Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

MUPIROCIN 2 % TOPICAL OINTMENT [10674]

Facility

$150.00

Service Code	NDC 68462018022
Hospital Revenue Code	637
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$90.00
Rate for Payer: Hawaii Western Management Group Commercial	$142.50
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Kaiser Permanente Commercial	$94.50
Rate for Payer: Kaiser Permanente Medicaid	$76.50
Rate for Payer: MDX Hawaii PPO	$145.50
Rate for Payer: University Health Alliance Commercial	$109.33

MUPIROCIN CALCIUM 2 % TOPICAL CREAM [22251]

Facility

$613.00

Service Code	NDC 51672137001
Hospital Revenue Code	250
Min. Negotiated Rate	$521.05
Max. Negotiated Rate	$594.61
Rate for Payer: Cash Price	$367.80
Rate for Payer: Health Management Network Commercial	$521.05
Rate for Payer: MDX Hawaii PPO	$594.61

MUPIROCIN CALCIUM 2 % TOPICAL CREAM [22251]

Facility

$613.00

Service Code	NDC 68462056417
Hospital Revenue Code	250
Min. Negotiated Rate	$521.05
Max. Negotiated Rate	$594.61
Rate for Payer: Cash Price	$367.80
Rate for Payer: Health Management Network Commercial	$521.05
Rate for Payer: MDX Hawaii PPO	$594.61

MUPIROCIN CALCIUM 2 % TOPICAL CREAM [22251]

Facility

$613.00

Service Code	NDC 68462056417
Hospital Revenue Code	637
Min. Negotiated Rate	$312.63
Max. Negotiated Rate	$594.61
Rate for Payer: Cash Price	$367.80
Rate for Payer: Hawaii Western Management Group Commercial	$582.35
Rate for Payer: Health Management Network Commercial	$521.05
Rate for Payer: Kaiser Permanente Commercial	$386.19
Rate for Payer: Kaiser Permanente Medicaid	$312.63
Rate for Payer: MDX Hawaii PPO	$594.61
Rate for Payer: University Health Alliance Commercial	$446.82

MUPIROCIN CALCIUM 2 % TOPICAL CREAM [22251]

Facility

$613.00

Service Code	NDC 51672137001
Hospital Revenue Code	637
Min. Negotiated Rate	$312.63
Max. Negotiated Rate	$594.61
Rate for Payer: Cash Price	$367.80
Rate for Payer: Hawaii Western Management Group Commercial	$582.35
Rate for Payer: Health Management Network Commercial	$521.05
Rate for Payer: Kaiser Permanente Commercial	$386.19
Rate for Payer: Kaiser Permanente Medicaid	$312.63
Rate for Payer: MDX Hawaii PPO	$594.61
Rate for Payer: University Health Alliance Commercial	$446.82

MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK

Facility

$6,743.44

Service Code	CPT 15734
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$4,186.36
Rate for Payer: AlohaCare Medicare	$4,186.36
Rate for Payer: Devoted Health Medicare	$4,605.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,232.95
Rate for Payer: Hawaii Medical Service Association Medicare	$4,186.36
Rate for Payer: Humana Medicare	$4,186.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,186.36
Rate for Payer: Ohana Health Plan Medicaid	$4,605.00
Rate for Payer: Ohana Health Plan Medicare	$4,186.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,186.36
Rate for Payer: University Health Alliance Commercial	$6,743.44

MUSCLE TRANSFER, ANY TYPE, SHOULDER OR UPPER ARM; SINGLE

Facility

$13,778.00

Service Code	CPT 23395
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$11,157.19

MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG

Facility

$3,976.93

Service Code	APR-DRG 3431
Min. Negotiated Rate	$3,976.93
Max. Negotiated Rate	$3,976.93
Rate for Payer: AlohaCare Medicaid	$3,976.93
Rate for Payer: Hawaii Medical Service Association ABD	$3,976.93
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,976.93
Rate for Payer: Kaiser Permanente Medicaid	$3,976.93
Rate for Payer: Ohana Health Plan Medicaid	$3,976.93
Rate for Payer: UnitedHealthcare Medicaid	$3,976.93

MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG

Facility

$4,678.13

Service Code	APR-DRG 3432
Min. Negotiated Rate	$4,678.13
Max. Negotiated Rate	$4,678.13
Rate for Payer: AlohaCare Medicaid	$4,678.13
Rate for Payer: Hawaii Medical Service Association ABD	$4,678.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,678.13
Rate for Payer: Kaiser Permanente Medicaid	$4,678.13
Rate for Payer: Ohana Health Plan Medicaid	$4,678.13
Rate for Payer: UnitedHealthcare Medicaid	$4,678.13

MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG

Facility

$6,818.90

Service Code	APR-DRG 3433
Min. Negotiated Rate	$6,818.90
Max. Negotiated Rate	$6,818.90
Rate for Payer: AlohaCare Medicaid	$6,818.90
Rate for Payer: Hawaii Medical Service Association ABD	$6,818.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,818.90
Rate for Payer: Kaiser Permanente Medicaid	$6,818.90
Rate for Payer: Ohana Health Plan Medicaid	$6,818.90
Rate for Payer: UnitedHealthcare Medicaid	$6,818.90

MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG

Facility

$11,213.95

Service Code	APR-DRG 3434
Min. Negotiated Rate	$11,213.95
Max. Negotiated Rate	$11,213.95
Rate for Payer: AlohaCare Medicaid	$11,213.95
Rate for Payer: Hawaii Medical Service Association ABD	$11,213.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,213.95
Rate for Payer: Kaiser Permanente Medicaid	$11,213.95
Rate for Payer: Ohana Health Plan Medicaid	$11,213.95
Rate for Payer: UnitedHealthcare Medicaid	$11,213.95

MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$11,400.30

Service Code	APR-DRG 9121
Min. Negotiated Rate	$11,400.30
Max. Negotiated Rate	$11,400.30
Rate for Payer: AlohaCare Medicaid	$11,400.30
Rate for Payer: Hawaii Medical Service Association ABD	$11,400.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,400.30
Rate for Payer: Kaiser Permanente Medicaid	$11,400.30
Rate for Payer: Ohana Health Plan Medicaid	$11,400.30
Rate for Payer: UnitedHealthcare Medicaid	$11,400.30

MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$34,533.21

Service Code	APR-DRG 9124
Min. Negotiated Rate	$34,533.21
Max. Negotiated Rate	$34,533.21
Rate for Payer: AlohaCare Medicaid	$34,533.21
Rate for Payer: Hawaii Medical Service Association ABD	$34,533.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$34,533.21
Rate for Payer: Kaiser Permanente Medicaid	$34,533.21
Rate for Payer: Ohana Health Plan Medicaid	$34,533.21
Rate for Payer: UnitedHealthcare Medicaid	$34,533.21

MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$11,507.57

Service Code	APR-DRG 9122
Min. Negotiated Rate	$11,507.57
Max. Negotiated Rate	$11,507.57
Rate for Payer: AlohaCare Medicaid	$11,507.57
Rate for Payer: Hawaii Medical Service Association ABD	$11,507.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11,507.57
Rate for Payer: Kaiser Permanente Medicaid	$11,507.57
Rate for Payer: Ohana Health Plan Medicaid	$11,507.57
Rate for Payer: UnitedHealthcare Medicaid	$11,507.57

MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$18,107.11

Service Code	APR-DRG 9123
Min. Negotiated Rate	$18,107.11
Max. Negotiated Rate	$18,107.11
Rate for Payer: AlohaCare Medicaid	$18,107.11
Rate for Payer: Hawaii Medical Service Association ABD	$18,107.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18,107.11
Rate for Payer: Kaiser Permanente Medicaid	$18,107.11
Rate for Payer: Ohana Health Plan Medicaid	$18,107.11
Rate for Payer: UnitedHealthcare Medicaid	$18,107.11

MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION [119571]

Facility

$33.00

Service Code	NDC 54643564901
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: MDX Hawaii PPO	$32.01

MYCOPHENOLATE MOFETIL 250 MG CAPSULE [15113]

Facility

$3.00

Service Code	HCPCS J7517
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.16
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: UnitedHealthcare Medicaid	$1.80
Rate for Payer: University Health Alliance Commercial	$2.19

MYCOPHENOLATE MOFETIL 250 MG CAPSULE [15113]

Facility

$3.00

Service Code	HCPCS J7517
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

MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; LUMBOSACRAL

Facility

$2,837.00

Service Code	CPT 62304
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$926.08
Rate for Payer: AlohaCare Medicare	$926.08
Rate for Payer: Devoted Health Medicare	$1,018.69
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$926.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$926.08
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$926.08
Rate for Payer: Ohana Health Plan Medicaid	$1,018.69
Rate for Payer: Ohana Health Plan Medicare	$926.08
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$926.08

