

$278,452.35

Service Code	MSDRG 790
Min. Negotiated Rate	$67,602.88
Max. Negotiated Rate	$278,452.35
Rate for Payer: AlohaCare Medicare	$67,602.88
Rate for Payer: Devoted Health Medicare	$74,363.17
Rate for Payer: Hawaii Medical Service Association Commercial	$278,452.35
Rate for Payer: Hawaii Medical Service Association Medicare	$67,602.88
Rate for Payer: Humana Medicare	$67,602.88
Rate for Payer: Kaiser Permanente Commercial	$102,525.38
Rate for Payer: Kaiser Permanente Medicare	$67,602.88
Rate for Payer: Ohana Health Plan Medicare	$67,602.88
Rate for Payer: UnitedHealthcare Medicare	$67,602.88

EYE INFECTIONS & OTHER EYE DISORDERS

Facility

$9,439.75

Service Code	APR-DRG 0824
Min. Negotiated Rate	$9,439.75
Max. Negotiated Rate	$9,439.75
Rate for Payer: AlohaCare Medicaid	$9,439.75
Rate for Payer: Hawaii Medical Service Association ABD	$9,439.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,439.75
Rate for Payer: Kaiser Permanente Medicaid	$9,439.75
Rate for Payer: Ohana Health Plan Medicaid	$9,439.75
Rate for Payer: UnitedHealthcare Medicaid	$9,439.75

EYE INFECTIONS & OTHER EYE DISORDERS

Facility

$4,835.33

Service Code	APR-DRG 0823
Min. Negotiated Rate	$4,835.33
Max. Negotiated Rate	$4,835.33
Rate for Payer: AlohaCare Medicaid	$4,835.33
Rate for Payer: Hawaii Medical Service Association ABD	$4,835.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,835.33
Rate for Payer: Kaiser Permanente Medicaid	$4,835.33
Rate for Payer: Ohana Health Plan Medicaid	$4,835.33
Rate for Payer: UnitedHealthcare Medicaid	$4,835.33

EYE INFECTIONS & OTHER EYE DISORDERS

Facility

$2,665.86

Service Code	APR-DRG 0821
Min. Negotiated Rate	$2,665.86
Max. Negotiated Rate	$2,665.86
Rate for Payer: AlohaCare Medicaid	$2,665.86
Rate for Payer: Hawaii Medical Service Association ABD	$2,665.86
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,665.86
Rate for Payer: Kaiser Permanente Medicaid	$2,665.86
Rate for Payer: Ohana Health Plan Medicaid	$2,665.86
Rate for Payer: UnitedHealthcare Medicaid	$2,665.86

EYE INFECTIONS & OTHER EYE DISORDERS

Facility

$3,383.36

Service Code	APR-DRG 0822
Min. Negotiated Rate	$3,383.36
Max. Negotiated Rate	$3,383.36
Rate for Payer: AlohaCare Medicaid	$3,383.36
Rate for Payer: Hawaii Medical Service Association ABD	$3,383.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,383.36
Rate for Payer: Kaiser Permanente Medicaid	$3,383.36
Rate for Payer: Ohana Health Plan Medicaid	$3,383.36
Rate for Payer: UnitedHealthcare Medicaid	$3,383.36

EZETIMIBE 10 MG TABLET [34153]

Facility

$31.00

Service Code	NDC 60687037311
Hospital Revenue Code	637
Min. Negotiated Rate	$15.81
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Kaiser Permanente Commercial	$19.53
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: University Health Alliance Commercial	$22.60

EZETIMIBE 10 MG TABLET [34153]

Facility

$31.00

Service Code	NDC 60687037321
Hospital Revenue Code	250
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: MDX Hawaii PPO	$30.07

EZETIMIBE 10 MG TABLET [34153]

Facility

$31.00

Service Code	NDC 60687037321
Hospital Revenue Code	637
Min. Negotiated Rate	$15.81
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Kaiser Permanente Commercial	$19.53
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: University Health Alliance Commercial	$22.60

EZETIMIBE 10 MG TABLET [34153]

Facility

$31.00

Service Code	NDC 60687037311
Hospital Revenue Code	250
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: MDX Hawaii PPO	$30.07

