Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

MORPHINE ER 30 MG TABLET,EXTENDED RELEASE [119007]

Facility

$13.00

Service Code	NDC 00406833023
Hospital Revenue Code	637
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$8.19
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: University Health Alliance Commercial	$9.48

MORPHINE ER 30 MG TABLET,EXTENDED RELEASE [119007]

Facility

$13.00

Service Code	NDC 00406833023
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: MDX Hawaii PPO	$12.61

MORPHINE ER 30 MG TABLET,EXTENDED RELEASE [119007]

Facility

$12.00

Service Code	NDC 68084015801
Hospital Revenue Code	250
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.20
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: MDX Hawaii PPO	$11.64

MORPHINE (PF) 1 MG/ML INJECTION SOLUTION [15852]

Facility

$122.00

Service Code	HCPCS J2274
Hospital Revenue Code	250
Min. Negotiated Rate	$103.70
Max. Negotiated Rate	$118.34
Rate for Payer: Cash Price	$73.20
Rate for Payer: Cash Price	$53.40
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: MDX Hawaii PPO	$118.34
Rate for Payer: MDX Hawaii PPO	$86.33

MORPHINE (PF) 1 MG/ML INJECTION SOLUTION [15852]

Facility

$89.00

Service Code	HCPCS J2274
Hospital Revenue Code	636
Min. Negotiated Rate	$10.79
Max. Negotiated Rate	$86.33
Rate for Payer: Cash Price	$53.40
Rate for Payer: Cash Price	$73.20
Rate for Payer: Cash Price	$73.20
Rate for Payer: Cash Price	$53.40
Rate for Payer: Hawaii Medical Service Association ABD	$10.79
Rate for Payer: Hawaii Medical Service Association ABD	$10.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.79
Rate for Payer: Hawaii Western Management Group Commercial	$115.90
Rate for Payer: Hawaii Western Management Group Commercial	$84.55
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Kaiser Permanente Commercial	$56.07
Rate for Payer: Kaiser Permanente Commercial	$76.86
Rate for Payer: Kaiser Permanente Medicaid	$62.22
Rate for Payer: Kaiser Permanente Medicaid	$45.39
Rate for Payer: MDX Hawaii PPO	$86.33
Rate for Payer: MDX Hawaii PPO	$118.34
Rate for Payer: UnitedHealthcare Medicaid	$73.20
Rate for Payer: UnitedHealthcare Medicaid	$53.40
Rate for Payer: University Health Alliance Commercial	$88.93
Rate for Payer: University Health Alliance Commercial	$64.87

MOUTH PROCEDURES WITH CC/MCC

Facility

$61,198.85

Service Code	MSDRG 137
Min. Negotiated Rate	$16,984.04
Max. Negotiated Rate	$61,198.85
Rate for Payer: AlohaCare Medicare	$16,984.04
Rate for Payer: Devoted Health Medicare	$18,682.44
Rate for Payer: Hawaii Medical Service Association Commercial	$61,198.85
Rate for Payer: Hawaii Medical Service Association Medicare	$16,984.04
Rate for Payer: Humana Medicare	$16,984.04
Rate for Payer: Kaiser Permanente Commercial	$25,757.70
Rate for Payer: Kaiser Permanente Medicare	$16,984.04
Rate for Payer: Ohana Health Plan Medicare	$16,984.04
Rate for Payer: UnitedHealthcare Medicare	$16,984.04

MOUTH PROCEDURES WITHOUT CC/MCC

Facility

$32,516.44

Service Code	MSDRG 138
Min. Negotiated Rate	$10,079.86
Max. Negotiated Rate	$32,516.44
Rate for Payer: AlohaCare Medicare	$10,079.86
Rate for Payer: Devoted Health Medicare	$11,087.85
Rate for Payer: Hawaii Medical Service Association Commercial	$32,516.44
Rate for Payer: Hawaii Medical Service Association Medicare	$10,079.86
Rate for Payer: Humana Medicare	$10,079.86
Rate for Payer: Kaiser Permanente Commercial	$15,286.95
Rate for Payer: Kaiser Permanente Medicare	$10,079.86
Rate for Payer: Ohana Health Plan Medicare	$10,079.86
Rate for Payer: UnitedHealthcare Medicare	$10,079.86

MOXIFLOXACIN 0.5 % EYE DROPS [35699]

Facility

$335.00

Service Code	NDC 60505058204
Hospital Revenue Code	637
Min. Negotiated Rate	$170.85
Max. Negotiated Rate	$324.95
Rate for Payer: Cash Price	$201.00
Rate for Payer: Hawaii Western Management Group Commercial	$318.25
Rate for Payer: Health Management Network Commercial	$284.75
Rate for Payer: Kaiser Permanente Commercial	$211.05
Rate for Payer: Kaiser Permanente Medicaid	$170.85
Rate for Payer: MDX Hawaii PPO	$324.95
Rate for Payer: University Health Alliance Commercial	$244.18

