Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS [10708]

Facility

$132.00

Service Code	NDC 61314063006
Hospital Revenue Code	637
Min. Negotiated Rate	$67.32
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$79.20
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$83.16
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: University Health Alliance Commercial	$96.21

NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS [10708]

Facility

$132.00

Service Code	NDC 61314063006
Hospital Revenue Code	250
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$79.20
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: MDX Hawaii PPO	$128.04

NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP [28810]

Facility

$296.00

Service Code	NDC 64980044801
Hospital Revenue Code	250
Min. Negotiated Rate	$251.60
Max. Negotiated Rate	$287.12
Rate for Payer: Cash Price	$177.60
Rate for Payer: Health Management Network Commercial	$251.60
Rate for Payer: MDX Hawaii PPO	$287.12

NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP [28810]

Facility

$296.00

Service Code	NDC 64980044801
Hospital Revenue Code	637
Min. Negotiated Rate	$150.96
Max. Negotiated Rate	$287.12
Rate for Payer: Cash Price	$177.60
Rate for Payer: Hawaii Western Management Group Commercial	$281.20
Rate for Payer: Health Management Network Commercial	$251.60
Rate for Payer: Kaiser Permanente Commercial	$186.48
Rate for Payer: Kaiser Permanente Medicaid	$150.96
Rate for Payer: MDX Hawaii PPO	$287.12
Rate for Payer: University Health Alliance Commercial	$215.75

NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP [28810]

Facility

$303.00

Service Code	NDC 24208063562
Hospital Revenue Code	637
Min. Negotiated Rate	$154.53
Max. Negotiated Rate	$293.91
Rate for Payer: Cash Price	$181.80
Rate for Payer: Hawaii Western Management Group Commercial	$287.85
Rate for Payer: Health Management Network Commercial	$257.55
Rate for Payer: Kaiser Permanente Commercial	$190.89
Rate for Payer: Kaiser Permanente Medicaid	$154.53
Rate for Payer: MDX Hawaii PPO	$293.91
Rate for Payer: University Health Alliance Commercial	$220.86

NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP [28810]

Facility

$303.00

Service Code	NDC 24208063562
Hospital Revenue Code	250
Min. Negotiated Rate	$257.55
Max. Negotiated Rate	$293.91
Rate for Payer: Cash Price	$181.80
Rate for Payer: Health Management Network Commercial	$257.55
Rate for Payer: MDX Hawaii PPO	$293.91

NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION [34814]

Facility

$303.00

Service Code	NDC 24208063110
Hospital Revenue Code	250
Min. Negotiated Rate	$257.55
Max. Negotiated Rate	$293.91
Rate for Payer: Cash Price	$181.80
Rate for Payer: Health Management Network Commercial	$257.55
Rate for Payer: MDX Hawaii PPO	$293.91

NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION [34814]

Facility

$303.00

Service Code	NDC 24208063110
Hospital Revenue Code	637
Min. Negotiated Rate	$154.53
Max. Negotiated Rate	$293.91
Rate for Payer: Cash Price	$181.80
Rate for Payer: Hawaii Western Management Group Commercial	$287.85
Rate for Payer: Health Management Network Commercial	$257.55
Rate for Payer: Kaiser Permanente Commercial	$190.89
Rate for Payer: Kaiser Permanente Medicaid	$154.53
Rate for Payer: MDX Hawaii PPO	$293.91
Rate for Payer: University Health Alliance Commercial	$220.86

NEONATAL AFTERCARE

Facility

$43,909.98

Service Code	APR-DRG 8634
Min. Negotiated Rate	$43,909.98
Max. Negotiated Rate	$43,909.98
Rate for Payer: AlohaCare Medicaid	$43,909.98
Rate for Payer: Hawaii Medical Service Association ABD	$43,909.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$43,909.98
Rate for Payer: Kaiser Permanente Medicaid	$43,909.98
Rate for Payer: Ohana Health Plan Medicaid	$43,909.98
Rate for Payer: UnitedHealthcare Medicaid	$43,909.98

NEONATAL AFTERCARE

Facility

$4,405.48

Service Code	APR-DRG 8631
Min. Negotiated Rate	$4,405.48
Max. Negotiated Rate	$4,405.48
Rate for Payer: AlohaCare Medicaid	$4,405.48
Rate for Payer: Hawaii Medical Service Association ABD	$4,405.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,405.48
Rate for Payer: Kaiser Permanente Medicaid	$4,405.48
Rate for Payer: Ohana Health Plan Medicaid	$4,405.48
Rate for Payer: UnitedHealthcare Medicaid	$4,405.48

