Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT [173366]

Facility

$30,434.00

Service Code	HCPCS J9281
Hospital Revenue Code	636
Min. Negotiated Rate	$317.42
Max. Negotiated Rate	$29,520.98
Rate for Payer: AlohaCare Medicaid	$323.17
Rate for Payer: AlohaCare Medicare	$323.17
Rate for Payer: Cash Price	$18,260.40
Rate for Payer: Cash Price	$18,260.40
Rate for Payer: Devoted Health Medicare	$355.49
Rate for Payer: Hawaii Medical Service Association ABD	$317.42
Rate for Payer: Hawaii Medical Service Association Commercial	$403.96
Rate for Payer: Hawaii Medical Service Association Medicare	$323.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$317.42
Rate for Payer: Hawaii Western Management Group Commercial	$28,912.30
Rate for Payer: Health Management Network Commercial	$25,868.90
Rate for Payer: Humana Medicare	$323.17
Rate for Payer: Kaiser Permanente Commercial	$19,173.42
Rate for Payer: Kaiser Permanente Medicaid	$15,521.34
Rate for Payer: Kaiser Permanente Medicare	$323.17
Rate for Payer: MDX Hawaii PPO	$29,520.98
Rate for Payer: Ohana Health Plan Medicaid	$355.49
Rate for Payer: Ohana Health Plan Medicare	$323.17
Rate for Payer: UnitedHealthcare Medicaid	$18,260.40
Rate for Payer: UnitedHealthcare Medicare	$323.17
Rate for Payer: University Health Alliance Commercial	$22,183.34

MITOMYCIN 5 MG/10ML IV (WET SOLR VIAL) [43010632]

Facility

$409.00

Service Code	HCPCS J9280
Hospital Revenue Code	636
Min. Negotiated Rate	$28.27
Max. Negotiated Rate	$396.73
Rate for Payer: AlohaCare Medicaid	$28.46
Rate for Payer: AlohaCare Medicare	$28.46
Rate for Payer: Cash Price	$245.40
Rate for Payer: Cash Price	$245.40
Rate for Payer: Devoted Health Medicare	$31.31
Rate for Payer: Hawaii Medical Service Association ABD	$28.27
Rate for Payer: Hawaii Medical Service Association Commercial	$35.58
Rate for Payer: Hawaii Medical Service Association Medicare	$28.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.27
Rate for Payer: Hawaii Western Management Group Commercial	$388.55
Rate for Payer: Health Management Network Commercial	$347.65
Rate for Payer: Humana Medicare	$28.46
Rate for Payer: Kaiser Permanente Commercial	$257.67
Rate for Payer: Kaiser Permanente Medicaid	$208.59
Rate for Payer: Kaiser Permanente Medicare	$28.46
Rate for Payer: MDX Hawaii PPO	$396.73
Rate for Payer: Ohana Health Plan Medicaid	$31.31
Rate for Payer: Ohana Health Plan Medicare	$28.46
Rate for Payer: UnitedHealthcare Medicaid	$245.40
Rate for Payer: UnitedHealthcare Medicare	$28.46
Rate for Payer: University Health Alliance Commercial	$298.12

MITOMYCIN 5 MG/10ML IV (WET SOLR VIAL) [43010632]

Facility

$409.00

Service Code	HCPCS J9280
Hospital Revenue Code	250
Min. Negotiated Rate	$347.65
Max. Negotiated Rate	$396.73
Rate for Payer: Cash Price	$245.40
Rate for Payer: Health Management Network Commercial	$347.65
Rate for Payer: MDX Hawaii PPO	$396.73

MITOMYCIN 5 MG INTRAVENOUS SOLUTION [10632]