MOXIFLOXACIN 0.5 % EYE DROPS [35699]

Facility

$335.00

Service Code	NDC 68180042201
Hospital Revenue Code	637
Min. Negotiated Rate	$170.85
Max. Negotiated Rate	$324.95
Rate for Payer: Cash Price	$201.00
Rate for Payer: Hawaii Western Management Group Commercial	$318.25
Rate for Payer: Health Management Network Commercial	$284.75
Rate for Payer: Kaiser Permanente Commercial	$211.05
Rate for Payer: Kaiser Permanente Medicaid	$170.85
Rate for Payer: MDX Hawaii PPO	$324.95
Rate for Payer: University Health Alliance Commercial	$244.18

MOXIFLOXACIN 0.5 % EYE DROPS [35699]

Facility

$335.00

Service Code	NDC 60505058204
Hospital Revenue Code	250
Min. Negotiated Rate	$284.75
Max. Negotiated Rate	$324.95
Rate for Payer: Cash Price	$201.00
Rate for Payer: Health Management Network Commercial	$284.75
Rate for Payer: MDX Hawaii PPO	$324.95

MOXIFLOXACIN 0.5 % EYE DROPS [35699]

Facility

$335.00

Service Code	NDC 68180042201
Hospital Revenue Code	250
Min. Negotiated Rate	$284.75
Max. Negotiated Rate	$324.95
Rate for Payer: Cash Price	$201.00
Rate for Payer: Health Management Network Commercial	$284.75
Rate for Payer: MDX Hawaii PPO	$324.95

MOXIFLOXACIN 0.5% OPHTH SOLUTION (VIGAMOX) (3 ML) (TAKE HOME) [4080377]

Facility

$15.00

Service Code	NDC 00004080165
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

MOXIFLOXACIN 0.5% OPHTH SOLUTION (VIGAMOX) (3 ML) (TAKE HOME) [4080377]

Facility

$15.00

Service Code	NDC 00004080165
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

MP CATH 14FR DRAINAGE APD

Facility

$400.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$388.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Hawaii Western Management Group Commercial	$380.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: Kaiser Permanente Commercial	$252.00
Rate for Payer: Kaiser Permanente Medicaid	$204.00
Rate for Payer: MDX Hawaii PPO	$388.00
Rate for Payer: University Health Alliance Commercial	$291.56

MP CATH 14FR DRAINAGE APD

Facility

$400.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$340.00
Max. Negotiated Rate	$388.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: MDX Hawaii PPO	$388.00

MP DRAIN CATH 14X45 6SH

Facility

$381.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$194.31
Max. Negotiated Rate	$369.57
Rate for Payer: Cash Price	$228.60
Rate for Payer: Hawaii Western Management Group Commercial	$361.95
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Kaiser Permanente Commercial	$240.03
Rate for Payer: Kaiser Permanente Medicaid	$194.31
Rate for Payer: MDX Hawaii PPO	$369.57
Rate for Payer: University Health Alliance Commercial	$277.71

MP DRAIN CATH 14X45 6SH

Facility

$381.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$323.85
Max. Negotiated Rate	$369.57
Rate for Payer: Cash Price	$228.60
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: MDX Hawaii PPO	$369.57

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC

Facility

$124,520.85

Service Code	MSDRG 427
Min. Negotiated Rate	$82,106.20
Max. Negotiated Rate	$124,520.85
Rate for Payer: AlohaCare Medicare	$82,106.20
Rate for Payer: Devoted Health Medicare	$90,316.82
Rate for Payer: Hawaii Medical Service Association Commercial	$118,345.28
Rate for Payer: Hawaii Medical Service Association Medicare	$82,106.20
Rate for Payer: Humana Medicare	$82,106.20
Rate for Payer: Kaiser Permanente Commercial	$124,520.85
Rate for Payer: Kaiser Permanente Medicare	$82,106.20
Rate for Payer: Ohana Health Plan Medicare	$82,106.20
Rate for Payer: UnitedHealthcare Medicare	$82,106.20

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$190,115.70

Service Code	MSDRG 426
Min. Negotiated Rate	$118,345.28
Max. Negotiated Rate	$190,115.70
Rate for Payer: AlohaCare Medicare	$125,357.95
Rate for Payer: Devoted Health Medicare	$137,893.74
Rate for Payer: Hawaii Medical Service Association Commercial	$118,345.28
Rate for Payer: Hawaii Medical Service Association Medicare	$125,357.95
Rate for Payer: Humana Medicare	$125,357.95
Rate for Payer: Kaiser Permanente Commercial	$190,115.70
Rate for Payer: Kaiser Permanente Medicare	$125,357.95
Rate for Payer: Ohana Health Plan Medicare	$125,357.95
Rate for Payer: UnitedHealthcare Medicare	$125,357.95

