Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES

Facility

$3,891.48

Service Code	APR-DRG 0431
Min. Negotiated Rate	$3,891.48
Max. Negotiated Rate	$3,891.48
Rate for Payer: AlohaCare Medicaid	$3,891.48
Rate for Payer: Hawaii Medical Service Association ABD	$3,891.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,891.48
Rate for Payer: Kaiser Permanente Medicaid	$3,891.48
Rate for Payer: Ohana Health Plan Medicaid	$3,891.48
Rate for Payer: UnitedHealthcare Medicaid	$3,891.48

MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES

Facility

$7,419.65

Service Code	APR-DRG 0433
Min. Negotiated Rate	$7,419.65
Max. Negotiated Rate	$7,419.65
Rate for Payer: AlohaCare Medicaid	$7,419.65
Rate for Payer: Hawaii Medical Service Association ABD	$7,419.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,419.65
Rate for Payer: Kaiser Permanente Medicaid	$7,419.65
Rate for Payer: Ohana Health Plan Medicaid	$7,419.65
Rate for Payer: UnitedHealthcare Medicaid	$7,419.65

MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES

Facility

$13,200.13

Service Code	APR-DRG 0434
Min. Negotiated Rate	$13,200.13
Max. Negotiated Rate	$13,200.13
Rate for Payer: AlohaCare Medicaid	$13,200.13
Rate for Payer: Hawaii Medical Service Association ABD	$13,200.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,200.13
Rate for Payer: Kaiser Permanente Medicaid	$13,200.13
Rate for Payer: Ohana Health Plan Medicaid	$13,200.13
Rate for Payer: UnitedHealthcare Medicaid	$13,200.13

MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES

Facility

$4,939.69

Service Code	APR-DRG 0432
Min. Negotiated Rate	$4,939.69
Max. Negotiated Rate	$4,939.69
Rate for Payer: AlohaCare Medicaid	$4,939.69
Rate for Payer: Hawaii Medical Service Association ABD	$4,939.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,939.69
Rate for Payer: Kaiser Permanente Medicaid	$4,939.69
Rate for Payer: Ohana Health Plan Medicaid	$4,939.69
Rate for Payer: UnitedHealthcare Medicaid	$4,939.69

MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE

Facility

$17,282.73

Service Code	APR-DRG 9304
Min. Negotiated Rate	$17,282.73
Max. Negotiated Rate	$17,282.73
Rate for Payer: AlohaCare Medicaid	$17,282.73
Rate for Payer: Hawaii Medical Service Association ABD	$17,282.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17,282.73
Rate for Payer: Kaiser Permanente Medicaid	$17,282.73
Rate for Payer: Ohana Health Plan Medicaid	$17,282.73
Rate for Payer: UnitedHealthcare Medicaid	$17,282.73

MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE

Facility

$4,329.68

Service Code	APR-DRG 9301
Min. Negotiated Rate	$4,329.68
Max. Negotiated Rate	$4,329.68
Rate for Payer: AlohaCare Medicaid	$4,329.68
Rate for Payer: Hawaii Medical Service Association ABD	$4,329.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,329.68
Rate for Payer: Kaiser Permanente Medicaid	$4,329.68
Rate for Payer: Ohana Health Plan Medicaid	$4,329.68
Rate for Payer: UnitedHealthcare Medicaid	$4,329.68

MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE

Facility

$8,202.55

Service Code	APR-DRG 9303
Min. Negotiated Rate	$8,202.55
Max. Negotiated Rate	$8,202.55
Rate for Payer: AlohaCare Medicaid	$8,202.55
Rate for Payer: Hawaii Medical Service Association ABD	$8,202.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,202.55
Rate for Payer: Kaiser Permanente Medicaid	$8,202.55
Rate for Payer: Ohana Health Plan Medicaid	$8,202.55
Rate for Payer: UnitedHealthcare Medicaid	$8,202.55

MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE

Facility

$5,162.32

Service Code	APR-DRG 9302
Min. Negotiated Rate	$5,162.32
Max. Negotiated Rate	$5,162.32
Rate for Payer: AlohaCare Medicaid	$5,162.32
Rate for Payer: Hawaii Medical Service Association ABD	$5,162.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,162.32
Rate for Payer: Kaiser Permanente Medicaid	$5,162.32
Rate for Payer: Ohana Health Plan Medicaid	$5,162.32
Rate for Payer: UnitedHealthcare Medicaid	$5,162.32

