Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]

Facility

$652.00

Service Code	NDC 69344010233
Hospital Revenue Code	637
Min. Negotiated Rate	$332.52
Max. Negotiated Rate	$632.44
Rate for Payer: Cash Price	$391.20
Rate for Payer: Hawaii Western Management Group Commercial	$619.40
Rate for Payer: Health Management Network Commercial	$554.20
Rate for Payer: Kaiser Permanente Commercial	$410.76
Rate for Payer: Kaiser Permanente Medicaid	$332.52
Rate for Payer: MDX Hawaii PPO	$632.44
Rate for Payer: University Health Alliance Commercial	$475.24

INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]

Facility

$619.00

Service Code	NDC 70710185207
Hospital Revenue Code	637
Min. Negotiated Rate	$315.69
Max. Negotiated Rate	$600.43
Rate for Payer: Cash Price	$371.40
Rate for Payer: Hawaii Western Management Group Commercial	$588.05
Rate for Payer: Health Management Network Commercial	$526.15
Rate for Payer: Kaiser Permanente Commercial	$389.97
Rate for Payer: Kaiser Permanente Medicaid	$315.69
Rate for Payer: MDX Hawaii PPO	$600.43
Rate for Payer: University Health Alliance Commercial	$451.19

INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]

Facility

$619.00

Service Code	NDC 70710185207
Hospital Revenue Code	250
Min. Negotiated Rate	$526.15
Max. Negotiated Rate	$600.43
Rate for Payer: Cash Price	$371.40
Rate for Payer: Health Management Network Commercial	$526.15
Rate for Payer: MDX Hawaii PPO	$600.43

INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]

Facility

$619.00

Service Code	NDC 70710185206
Hospital Revenue Code	250
Min. Negotiated Rate	$526.15
Max. Negotiated Rate	$600.43
Rate for Payer: Cash Price	$371.40
Rate for Payer: Health Management Network Commercial	$526.15
Rate for Payer: MDX Hawaii PPO	$600.43

INDOMETHACIN CAPSULES (INDOCIN) 50 MG (TAKE HOME) [4080369]

Facility

$15.00

Service Code	NDC 00004080157
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

INDOMETHACIN CAPSULES (INDOCIN) 50 MG (TAKE HOME) [4080369]

Facility

$15.00

Service Code	NDC 00004080157
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

INDUCED ABORTION, BY DILATION AND CURETTAGE

Facility

$11,157.19

Service Code	CPT 59840
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$11,157.19
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	$11,157.19

INDUCED ABORTION, BY DILATION AND EVACUATION

Facility

$11,157.19

Service Code	CPT 59841
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$11,157.19
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	$11,157.19

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC

Facility

$16,887.75

Service Code	MSDRG 758
Min. Negotiated Rate	$11,135.40
Max. Negotiated Rate	$16,887.75
Rate for Payer: AlohaCare Medicare	$11,135.40
Rate for Payer: Devoted Health Medicare	$12,248.94
Rate for Payer: Hawaii Medical Service Association Commercial	$13,977.22
Rate for Payer: Hawaii Medical Service Association Medicare	$11,135.40
Rate for Payer: Humana Medicare	$11,135.40
Rate for Payer: Kaiser Permanente Commercial	$16,887.75
Rate for Payer: Kaiser Permanente Medicare	$11,135.40
Rate for Payer: Ohana Health Plan Medicare	$11,135.40
Rate for Payer: UnitedHealthcare Medicare	$11,135.40

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$24,700.28

Service Code	MSDRG 757
Min. Negotiated Rate	$13,977.22
Max. Negotiated Rate	$24,700.28
Rate for Payer: AlohaCare Medicare	$16,286.80
Rate for Payer: Devoted Health Medicare	$17,915.48
Rate for Payer: Hawaii Medical Service Association Commercial	$13,977.22
Rate for Payer: Hawaii Medical Service Association Medicare	$16,286.80
Rate for Payer: Humana Medicare	$16,286.80
Rate for Payer: Kaiser Permanente Commercial	$24,700.28
Rate for Payer: Kaiser Permanente Medicare	$16,286.80
Rate for Payer: Ohana Health Plan Medicare	$16,286.80
Rate for Payer: UnitedHealthcare Medicare	$16,286.80

