Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC

Facility

$16,379.55

Service Code	MSDRG 601
Min. Negotiated Rate	$6,881.41
Max. Negotiated Rate	$16,379.55
Rate for Payer: AlohaCare Medicare	$6,881.41
Rate for Payer: Devoted Health Medicare	$7,569.55
Rate for Payer: Hawaii Medical Service Association Commercial	$16,379.55
Rate for Payer: Hawaii Medical Service Association Medicare	$6,881.41
Rate for Payer: Humana Medicare	$6,881.41
Rate for Payer: Kaiser Permanente Commercial	$10,436.25
Rate for Payer: Kaiser Permanente Medicare	$6,881.41
Rate for Payer: Ohana Health Plan Medicare	$6,881.41
Rate for Payer: UnitedHealthcare Medicare	$6,881.41

NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT

Facility

$4,239.15

Service Code	APR-DRG 0462
Min. Negotiated Rate	$4,239.15
Max. Negotiated Rate	$4,239.15
Rate for Payer: AlohaCare Medicaid	$4,239.15
Rate for Payer: Hawaii Medical Service Association ABD	$4,239.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,239.15
Rate for Payer: Kaiser Permanente Medicaid	$4,239.15
Rate for Payer: Ohana Health Plan Medicaid	$4,239.15
Rate for Payer: UnitedHealthcare Medicaid	$4,239.15

NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT

Facility

$9,812.20

Service Code	APR-DRG 0464
Min. Negotiated Rate	$9,812.20
Max. Negotiated Rate	$9,812.20
Rate for Payer: AlohaCare Medicaid	$9,812.20
Rate for Payer: Hawaii Medical Service Association ABD	$9,812.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,812.20
Rate for Payer: Kaiser Permanente Medicaid	$9,812.20
Rate for Payer: Ohana Health Plan Medicaid	$9,812.20
Rate for Payer: UnitedHealthcare Medicaid	$9,812.20

NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT

Facility

$5,440.64

Service Code	APR-DRG 0463
Min. Negotiated Rate	$5,440.64
Max. Negotiated Rate	$5,440.64
Rate for Payer: AlohaCare Medicaid	$5,440.64
Rate for Payer: Hawaii Medical Service Association ABD	$5,440.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,440.64
Rate for Payer: Kaiser Permanente Medicaid	$5,440.64
Rate for Payer: Ohana Health Plan Medicaid	$5,440.64
Rate for Payer: UnitedHealthcare Medicaid	$5,440.64

NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT

Facility

$3,488.38

Service Code	APR-DRG 0461
Min. Negotiated Rate	$3,488.38
Max. Negotiated Rate	$3,488.38
Rate for Payer: AlohaCare Medicaid	$3,488.38
Rate for Payer: Hawaii Medical Service Association ABD	$3,488.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,488.38
Rate for Payer: Kaiser Permanente Medicaid	$3,488.38
Rate for Payer: Ohana Health Plan Medicaid	$3,488.38
Rate for Payer: UnitedHealthcare Medicaid	$3,488.38

NONTRAUMATIC STUPOR AND COMA WITH MCC

Facility

$33,341.48

Service Code	MSDRG 080
Min. Negotiated Rate	$20,587.40
Max. Negotiated Rate	$33,341.48
Rate for Payer: AlohaCare Medicare	$20,587.40
Rate for Payer: Devoted Health Medicare	$22,646.14
Rate for Payer: Hawaii Medical Service Association Commercial	$33,341.48
Rate for Payer: Hawaii Medical Service Association Medicare	$20,587.40
Rate for Payer: Humana Medicare	$20,587.40
Rate for Payer: Kaiser Permanente Commercial	$31,222.50
Rate for Payer: Kaiser Permanente Medicare	$20,587.40
Rate for Payer: Ohana Health Plan Medicare	$20,587.40
Rate for Payer: UnitedHealthcare Medicare	$20,587.40

NONTRAUMATIC STUPOR AND COMA WITHOUT MCC

Facility

$33,341.48

Service Code	MSDRG 081
Min. Negotiated Rate	$10,186.77
Max. Negotiated Rate	$33,341.48
Rate for Payer: AlohaCare Medicare	$10,186.77
Rate for Payer: Devoted Health Medicare	$11,205.45
Rate for Payer: Hawaii Medical Service Association Commercial	$33,341.48
Rate for Payer: Hawaii Medical Service Association Medicare	$10,186.77
Rate for Payer: Humana Medicare	$10,186.77
Rate for Payer: Kaiser Permanente Commercial	$15,449.10
Rate for Payer: Kaiser Permanente Medicare	$10,186.77
Rate for Payer: Ohana Health Plan Medicare	$10,186.77
Rate for Payer: UnitedHealthcare Medicare	$10,186.77

NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV [136921]

Facility

$346.00

Service Code	NDC 44567064210
Hospital Revenue Code	250
Min. Negotiated Rate	$294.10
Max. Negotiated Rate	$335.62
Rate for Payer: Cash Price	$207.60
Rate for Payer: Health Management Network Commercial	$294.10
Rate for Payer: MDX Hawaii PPO	$335.62

NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV [136921]