NEONATAL AFTERCARE

Facility

$21,833.67

Service Code	APR-DRG 8633
Min. Negotiated Rate	$21,833.67
Max. Negotiated Rate	$21,833.67
Rate for Payer: AlohaCare Medicaid	$21,833.67
Rate for Payer: Hawaii Medical Service Association ABD	$21,833.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21,833.67
Rate for Payer: Kaiser Permanente Medicaid	$21,833.67
Rate for Payer: Ohana Health Plan Medicaid	$21,833.67
Rate for Payer: UnitedHealthcare Medicaid	$21,833.67

NEONATAL AFTERCARE

Facility

$9,746.98

Service Code	APR-DRG 8632
Min. Negotiated Rate	$9,746.98
Max. Negotiated Rate	$9,746.98
Rate for Payer: AlohaCare Medicaid	$9,746.98
Rate for Payer: Hawaii Medical Service Association ABD	$9,746.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,746.98
Rate for Payer: Kaiser Permanente Medicaid	$9,746.98
Rate for Payer: Ohana Health Plan Medicaid	$9,746.98
Rate for Payer: UnitedHealthcare Medicaid	$9,746.98

NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION

Facility

$114,788.23

Service Code	APR-DRG 6034
Min. Negotiated Rate	$114,788.23
Max. Negotiated Rate	$114,788.23
Rate for Payer: AlohaCare Medicaid	$114,788.23
Rate for Payer: Hawaii Medical Service Association ABD	$114,788.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$114,788.23
Rate for Payer: Kaiser Permanente Medicaid	$114,788.23
Rate for Payer: Ohana Health Plan Medicaid	$114,788.23
Rate for Payer: UnitedHealthcare Medicaid	$114,788.23

NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION

Facility

$89,262.77

Service Code	APR-DRG 6033
Min. Negotiated Rate	$89,262.77
Max. Negotiated Rate	$89,262.77
Rate for Payer: AlohaCare Medicaid	$89,262.77
Rate for Payer: Hawaii Medical Service Association ABD	$89,262.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$89,262.77
Rate for Payer: Kaiser Permanente Medicaid	$89,262.77
Rate for Payer: Ohana Health Plan Medicaid	$89,262.77
Rate for Payer: UnitedHealthcare Medicaid	$89,262.77

NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION

Facility

$18,267.28

Service Code	APR-DRG 6031
Min. Negotiated Rate	$18,267.28
Max. Negotiated Rate	$18,267.28
Rate for Payer: AlohaCare Medicaid	$18,267.28
Rate for Payer: Hawaii Medical Service Association ABD	$18,267.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18,267.28
Rate for Payer: Kaiser Permanente Medicaid	$18,267.28
Rate for Payer: Ohana Health Plan Medicaid	$18,267.28
Rate for Payer: UnitedHealthcare Medicaid	$18,267.28

NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION

Facility

$57,264.70

Service Code	APR-DRG 6032
Min. Negotiated Rate	$57,264.70
Max. Negotiated Rate	$57,264.70
Rate for Payer: AlohaCare Medicaid	$57,264.70
Rate for Payer: Hawaii Medical Service Association ABD	$57,264.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$57,264.70
Rate for Payer: Kaiser Permanente Medicaid	$57,264.70
Rate for Payer: Ohana Health Plan Medicaid	$57,264.70
Rate for Payer: UnitedHealthcare Medicaid	$57,264.70

NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION

Facility

$48,882.26

Service Code	APR-DRG 6133
Min. Negotiated Rate	$48,882.26
Max. Negotiated Rate	$48,882.26
Rate for Payer: AlohaCare Medicaid	$48,882.26
Rate for Payer: Hawaii Medical Service Association ABD	$48,882.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48,882.26
Rate for Payer: Kaiser Permanente Medicaid	$48,882.26
Rate for Payer: Ohana Health Plan Medicaid	$48,882.26
Rate for Payer: UnitedHealthcare Medicaid	$48,882.26

NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION

Facility

$19,394.58

Service Code	APR-DRG 6131
Min. Negotiated Rate	$19,394.58
Max. Negotiated Rate	$19,394.58
Rate for Payer: AlohaCare Medicaid	$19,394.58
Rate for Payer: Hawaii Medical Service Association ABD	$19,394.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19,394.58
Rate for Payer: Kaiser Permanente Medicaid	$19,394.58
Rate for Payer: Ohana Health Plan Medicaid	$19,394.58
Rate for Payer: UnitedHealthcare Medicaid	$19,394.58

NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION

Facility

$31,550.18

Service Code	APR-DRG 6132
Min. Negotiated Rate	$31,550.18
Max. Negotiated Rate	$31,550.18
Rate for Payer: AlohaCare Medicaid	$31,550.18
Rate for Payer: Hawaii Medical Service Association ABD	$31,550.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$31,550.18
Rate for Payer: Kaiser Permanente Medicaid	$31,550.18
Rate for Payer: Ohana Health Plan Medicaid	$31,550.18
Rate for Payer: UnitedHealthcare Medicaid	$31,550.18

NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION

Facility

$56,728.86

Service Code	APR-DRG 6134
Min. Negotiated Rate	$56,728.86
Max. Negotiated Rate	$56,728.86
Rate for Payer: AlohaCare Medicaid	$56,728.86
Rate for Payer: Hawaii Medical Service Association ABD	$56,728.86
Rate for Payer: Hawaii Medical Service Association Non-ABD	$56,728.86
Rate for Payer: Kaiser Permanente Medicaid	$56,728.86
Rate for Payer: Ohana Health Plan Medicaid	$56,728.86
Rate for Payer: UnitedHealthcare Medicaid	$56,728.86

NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY

Facility

$30,390.53

Service Code	APR-DRG 6112
Min. Negotiated Rate	$30,390.53
Max. Negotiated Rate	$30,390.53
Rate for Payer: AlohaCare Medicaid	$30,390.53
Rate for Payer: Hawaii Medical Service Association ABD	$30,390.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30,390.53
Rate for Payer: Kaiser Permanente Medicaid	$30,390.53
Rate for Payer: Ohana Health Plan Medicaid	$30,390.53
Rate for Payer: UnitedHealthcare Medicaid	$30,390.53

NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY

Facility

$51,313.78

Service Code	APR-DRG 6113
Min. Negotiated Rate	$51,313.78
Max. Negotiated Rate	$51,313.78
Rate for Payer: AlohaCare Medicaid	$51,313.78
Rate for Payer: Hawaii Medical Service Association ABD	$51,313.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51,313.78
Rate for Payer: Kaiser Permanente Medicaid	$51,313.78
Rate for Payer: Ohana Health Plan Medicaid	$51,313.78
Rate for Payer: UnitedHealthcare Medicaid	$51,313.78

NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY

Facility

$14,818.66

Service Code	APR-DRG 6111
Min. Negotiated Rate	$14,818.66
Max. Negotiated Rate	$14,818.66
Rate for Payer: AlohaCare Medicaid	$14,818.66
Rate for Payer: Hawaii Medical Service Association ABD	$14,818.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14,818.66
Rate for Payer: Kaiser Permanente Medicaid	$14,818.66
Rate for Payer: Ohana Health Plan Medicaid	$14,818.66
Rate for Payer: UnitedHealthcare Medicaid	$14,818.66

NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY

Facility

$85,321.78

Service Code	APR-DRG 6114
Min. Negotiated Rate	$85,321.78
Max. Negotiated Rate	$85,321.78
Rate for Payer: AlohaCare Medicaid	$85,321.78
Rate for Payer: Hawaii Medical Service Association ABD	$85,321.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$85,321.78
Rate for Payer: Kaiser Permanente Medicaid	$85,321.78
Rate for Payer: Ohana Health Plan Medicaid	$85,321.78
Rate for Payer: UnitedHealthcare Medicaid	$85,321.78

NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM

Facility

$2,321.62

Service Code	APR-DRG 6403
Min. Negotiated Rate	$2,321.62
Max. Negotiated Rate	$2,321.62
Rate for Payer: AlohaCare Medicaid	$2,321.62
Rate for Payer: Hawaii Medical Service Association ABD	$2,321.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,321.62
Rate for Payer: Kaiser Permanente Medicaid	$2,321.62
Rate for Payer: Ohana Health Plan Medicaid	$2,321.62
Rate for Payer: UnitedHealthcare Medicaid	$2,321.62

Know your out-of-pocket cost for care.

All Charges