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES

Facility

$6,522.77

Service Code	APR-DRG 0921
Min. Negotiated Rate	$6,522.77
Max. Negotiated Rate	$6,522.77
Rate for Payer: AlohaCare Medicaid	$6,522.77
Rate for Payer: Hawaii Medical Service Association ABD	$6,522.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,522.77
Rate for Payer: Kaiser Permanente Medicaid	$6,522.77
Rate for Payer: Ohana Health Plan Medicaid	$6,522.77
Rate for Payer: UnitedHealthcare Medicaid	$6,522.77

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES

Facility

$8,758.78

Service Code	APR-DRG 0922
Min. Negotiated Rate	$8,758.78
Max. Negotiated Rate	$8,758.78
Rate for Payer: AlohaCare Medicaid	$8,758.78
Rate for Payer: Hawaii Medical Service Association ABD	$8,758.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,758.78
Rate for Payer: Kaiser Permanente Medicaid	$8,758.78
Rate for Payer: Ohana Health Plan Medicaid	$8,758.78
Rate for Payer: UnitedHealthcare Medicaid	$8,758.78

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES

Facility

$13,753.91

Service Code	APR-DRG 0923
Min. Negotiated Rate	$13,753.91
Max. Negotiated Rate	$13,753.91
Rate for Payer: AlohaCare Medicaid	$13,753.91
Rate for Payer: Hawaii Medical Service Association ABD	$13,753.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,753.91
Rate for Payer: Kaiser Permanente Medicaid	$13,753.91
Rate for Payer: Ohana Health Plan Medicaid	$13,753.91
Rate for Payer: UnitedHealthcare Medicaid	$13,753.91

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES

Facility

$29,906.25

Service Code	APR-DRG 0924
Min. Negotiated Rate	$29,906.25
Max. Negotiated Rate	$29,906.25
Rate for Payer: AlohaCare Medicaid	$29,906.25
Rate for Payer: Hawaii Medical Service Association ABD	$29,906.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29,906.25
Rate for Payer: Kaiser Permanente Medicaid	$29,906.25
Rate for Payer: Ohana Health Plan Medicaid	$29,906.25
Rate for Payer: UnitedHealthcare Medicaid	$29,906.25

FACILITY SERVICES FOR DENTAL REHABILITATION PROCEDURE(S) PERFORMED ON A PATIENT WHO REQUIRES MONITORED ANESTHESIA (E.G., GENERAL, INTRAVENOUS SEDATION (MONITORED ANESTHESIA CARE) AND USE OF AN OPERATING ROOM

Facility

$4,895.88

Service Code	CPT G0330
Hospital Revenue Code	360
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4,895.88
Rate for Payer: AlohaCare Medicaid	$3,916.70
Rate for Payer: AlohaCare Medicare	$3,916.70
Rate for Payer: Devoted Health Medicare	$4,308.37
Rate for Payer: Hawaii Medical Service Association Commercial	$4,895.88
Rate for Payer: Hawaii Medical Service Association Medicare	$3,916.70
Rate for Payer: Humana Medicare	$3,916.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,916.70
Rate for Payer: Ohana Health Plan Medicaid	$4,308.37
Rate for Payer: Ohana Health Plan Medicare	$3,916.70
Rate for Payer: UnitedHealthcare Medicaid	$2.00
Rate for Payer: UnitedHealthcare Medicare	$3,916.70

FAMCICLOVIR 125 MG TABLET [16082]

Facility

$21.00

Service Code	NDC 33342002407
Hospital Revenue Code	637
Min. Negotiated Rate	$10.71
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$13.23
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: University Health Alliance Commercial	$15.31

FAMCICLOVIR 125 MG TABLET [16082]

Facility

$21.00

Service Code	NDC 33342002407
Hospital Revenue Code	250
Min. Negotiated Rate	$17.85
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: MDX Hawaii PPO	$20.37

FAMCICLOVIR 500 MG TABLET [13358]

Facility

$32.00

Service Code	NDC 33342002607
Hospital Revenue Code	250
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: MDX Hawaii PPO	$31.04

FAMCICLOVIR 500 MG TABLET [13358]

Facility

$32.00

Service Code	NDC 33342002607
Hospital Revenue Code	637
Min. Negotiated Rate	$16.32
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Hawaii Western Management Group Commercial	$30.40
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Kaiser Permanente Commercial	$20.16
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: University Health Alliance Commercial	$23.32

FAMOTIDINE 20 MG TABLET [10011]

Facility

$1.00

Service Code	NDC 60687059501
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

Know your out-of-pocket cost for care.

All Charges