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC

Facility

$13,977.22

Service Code	MSDRG 759
Min. Negotiated Rate	$7,547.96
Max. Negotiated Rate	$13,977.22
Rate for Payer: AlohaCare Medicare	$7,547.96
Rate for Payer: Devoted Health Medicare	$8,302.76
Rate for Payer: Hawaii Medical Service Association Commercial	$13,977.22
Rate for Payer: Hawaii Medical Service Association Medicare	$7,547.96
Rate for Payer: Humana Medicare	$7,547.96
Rate for Payer: Kaiser Permanente Commercial	$11,447.10
Rate for Payer: Kaiser Permanente Medicare	$7,547.96
Rate for Payer: Ohana Health Plan Medicare	$7,547.96
Rate for Payer: UnitedHealthcare Medicare	$7,547.96

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$7,004.80

Service Code	APR-DRG 1134
Min. Negotiated Rate	$7,004.80
Max. Negotiated Rate	$7,004.80
Rate for Payer: AlohaCare Medicaid	$7,004.80
Rate for Payer: Hawaii Medical Service Association ABD	$7,004.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,004.80
Rate for Payer: Kaiser Permanente Medicaid	$7,004.80
Rate for Payer: Ohana Health Plan Medicaid	$7,004.80
Rate for Payer: UnitedHealthcare Medicaid	$7,004.80

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$2,543.88

Service Code	APR-DRG 1132
Min. Negotiated Rate	$2,543.88
Max. Negotiated Rate	$2,543.88
Rate for Payer: AlohaCare Medicaid	$2,543.88
Rate for Payer: Hawaii Medical Service Association ABD	$2,543.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,543.88
Rate for Payer: Kaiser Permanente Medicaid	$2,543.88
Rate for Payer: Ohana Health Plan Medicaid	$2,543.88
Rate for Payer: UnitedHealthcare Medicaid	$2,543.88

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$1,785.28

Service Code	APR-DRG 1131
Min. Negotiated Rate	$1,785.28
Max. Negotiated Rate	$1,785.28
Rate for Payer: AlohaCare Medicaid	$1,785.28
Rate for Payer: Hawaii Medical Service Association ABD	$1,785.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,785.28
Rate for Payer: Kaiser Permanente Medicaid	$1,785.28
Rate for Payer: Ohana Health Plan Medicaid	$1,785.28
Rate for Payer: UnitedHealthcare Medicaid	$1,785.28

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$3,797.56

Service Code	APR-DRG 1133
Min. Negotiated Rate	$3,797.56
Max. Negotiated Rate	$3,797.56
Rate for Payer: AlohaCare Medicaid	$3,797.56
Rate for Payer: Hawaii Medical Service Association ABD	$3,797.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,797.56
Rate for Payer: Kaiser Permanente Medicaid	$3,797.56
Rate for Payer: Ohana Health Plan Medicaid	$3,797.56
Rate for Payer: UnitedHealthcare Medicaid	$3,797.56

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC

Facility

$157,704.73

Service Code	MSDRG 854
Min. Negotiated Rate	$22,726.90
Max. Negotiated Rate	$157,704.73
Rate for Payer: AlohaCare Medicare	$22,726.90
Rate for Payer: Devoted Health Medicare	$24,999.59
Rate for Payer: Hawaii Medical Service Association Commercial	$157,704.73
Rate for Payer: Hawaii Medical Service Association Medicare	$22,726.90
Rate for Payer: Humana Medicare	$22,726.90
Rate for Payer: Kaiser Permanente Commercial	$34,467.22
Rate for Payer: Kaiser Permanente Medicare	$22,726.90
Rate for Payer: Ohana Health Plan Medicare	$22,726.90
Rate for Payer: UnitedHealthcare Medicare	$22,726.90

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC

Facility

$157,704.73

Service Code	MSDRG 853
Min. Negotiated Rate	$56,172.91
Max. Negotiated Rate	$157,704.73
Rate for Payer: AlohaCare Medicare	$56,172.91
Rate for Payer: Devoted Health Medicare	$61,790.20
Rate for Payer: Hawaii Medical Service Association Commercial	$157,704.73
Rate for Payer: Hawaii Medical Service Association Medicare	$56,172.91
Rate for Payer: Humana Medicare	$56,172.91
Rate for Payer: Kaiser Permanente Commercial	$85,190.85
Rate for Payer: Kaiser Permanente Medicare	$56,172.91
Rate for Payer: Ohana Health Plan Medicare	$56,172.91
Rate for Payer: UnitedHealthcare Medicare	$56,172.91