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC

Facility

$118,345.28

Service Code	MSDRG 428
Min. Negotiated Rate	$63,946.06
Max. Negotiated Rate	$118,345.28
Rate for Payer: AlohaCare Medicare	$63,946.06
Rate for Payer: Devoted Health Medicare	$70,340.67
Rate for Payer: Hawaii Medical Service Association Commercial	$118,345.28
Rate for Payer: Hawaii Medical Service Association Medicare	$63,946.06
Rate for Payer: Humana Medicare	$63,946.06
Rate for Payer: Kaiser Permanente Commercial	$96,979.50
Rate for Payer: Kaiser Permanente Medicare	$63,946.06
Rate for Payer: Ohana Health Plan Medicare	$63,946.06
Rate for Payer: UnitedHealthcare Medicare	$63,946.06

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$115,257.60

Service Code	MSDRG 447
Min. Negotiated Rate	$75,998.23
Max. Negotiated Rate	$115,257.60
Rate for Payer: AlohaCare Medicare	$75,998.23
Rate for Payer: Devoted Health Medicare	$83,598.05
Rate for Payer: Hawaii Medical Service Association Commercial	$86,265.63
Rate for Payer: Hawaii Medical Service Association Medicare	$75,998.23
Rate for Payer: Humana Medicare	$75,998.23
Rate for Payer: Kaiser Permanente Commercial	$115,257.60
Rate for Payer: Kaiser Permanente Medicare	$75,998.23
Rate for Payer: Ohana Health Plan Medicare	$75,998.23
Rate for Payer: UnitedHealthcare Medicare	$75,998.23

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$81,169.77

Service Code	MSDRG 448
Min. Negotiated Rate	$48,235.95
Max. Negotiated Rate	$81,169.77
Rate for Payer: AlohaCare Medicare	$48,235.95
Rate for Payer: Devoted Health Medicare	$53,059.54
Rate for Payer: Hawaii Medical Service Association Commercial	$81,169.77
Rate for Payer: Hawaii Medical Service Association Medicare	$48,235.95
Rate for Payer: Humana Medicare	$48,235.95
Rate for Payer: Kaiser Permanente Commercial	$73,153.80
Rate for Payer: Kaiser Permanente Medicare	$48,235.95
Rate for Payer: Ohana Health Plan Medicare	$48,235.95
Rate for Payer: UnitedHealthcare Medicare	$48,235.95

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC

Facility

$21,405.53

Service Code	MSDRG 059
Min. Negotiated Rate	$14,114.31
Max. Negotiated Rate	$21,405.53
Rate for Payer: AlohaCare Medicare	$14,114.31
Rate for Payer: Devoted Health Medicare	$15,525.74
Rate for Payer: Hawaii Medical Service Association Commercial	$20,650.37
Rate for Payer: Hawaii Medical Service Association Medicare	$14,114.31
Rate for Payer: Humana Medicare	$14,114.31
Rate for Payer: Kaiser Permanente Commercial	$21,405.53
Rate for Payer: Kaiser Permanente Medicare	$14,114.31
Rate for Payer: Ohana Health Plan Medicare	$14,114.31
Rate for Payer: UnitedHealthcare Medicare	$14,114.31

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC

Facility

$29,488.88

Service Code	MSDRG 058
Min. Negotiated Rate	$19,444.29
Max. Negotiated Rate	$29,488.88
Rate for Payer: AlohaCare Medicare	$19,444.29
Rate for Payer: Devoted Health Medicare	$21,388.72
Rate for Payer: Hawaii Medical Service Association Commercial	$20,650.37
Rate for Payer: Hawaii Medical Service Association Medicare	$19,444.29
Rate for Payer: Humana Medicare	$19,444.29
Rate for Payer: Kaiser Permanente Commercial	$29,488.88
Rate for Payer: Kaiser Permanente Medicare	$19,444.29
Rate for Payer: Ohana Health Plan Medicare	$19,444.29
Rate for Payer: UnitedHealthcare Medicare	$19,444.29

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC

Facility

$20,650.37

Service Code	MSDRG 060
Min. Negotiated Rate	$10,462.03
Max. Negotiated Rate	$20,650.37
Rate for Payer: AlohaCare Medicare	$10,462.03
Rate for Payer: Devoted Health Medicare	$11,508.23
Rate for Payer: Hawaii Medical Service Association Commercial	$20,650.37
Rate for Payer: Hawaii Medical Service Association Medicare	$10,462.03
Rate for Payer: Humana Medicare	$10,462.03
Rate for Payer: Kaiser Permanente Commercial	$15,866.55
Rate for Payer: Kaiser Permanente Medicare	$10,462.03
Rate for Payer: Ohana Health Plan Medicare	$10,462.03
Rate for Payer: UnitedHealthcare Medicare	$10,462.03

Know your out-of-pocket cost for care.

All Charges