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC

Facility

$75,200.33

Service Code	MSDRG 827
Min. Negotiated Rate	$26,288.19
Max. Negotiated Rate	$75,200.33
Rate for Payer: AlohaCare Medicare	$26,288.19
Rate for Payer: Devoted Health Medicare	$28,917.01
Rate for Payer: Hawaii Medical Service Association Commercial	$75,200.33
Rate for Payer: Hawaii Medical Service Association Medicare	$26,288.19
Rate for Payer: Humana Medicare	$26,288.19
Rate for Payer: Kaiser Permanente Commercial	$39,868.20
Rate for Payer: Kaiser Permanente Medicare	$26,288.19
Rate for Payer: Ohana Health Plan Medicare	$26,288.19
Rate for Payer: UnitedHealthcare Medicare	$26,288.19

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$80,692.05

Service Code	MSDRG 826
Min. Negotiated Rate	$53,206.50
Max. Negotiated Rate	$80,692.05
Rate for Payer: AlohaCare Medicare	$53,206.50
Rate for Payer: Devoted Health Medicare	$58,527.15
Rate for Payer: Hawaii Medical Service Association Commercial	$75,200.33
Rate for Payer: Hawaii Medical Service Association Medicare	$53,206.50
Rate for Payer: Humana Medicare	$53,206.50
Rate for Payer: Kaiser Permanente Commercial	$80,692.05
Rate for Payer: Kaiser Permanente Medicare	$53,206.50
Rate for Payer: Ohana Health Plan Medicare	$53,206.50
Rate for Payer: UnitedHealthcare Medicare	$53,206.50

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$37,952.02

Service Code	MSDRG 828
Min. Negotiated Rate	$19,379.44
Max. Negotiated Rate	$37,952.02
Rate for Payer: AlohaCare Medicare	$19,379.44
Rate for Payer: Devoted Health Medicare	$21,317.38
Rate for Payer: Hawaii Medical Service Association Commercial	$37,952.02
Rate for Payer: Hawaii Medical Service Association Medicare	$19,379.44
Rate for Payer: Humana Medicare	$19,379.44
Rate for Payer: Kaiser Permanente Commercial	$29,390.55
Rate for Payer: Kaiser Permanente Medicare	$19,379.44
Rate for Payer: Ohana Health Plan Medicare	$19,379.44
Rate for Payer: UnitedHealthcare Medicare	$19,379.44

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC

Facility

$54,510.00

Service Code	MSDRG 829
Min. Negotiated Rate	$35,942.63
Max. Negotiated Rate	$54,510.00
Rate for Payer: AlohaCare Medicare	$35,942.63
Rate for Payer: Devoted Health Medicare	$39,536.89
Rate for Payer: Hawaii Medical Service Association Commercial	$47,925.35
Rate for Payer: Hawaii Medical Service Association Medicare	$35,942.63
Rate for Payer: Humana Medicare	$35,942.63
Rate for Payer: Kaiser Permanente Commercial	$54,510.00
Rate for Payer: Kaiser Permanente Medicare	$35,942.63
Rate for Payer: Ohana Health Plan Medicare	$35,942.63
Rate for Payer: UnitedHealthcare Medicare	$35,942.63

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC

Facility

$47,925.35

Service Code	MSDRG 830
Min. Negotiated Rate	$17,118.26
Max. Negotiated Rate	$47,925.35
Rate for Payer: AlohaCare Medicare	$17,118.26
Rate for Payer: Devoted Health Medicare	$18,830.09
Rate for Payer: Hawaii Medical Service Association Commercial	$47,925.35
Rate for Payer: Hawaii Medical Service Association Medicare	$17,118.26
Rate for Payer: Humana Medicare	$17,118.26
Rate for Payer: Kaiser Permanente Commercial	$25,961.25
Rate for Payer: Kaiser Permanente Medicare	$17,118.26
Rate for Payer: Ohana Health Plan Medicare	$17,118.26
Rate for Payer: UnitedHealthcare Medicare	$17,118.26

MYNX CONTROL VENOUS 6F-12F

Facility

$945.00

Service Code	HCPCS C1760
Hospital Revenue Code	272
Min. Negotiated Rate	$803.25
Max. Negotiated Rate	$916.65
Rate for Payer: Cash Price	$567.00
Rate for Payer: Health Management Network Commercial	$803.25
Rate for Payer: MDX Hawaii PPO	$916.65

Know your out-of-pocket cost for care.

All Charges