Facility

$1,210.00

Service Code	HCPCS J9280
Hospital Revenue Code	250
Min. Negotiated Rate	$1,028.50
Max. Negotiated Rate	$1,173.70
Rate for Payer: Cash Price	$726.00
Rate for Payer: Cash Price	$245.40
Rate for Payer: Health Management Network Commercial	$347.65
Rate for Payer: Health Management Network Commercial	$1,028.50
Rate for Payer: MDX Hawaii PPO	$1,173.70
Rate for Payer: MDX Hawaii PPO	$396.73

MITOMYCIN 5 MG INTRAVENOUS SOLUTION [10632]

Facility

$409.00

Service Code	HCPCS J9280
Hospital Revenue Code	636
Min. Negotiated Rate	$28.27
Max. Negotiated Rate	$396.73
Rate for Payer: Ohana Health Plan Medicare	$28.46
Rate for Payer: AlohaCare Medicaid	$28.46
Rate for Payer: AlohaCare Medicaid	$28.46
Rate for Payer: AlohaCare Medicare	$28.46
Rate for Payer: AlohaCare Medicare	$28.46
Rate for Payer: Cash Price	$726.00
Rate for Payer: Cash Price	$726.00
Rate for Payer: Cash Price	$245.40
Rate for Payer: Cash Price	$245.40
Rate for Payer: Devoted Health Medicare	$31.31
Rate for Payer: Devoted Health Medicare	$31.31
Rate for Payer: Hawaii Medical Service Association ABD	$28.27
Rate for Payer: Hawaii Medical Service Association ABD	$28.27
Rate for Payer: Hawaii Medical Service Association Commercial	$35.58
Rate for Payer: Hawaii Medical Service Association Commercial	$35.58
Rate for Payer: Hawaii Medical Service Association Medicare	$28.46
Rate for Payer: Hawaii Medical Service Association Medicare	$28.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.27
Rate for Payer: Hawaii Western Management Group Commercial	$1,149.50
Rate for Payer: Hawaii Western Management Group Commercial	$388.55
Rate for Payer: Health Management Network Commercial	$1,028.50
Rate for Payer: Health Management Network Commercial	$347.65
Rate for Payer: Humana Medicare	$28.46
Rate for Payer: Humana Medicare	$28.46
Rate for Payer: Kaiser Permanente Commercial	$762.30
Rate for Payer: Kaiser Permanente Commercial	$257.67
Rate for Payer: Kaiser Permanente Medicaid	$208.59
Rate for Payer: Kaiser Permanente Medicaid	$617.10
Rate for Payer: Kaiser Permanente Medicare	$28.46
Rate for Payer: Kaiser Permanente Medicare	$28.46
Rate for Payer: MDX Hawaii PPO	$1,173.70
Rate for Payer: MDX Hawaii PPO	$396.73
Rate for Payer: Ohana Health Plan Medicaid	$31.31
Rate for Payer: Ohana Health Plan Medicaid	$31.31
Rate for Payer: Ohana Health Plan Medicare	$28.46
Rate for Payer: UnitedHealthcare Medicaid	$245.40
Rate for Payer: UnitedHealthcare Medicaid	$726.00
Rate for Payer: UnitedHealthcare Medicare	$28.46
Rate for Payer: UnitedHealthcare Medicare	$28.46
Rate for Payer: University Health Alliance Commercial	$881.97
Rate for Payer: University Health Alliance Commercial	$298.12

M/L TAPER 9 STD 00-7711-009-00

Facility

$5,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,652.00
Max. Negotiated Rate	$5,044.00
Rate for Payer: Cash Price	$3,120.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,640.00
Rate for Payer: Health Management Network Commercial	$4,420.00
Rate for Payer: Kaiser Permanente Commercial	$3,276.00
Rate for Payer: Kaiser Permanente Medicaid	$2,652.00
Rate for Payer: MDX Hawaii PPO	$5,044.00
Rate for Payer: University Health Alliance Commercial	$2,912.00

M/L TAPER 9 STD 00-7711-009-00

Facility

$5,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,912.00
Max. Negotiated Rate	$5,044.00
Rate for Payer: Cash Price	$3,120.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,640.00
Rate for Payer: Health Management Network Commercial	$4,420.00
Rate for Payer: MDX Hawaii PPO	$5,044.00
Rate for Payer: University Health Alliance Commercial	$2,912.00