Facility

$346.00

Service Code	NDC 44567064201
Hospital Revenue Code	250
Min. Negotiated Rate	$294.10
Max. Negotiated Rate	$335.62
Rate for Payer: Cash Price	$207.60
Rate for Payer: Health Management Network Commercial	$294.10
Rate for Payer: MDX Hawaii PPO	$335.62

NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION [128328]

Facility

$77.00

Service Code	NDC 67457085200
Hospital Revenue Code	250
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$74.69
Rate for Payer: Cash Price	$46.20
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: MDX Hawaii PPO	$74.69

NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION [128328]

Facility

$77.00

Service Code	NDC 67457085204
Hospital Revenue Code	250
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$74.69
Rate for Payer: Cash Price	$46.20
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: MDX Hawaii PPO	$74.69

NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV [134605]

Facility

$162.00

Service Code	NDC 44567064010
Hospital Revenue Code	250
Min. Negotiated Rate	$137.70
Max. Negotiated Rate	$157.14
Rate for Payer: Cash Price	$97.20
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: MDX Hawaii PPO	$157.14

NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV [134605]

Facility

$162.00

Service Code	NDC 44567064001
Hospital Revenue Code	250
Min. Negotiated Rate	$137.70
Max. Negotiated Rate	$157.14
Rate for Payer: Cash Price	$97.20
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: MDX Hawaii PPO	$157.14

NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV [134543]

Facility

$215.00

Service Code	NDC 44567064101
Hospital Revenue Code	250
Min. Negotiated Rate	$182.75
Max. Negotiated Rate	$208.55
Rate for Payer: Cash Price	$129.00
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: MDX Hawaii PPO	$208.55

NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV [134543]

Facility

$215.00

Service Code	NDC 44567064110
Hospital Revenue Code	250
Min. Negotiated Rate	$182.75
Max. Negotiated Rate	$208.55
Rate for Payer: Cash Price	$129.00
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: MDX Hawaii PPO	$208.55

NORETHINDRONE 1 MG-ETHINYL ESTRADIOL 35 MCG TABLET [10742]

Facility

$4.00

Service Code	NDC 00555901079
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

NORETHINDRONE 1 MG-ETHINYL ESTRADIOL 35 MCG TABLET [10742]

Facility

$4.00

Service Code	NDC 00555901079
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.92

NORETHINDRONE 1 MG-ETHINYL ESTRADIOL 35 MCG TABLET [10742]

Facility

$4.00

Service Code	NDC 00555901058
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.92

NORETHINDRONE 1 MG-ETHINYL ESTRADIOL 35 MCG TABLET [10742]

Facility

$4.00

Service Code	NDC 00555901058
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY [39802]

Facility

$123.00

Service Code	NDC 00802000000
Hospital Revenue Code	250
Min. Negotiated Rate	$104.55
Max. Negotiated Rate	$119.31
Rate for Payer: Cash Price	$73.80
Rate for Payer: Health Management Network Commercial	$104.55
Rate for Payer: MDX Hawaii PPO	$119.31

NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY [39802]

Facility

$123.00

Service Code	NDC 00802000000
Hospital Revenue Code	637
Min. Negotiated Rate	$62.73
Max. Negotiated Rate	$119.31
Rate for Payer: Cash Price	$73.80
Rate for Payer: Hawaii Western Management Group Commercial	$116.85
Rate for Payer: Health Management Network Commercial	$104.55
Rate for Payer: Kaiser Permanente Commercial	$77.49
Rate for Payer: Kaiser Permanente Medicaid	$62.73
Rate for Payer: MDX Hawaii PPO	$119.31
Rate for Payer: University Health Alliance Commercial	$89.65

NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY [39802]

Facility

$118.00

Service Code	NDC 00803000000
Hospital Revenue Code	637
Min. Negotiated Rate	$60.18
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$70.80
Rate for Payer: Hawaii Western Management Group Commercial	$112.10
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Kaiser Permanente Commercial	$74.34
Rate for Payer: Kaiser Permanente Medicaid	$60.18
Rate for Payer: MDX Hawaii PPO	$114.46
Rate for Payer: University Health Alliance Commercial	$86.01

NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY [39802]

Facility

$118.00

Service Code	NDC 00803000000
Hospital Revenue Code	250
Min. Negotiated Rate	$100.30
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$70.80
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: MDX Hawaii PPO	$114.46

NORIAN DRILLABLE 5CC

Facility

$4,282.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,183.82
Max. Negotiated Rate	$4,153.54
Rate for Payer: Cash Price	$2,569.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,997.40
Rate for Payer: Health Management Network Commercial	$3,639.70
Rate for Payer: Kaiser Permanente Commercial	$2,697.66
Rate for Payer: Kaiser Permanente Medicaid	$2,183.82
Rate for Payer: MDX Hawaii PPO	$4,153.54
Rate for Payer: University Health Alliance Commercial	$2,397.92

NORIAN DRILLABLE 5CC

Facility

$4,282.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,397.92
Max. Negotiated Rate	$4,153.54
Rate for Payer: Cash Price	$2,569.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,997.40
Rate for Payer: Health Management Network Commercial	$3,639.70
Rate for Payer: MDX Hawaii PPO	$4,153.54
Rate for Payer: University Health Alliance Commercial	$2,397.92

Know your out-of-pocket cost for care.

All Charges