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$157,704.73

Service Code	MSDRG 855
Min. Negotiated Rate	$17,029.53
Max. Negotiated Rate	$157,704.73
Rate for Payer: AlohaCare Medicare	$17,029.53
Rate for Payer: Devoted Health Medicare	$18,732.48
Rate for Payer: Hawaii Medical Service Association Commercial	$157,704.73
Rate for Payer: Hawaii Medical Service Association Medicare	$17,029.53
Rate for Payer: Humana Medicare	$17,029.53
Rate for Payer: Kaiser Permanente Commercial	$25,826.70
Rate for Payer: Kaiser Permanente Medicare	$17,029.53
Rate for Payer: Ohana Health Plan Medicare	$17,029.53
Rate for Payer: UnitedHealthcare Medicare	$17,029.53

INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE

Facility

$5,743.95

Service Code	APR-DRG 7101
Min. Negotiated Rate	$5,743.95
Max. Negotiated Rate	$5,743.95
Rate for Payer: AlohaCare Medicaid	$5,743.95
Rate for Payer: Hawaii Medical Service Association ABD	$5,743.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,743.95
Rate for Payer: Kaiser Permanente Medicaid	$5,743.95
Rate for Payer: Ohana Health Plan Medicaid	$5,743.95
Rate for Payer: UnitedHealthcare Medicaid	$5,743.95

INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE

Facility

$13,059.89

Service Code	APR-DRG 7103
Min. Negotiated Rate	$13,059.89
Max. Negotiated Rate	$13,059.89
Rate for Payer: AlohaCare Medicaid	$13,059.89
Rate for Payer: Hawaii Medical Service Association ABD	$13,059.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,059.89
Rate for Payer: Kaiser Permanente Medicaid	$13,059.89
Rate for Payer: Ohana Health Plan Medicaid	$13,059.89
Rate for Payer: UnitedHealthcare Medicaid	$13,059.89

INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE

Facility

$8,477.64

Service Code	APR-DRG 7102
Min. Negotiated Rate	$8,477.64
Max. Negotiated Rate	$8,477.64
Rate for Payer: AlohaCare Medicaid	$8,477.64
Rate for Payer: Hawaii Medical Service Association ABD	$8,477.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,477.64
Rate for Payer: Kaiser Permanente Medicaid	$8,477.64
Rate for Payer: Ohana Health Plan Medicaid	$8,477.64
Rate for Payer: UnitedHealthcare Medicaid	$8,477.64

INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE

Facility

$23,280.42

Service Code	APR-DRG 7104
Min. Negotiated Rate	$23,280.42
Max. Negotiated Rate	$23,280.42
Rate for Payer: AlohaCare Medicaid	$23,280.42
Rate for Payer: Hawaii Medical Service Association ABD	$23,280.42
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23,280.42
Rate for Payer: Kaiser Permanente Medicaid	$23,280.42
Rate for Payer: Ohana Health Plan Medicaid	$23,280.42
Rate for Payer: UnitedHealthcare Medicaid	$23,280.42

INFILTRATION TUBING ASP-TB-TUM

Facility

$79.00

Hospital Revenue Code	272
Min. Negotiated Rate	$67.15
Max. Negotiated Rate	$76.63
Rate for Payer: Cash Price	$47.40
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: MDX Hawaii PPO	$76.63

INFILTRATION TUBING ASP-TB-TUM

Facility

$79.00

Hospital Revenue Code	272
Min. Negotiated Rate	$40.29
Max. Negotiated Rate	$76.63
Rate for Payer: Cash Price	$47.40
Rate for Payer: Hawaii Western Management Group Commercial	$75.05
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: Kaiser Permanente Commercial	$49.77
Rate for Payer: Kaiser Permanente Medicaid	$40.29
Rate for Payer: MDX Hawaii PPO	$76.63
Rate for Payer: University Health Alliance Commercial	$57.58

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$25,580.03

Service Code	MSDRG 727
Min. Negotiated Rate	$13,491.90
Max. Negotiated Rate	$25,580.03
Rate for Payer: AlohaCare Medicare	$16,866.88
Rate for Payer: Devoted Health Medicare	$18,553.57
Rate for Payer: Hawaii Medical Service Association Commercial	$13,491.90
Rate for Payer: Hawaii Medical Service Association Medicare	$16,866.88
Rate for Payer: Humana Medicare	$16,866.88
Rate for Payer: Kaiser Permanente Commercial	$25,580.03
Rate for Payer: Kaiser Permanente Medicare	$16,866.88
Rate for Payer: Ohana Health Plan Medicare	$16,866.88
Rate for Payer: UnitedHealthcare Medicare	$16,866.88

Know your out-of-pocket cost for care.

All Charges