MULTITASC SIZE 6 #4500-04

Facility

$5,358.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,732.58
Max. Negotiated Rate	$5,197.26
Rate for Payer: Cash Price	$3,214.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,090.10
Rate for Payer: Health Management Network Commercial	$4,554.30
Rate for Payer: Kaiser Permanente Commercial	$3,375.54
Rate for Payer: Kaiser Permanente Medicaid	$2,732.58
Rate for Payer: MDX Hawaii PPO	$5,197.26
Rate for Payer: University Health Alliance Commercial	$3,905.45

MULTITASC SIZE 6 #4500-04

Facility

$5,358.00

Hospital Revenue Code	272
Min. Negotiated Rate	$4,554.30
Max. Negotiated Rate	$5,197.26
Rate for Payer: Cash Price	$3,214.80
Rate for Payer: Health Management Network Commercial	$4,554.30
Rate for Payer: MDX Hawaii PPO	$5,197.26

MULTITASC SIZE 7 #4500-05

Facility

$5,358.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,732.58
Max. Negotiated Rate	$5,197.26
Rate for Payer: Cash Price	$3,214.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,090.10
Rate for Payer: Health Management Network Commercial	$4,554.30
Rate for Payer: Kaiser Permanente Commercial	$3,375.54
Rate for Payer: Kaiser Permanente Medicaid	$2,732.58
Rate for Payer: MDX Hawaii PPO	$5,197.26
Rate for Payer: University Health Alliance Commercial	$3,905.45

MULTITASC SIZE 7 #4500-05

Facility

$5,358.00

Hospital Revenue Code	272
Min. Negotiated Rate	$4,554.30
Max. Negotiated Rate	$5,197.26
Rate for Payer: Cash Price	$3,214.80
Rate for Payer: Health Management Network Commercial	$4,554.30
Rate for Payer: MDX Hawaii PPO	$5,197.26

MULTI VAC 50 XL HIP

Facility

$1,586.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,348.10
Max. Negotiated Rate	$1,538.42
Rate for Payer: Cash Price	$951.60
Rate for Payer: Health Management Network Commercial	$1,348.10
Rate for Payer: MDX Hawaii PPO	$1,538.42

MULTI VAC 50 XL HIP

Facility

$1,586.00

Hospital Revenue Code	272
Min. Negotiated Rate	$808.86
Max. Negotiated Rate	$1,538.42
Rate for Payer: Cash Price	$951.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,506.70
Rate for Payer: Health Management Network Commercial	$1,348.10
Rate for Payer: Kaiser Permanente Commercial	$999.18
Rate for Payer: Kaiser Permanente Medicaid	$808.86
Rate for Payer: MDX Hawaii PPO	$1,538.42
Rate for Payer: University Health Alliance Commercial	$1,156.04

MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [37053]

Facility

$1.00

Service Code	NDC 43233000000
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

MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [37053]

Facility

$1.00

Service Code	NDC 22368000000
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

MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [37053]

Facility

$1.00

Service Code	NDC 22368000000
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

MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [37053]

Facility

$1.00

Service Code	NDC 43233000000
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

MULTIVITAMIN WITH FOLIC ACID 400 MCG TABLET [5821]

Facility

$1.00

Service Code	NDC 53061000000
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

MULTIVITAMIN WITH FOLIC ACID 400 MCG TABLET [5821]

Facility

$1.00

Service Code	NDC 53061000000
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

MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID [1481]

Facility

$19.00

Service Code	NDC 00858000000
Hospital Revenue Code	637
Min. Negotiated Rate	$9.69
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$11.97
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: University Health Alliance Commercial	$13.85

MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID [1481]

Facility

$19.00

Service Code	NDC 00858000000
Hospital Revenue Code	250
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: MDX Hawaii PPO	$18.43

MUPIROCIN 2% OINTMENT (BACTROBAN) (22 GRAM) (TAKE HOME) [4080378]

Facility

$15.00

Service Code	NDC 00004080166
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

MUPIROCIN 2% OINTMENT (BACTROBAN) (22 GRAM) (TAKE HOME) [4080378]

Facility

$15.00

Service Code	NDC 00004080166
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

MUPIROCIN 2 % TOPICAL OINTMENT [10674]

Facility

$150.00

Service Code	NDC 68462018022
Hospital Revenue Code	250
Min. Negotiated Rate	$127.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$90.00
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: MDX Hawaii PPO	$145.50

Know your out-of-pocket cost for care.

All Charges