MODAFINIL 100 MG TABLET [24702]

Facility

$66.00

Service Code	NDC 68084062121
Hospital Revenue Code	637
Min. Negotiated Rate	$33.66
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$39.60
Rate for Payer: Hawaii Western Management Group Commercial	$62.70
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$41.58
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: University Health Alliance Commercial	$48.11

MODAFINIL 100 MG TABLET [24702]

Facility

$66.00

Service Code	NDC 68084062121
Hospital Revenue Code	250
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$39.60
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: MDX Hawaii PPO	$64.02

MODAFINIL 100 MG TABLET [24702]

Facility

$28.00

Service Code	NDC 00904679104
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: MDX Hawaii PPO	$27.16

MODAFINIL 100 MG TABLET [24702]

Facility

$28.00

Service Code	NDC 00904679104
Hospital Revenue Code	637
Min. Negotiated Rate	$14.28
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$17.64
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: University Health Alliance Commercial	$20.41

MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$6,553.43

Service Code	APR-DRG 7932
Min. Negotiated Rate	$6,553.43
Max. Negotiated Rate	$6,553.43
Rate for Payer: AlohaCare Medicaid	$6,553.43
Rate for Payer: Hawaii Medical Service Association ABD	$6,553.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,553.43
Rate for Payer: Kaiser Permanente Medicaid	$6,553.43
Rate for Payer: Ohana Health Plan Medicaid	$6,553.43
Rate for Payer: UnitedHealthcare Medicaid	$6,553.43

MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$4,730.31

Service Code	APR-DRG 7931
Min. Negotiated Rate	$4,730.31
Max. Negotiated Rate	$4,730.31
Rate for Payer: AlohaCare Medicaid	$4,730.31
Rate for Payer: Hawaii Medical Service Association ABD	$4,730.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,730.31
Rate for Payer: Kaiser Permanente Medicaid	$4,730.31
Rate for Payer: Ohana Health Plan Medicaid	$4,730.31
Rate for Payer: UnitedHealthcare Medicaid	$4,730.31

MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$19,392.85

Service Code	APR-DRG 7934
Min. Negotiated Rate	$19,392.85
Max. Negotiated Rate	$19,392.85
Rate for Payer: AlohaCare Medicaid	$19,392.85
Rate for Payer: Hawaii Medical Service Association ABD	$19,392.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19,392.85
Rate for Payer: Kaiser Permanente Medicaid	$19,392.85
Rate for Payer: Ohana Health Plan Medicaid	$19,392.85
Rate for Payer: UnitedHealthcare Medicaid	$19,392.85

MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$9,917.22

Service Code	APR-DRG 7933
Min. Negotiated Rate	$9,917.22
Max. Negotiated Rate	$9,917.22
Rate for Payer: AlohaCare Medicaid	$9,917.22
Rate for Payer: Hawaii Medical Service Association ABD	$9,917.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,917.22
Rate for Payer: Kaiser Permanente Medicaid	$9,917.22
Rate for Payer: Ohana Health Plan Medicaid	$9,917.22
Rate for Payer: UnitedHealthcare Medicaid	$9,917.22

MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$7,775.79

Service Code	APR-DRG 9512
Min. Negotiated Rate	$7,775.79
Max. Negotiated Rate	$7,775.79
Rate for Payer: AlohaCare Medicaid	$7,775.79
Rate for Payer: Hawaii Medical Service Association ABD	$7,775.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,775.79
Rate for Payer: Kaiser Permanente Medicaid	$7,775.79
Rate for Payer: Ohana Health Plan Medicaid	$7,775.79
Rate for Payer: UnitedHealthcare Medicaid	$7,775.79

MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$5,601.75

Service Code	APR-DRG 9511
Min. Negotiated Rate	$5,601.75
Max. Negotiated Rate	$5,601.75
Rate for Payer: AlohaCare Medicaid	$5,601.75
Rate for Payer: Hawaii Medical Service Association ABD	$5,601.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,601.75
Rate for Payer: Kaiser Permanente Medicaid	$5,601.75
Rate for Payer: Ohana Health Plan Medicaid	$5,601.75
Rate for Payer: UnitedHealthcare Medicaid	$5,601.75

MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$11,408.98

Service Code	APR-DRG 9513
Min. Negotiated Rate	$11,408.98
Max. Negotiated Rate	$11,408.98
Rate for Payer: AlohaCare Medicaid	$11,408.98
Rate for Payer: Hawaii Medical Service Association ABD	$11,408.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,408.98
Rate for Payer: Kaiser Permanente Medicaid	$11,408.98
Rate for Payer: Ohana Health Plan Medicaid	$11,408.98
Rate for Payer: UnitedHealthcare Medicaid	$11,408.98

MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$21,320.33

Service Code	APR-DRG 9514
Min. Negotiated Rate	$21,320.33
Max. Negotiated Rate	$21,320.33
Rate for Payer: AlohaCare Medicaid	$21,320.33
Rate for Payer: Hawaii Medical Service Association ABD	$21,320.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21,320.33
Rate for Payer: Kaiser Permanente Medicaid	$21,320.33
Rate for Payer: Ohana Health Plan Medicaid	$21,320.33
Rate for Payer: UnitedHealthcare Medicaid	$21,320.33

MODIFIED LANOLIN 100 % TOPICAL CREAM [170446]

Facility

$10.00

Service Code	NDC 10202000000
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: MDX Hawaii PPO	$9.70

MODIFIED LANOLIN 100 % TOPICAL CREAM [170446]

Facility

$10.00

Service Code	NDC 10202000000
Hospital Revenue Code	637
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: University Health Alliance Commercial	$7.29

MODULAR FLEX DRILL BIT 30MM

Facility

$818.00

Hospital Revenue Code	272
Min. Negotiated Rate	$417.18
Max. Negotiated Rate	$793.46
Rate for Payer: Cash Price	$490.80
Rate for Payer: Hawaii Western Management Group Commercial	$777.10
Rate for Payer: Health Management Network Commercial	$695.30
Rate for Payer: Kaiser Permanente Commercial	$515.34
Rate for Payer: Kaiser Permanente Medicaid	$417.18
Rate for Payer: MDX Hawaii PPO	$793.46
Rate for Payer: University Health Alliance Commercial	$596.24

MODULAR FLEX DRILL BIT 30MM

Facility

$818.00

Hospital Revenue Code	272
Min. Negotiated Rate	$695.30
Max. Negotiated Rate	$793.46
Rate for Payer: Cash Price	$490.80
Rate for Payer: Health Management Network Commercial	$695.30
Rate for Payer: MDX Hawaii PPO	$793.46

MODULAR HIIP SYS 6276-1-025

Facility

$8,969.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,574.19
Max. Negotiated Rate	$8,699.93
Rate for Payer: Cash Price	$5,381.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,278.30
Rate for Payer: Health Management Network Commercial	$7,623.65
Rate for Payer: Kaiser Permanente Commercial	$5,650.47
Rate for Payer: Kaiser Permanente Medicaid	$4,574.19
Rate for Payer: MDX Hawaii PPO	$8,699.93
Rate for Payer: University Health Alliance Commercial	$5,022.64

MODULAR HIIP SYS 6276-1-025

Facility

$8,969.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,022.64
Max. Negotiated Rate	$8,699.93
Rate for Payer: Cash Price	$5,381.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,278.30
Rate for Payer: Health Management Network Commercial	$7,623.65
Rate for Payer: MDX Hawaii PPO	$8,699.93
Rate for Payer: University Health Alliance Commercial	$5,022.64

Know your out-of-pocket cost for care.

All Charges