Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

MELATONIN 3 MG TABLET [16830]

Facility

$1.00

Service Code	NDC 61502000000
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

MELATONIN 3 MG TABLET [16830]

Facility

$2.00

Service Code	NDC 52411000000
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

MELATONIN 3 MG TABLET [16830]

Facility

$2.00

Service Code	NDC 52415000000
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

MELATONIN 3 MG TABLET [16830]

Facility

$1.00

Service Code	NDC 61502000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: University Health Alliance Commercial	$0.73

MELATONIN 3 MG TABLET [16830]

Facility

$2.00

Service Code	NDC 52411000000
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

MELATONIN 3 MG TABLET [16830]

Facility

$2.00

Service Code	NDC 52415000000
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

MEMANTINE 10 MG TABLET [36966]

Facility

$3.00

Service Code	NDC 60687018411
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

MEMANTINE 10 MG TABLET [36966]

Facility

$3.00

Service Code	NDC 60687018457
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

MEMANTINE 10 MG TABLET [36966]

Facility

$3.00

Service Code	NDC 60687018411
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

MEMANTINE 10 MG TABLET [36966]

Facility

$3.00

Service Code	NDC 60687018457
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

MEMANTINE 5 MG TABLET [37170]

Facility

$3.00

Service Code	NDC 60687017311
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

MEMANTINE 5 MG TABLET [37170]

Facility

$3.00

Service Code	NDC 60687017311
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

MEMANTINE 5 MG TABLET [37170]

Facility

$3.00

Service Code	NDC 60687017357
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

MEMANTINE 5 MG TABLET [37170]

Facility

$3.00

Service Code	NDC 60687017357
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

MENINGOCOCCAL VAC A,C,Y,W-135,CONJ TET (PF) 10 MCG/0.5 ML IM SOLUTION [180674]

Facility

$310.00

Service Code	NDC 49281059005
Hospital Revenue Code	250
Min. Negotiated Rate	$263.50
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$186.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: MDX Hawaii PPO	$300.70

MENINGOCOCCAL VAC A,C,Y,W-135,CONJ TET (PF) 10 MCG/0.5 ML IM SOLUTION [180674]

Facility

$310.00

Service Code	NDC 49281059010
Hospital Revenue Code	250
Min. Negotiated Rate	$263.50
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$186.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: MDX Hawaii PPO	$300.70

MENINGOCOCCAL VAC A,C,Y,W-135,CONJ TET (PF) 10 MCG/0.5 ML IM SOLUTION [180674]

Facility

$310.00

Service Code	NDC 49281059058
Hospital Revenue Code	250
Min. Negotiated Rate	$263.50
Max. Negotiated Rate	$300.70
Rate for Payer: Cash Price	$186.00
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: MDX Hawaii PPO	$300.70

MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM KIT (2 VIALS) [204528]

Facility

$300.00

Service Code	NDC 58160095509
Hospital Revenue Code	250
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: MDX Hawaii PPO	$291.00

MENISCAL CINCH DISP #AR-4500

Facility

$1,428.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$728.28
Max. Negotiated Rate	$1,385.16
Rate for Payer: Cash Price	$856.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,356.60
Rate for Payer: Health Management Network Commercial	$1,213.80
Rate for Payer: Kaiser Permanente Commercial	$899.64
Rate for Payer: Kaiser Permanente Medicaid	$728.28
Rate for Payer: MDX Hawaii PPO	$1,385.16
Rate for Payer: University Health Alliance Commercial	$1,040.87

MENISCAL CINCH DISP #AR-4500

Facility

$1,428.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$1,213.80
Max. Negotiated Rate	$1,385.16
Rate for Payer: Cash Price	$856.80
Rate for Payer: Health Management Network Commercial	$1,213.80
Rate for Payer: MDX Hawaii PPO	$1,385.16

MENISCAL CINCH II AR-4501

Facility

$1,383.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$774.48
Max. Negotiated Rate	$1,341.51
Rate for Payer: Cash Price	$829.80
Rate for Payer: Hawaii Western Management Group Commercial	$968.10
Rate for Payer: Health Management Network Commercial	$1,175.55
Rate for Payer: MDX Hawaii PPO	$1,341.51
Rate for Payer: University Health Alliance Commercial	$774.48

MENISCAL CINCH II AR-4501

Facility

$1,383.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$705.33
Max. Negotiated Rate	$1,341.51
Rate for Payer: Cash Price	$829.80
Rate for Payer: Hawaii Western Management Group Commercial	$968.10
Rate for Payer: Health Management Network Commercial	$1,175.55
Rate for Payer: Kaiser Permanente Commercial	$871.29
Rate for Payer: Kaiser Permanente Medicaid	$705.33
Rate for Payer: MDX Hawaii PPO	$1,341.51
Rate for Payer: University Health Alliance Commercial	$774.48

MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC

Facility

$17,379.38

Service Code	MSDRG 760
Min. Negotiated Rate	$11,459.54
Max. Negotiated Rate	$17,379.38
Rate for Payer: AlohaCare Medicare	$11,459.54
Rate for Payer: Devoted Health Medicare	$12,605.49
Rate for Payer: Hawaii Medical Service Association Commercial	$12,278.60
Rate for Payer: Hawaii Medical Service Association Medicare	$11,459.54
Rate for Payer: Humana Medicare	$11,459.54
Rate for Payer: Kaiser Permanente Commercial	$17,379.38
Rate for Payer: Kaiser Permanente Medicare	$11,459.54
Rate for Payer: Ohana Health Plan Medicare	$11,459.54
Rate for Payer: UnitedHealthcare Medicare	$11,459.54

MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC

Facility

$12,278.60

Service Code	MSDRG 761
Min. Negotiated Rate	$6,489.02
Max. Negotiated Rate	$12,278.60
Rate for Payer: AlohaCare Medicare	$6,489.02
Rate for Payer: Devoted Health Medicare	$7,137.92
Rate for Payer: Hawaii Medical Service Association Commercial	$12,278.60
Rate for Payer: Hawaii Medical Service Association Medicare	$6,489.02
Rate for Payer: Humana Medicare	$6,489.02
Rate for Payer: Kaiser Permanente Commercial	$9,825.60
Rate for Payer: Kaiser Permanente Medicare	$6,489.02
Rate for Payer: Ohana Health Plan Medicare	$6,489.02
Rate for Payer: UnitedHealthcare Medicare	$6,489.02

MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS

Facility

$4,366.34

Service Code	APR-DRG 5323
Min. Negotiated Rate	$4,366.34
Max. Negotiated Rate	$4,366.34
Rate for Payer: AlohaCare Medicaid	$4,366.34
Rate for Payer: Hawaii Medical Service Association ABD	$4,366.34
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,366.34
Rate for Payer: Kaiser Permanente Medicaid	$4,366.34
Rate for Payer: Ohana Health Plan Medicaid	$4,366.34
Rate for Payer: UnitedHealthcare Medicaid	$4,366.34

Know your out-of-pocket cost for care.

All Charges