Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

VALSARTAN 40 MG TABLET [33541]

Facility

$6.00

Service Code	NDC 55111073130
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

VALSARTAN 40 MG TABLET [33541]

Facility

$15.00

Service Code	NDC 31722015130
Hospital Revenue Code	250
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

VALVE QUICK FLUSH #AR-2700

Facility

$129.00

Hospital Revenue Code	272
Min. Negotiated Rate	$65.79
Max. Negotiated Rate	$125.13
Rate for Payer: Cash Price	$77.40
Rate for Payer: Hawaii Western Management Group Commercial	$122.55
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Kaiser Permanente Commercial	$81.27
Rate for Payer: Kaiser Permanente Medicaid	$65.79
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: University Health Alliance Commercial	$94.03

VALVE QUICK FLUSH #AR-2700

Facility

$129.00

Hospital Revenue Code	272
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$125.13
Rate for Payer: Cash Price	$77.40
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: MDX Hawaii PPO	$125.13

VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [162638]

Facility

$7.00

Service Code	HCPCS J3373
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$29.40
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$29.40
Rate for Payer: Cash Price	$6.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Western Management Group Commercial	$46.55
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Commercial	$4.41
Rate for Payer: Kaiser Permanente Commercial	$30.87
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicaid	$24.99
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: MDX Hawaii PPO	$47.53
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: UnitedHealthcare Medicaid	$6.00
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: UnitedHealthcare Medicaid	$29.40
Rate for Payer: UnitedHealthcare Medicaid	$3.00
Rate for Payer: University Health Alliance Commercial	$4.37
Rate for Payer: University Health Alliance Commercial	$3.64
Rate for Payer: University Health Alliance Commercial	$35.72
Rate for Payer: University Health Alliance Commercial	$7.29
Rate for Payer: University Health Alliance Commercial	$5.10

VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [162638]

Facility

$10.00

Service Code	HCPCS J3373
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$29.40
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: MDX Hawaii PPO	$47.53

VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION [11627]

Facility

$132.00

Service Code	HCPCS J3490
Hospital Revenue Code	636
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: UnitedHealthcare Medicaid	$79.20
Rate for Payer: University Health Alliance Commercial	$96.21

VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION [11627]

Facility

$386.00

Service Code	HCPCS J3373
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$374.42
Rate for Payer: Cash Price	$231.60
Rate for Payer: Cash Price	$231.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Western Management Group Commercial	$366.70
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: Kaiser Permanente Commercial	$243.18
Rate for Payer: Kaiser Permanente Medicaid	$196.86
Rate for Payer: MDX Hawaii PPO	$374.42
Rate for Payer: UnitedHealthcare Medicaid	$231.60
Rate for Payer: University Health Alliance Commercial	$281.36

VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION [11627]

Facility

$132.00

Service Code	HCPCS J3490
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

VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION [11627]

Facility

$386.00

Service Code	HCPCS J3373
Hospital Revenue Code	250
Min. Negotiated Rate	$328.10
Max. Negotiated Rate	$374.42
Rate for Payer: Cash Price	$231.60
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: MDX Hawaii PPO	$374.42

VANCOMYCIN 1.25 GRAM/250 ML IN DILUENT COMBINATION IV PIGGYBACK [174638]

Facility

$84.00

Service Code	HCPCS J3375
Hospital Revenue Code	250
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$50.40
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: MDX Hawaii PPO	$81.48

VANCOMYCIN 1.25 GRAM/250 ML IN DILUENT COMBINATION IV PIGGYBACK [174638]

Facility

$84.00

Service Code	HCPCS J3375
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cash Price	$50.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.13
Rate for Payer: Hawaii Western Management Group Commercial	$79.80
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Kaiser Permanente Commercial	$52.92
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: UnitedHealthcare Medicaid	$50.40
Rate for Payer: University Health Alliance Commercial	$61.23

VANCOMYCIN 1.5 GRAM/300 ML IN DILUENT COMBINATION IV PIGGYBACK [166612]

Facility

$97.00

Service Code	HCPCS J3375
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$94.09
Rate for Payer: Cash Price	$58.20
Rate for Payer: Cash Price	$58.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.13
Rate for Payer: Hawaii Western Management Group Commercial	$92.15
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Kaiser Permanente Commercial	$61.11
Rate for Payer: Kaiser Permanente Medicaid	$49.47
Rate for Payer: MDX Hawaii PPO	$94.09
Rate for Payer: UnitedHealthcare Medicaid	$58.20
Rate for Payer: University Health Alliance Commercial	$70.70

VANCOMYCIN 1.5 GRAM/300 ML IN DILUENT COMBINATION IV PIGGYBACK [166612]

Facility

$97.00

Service Code	HCPCS J3375
Hospital Revenue Code	250
Min. Negotiated Rate	$82.45
Max. Negotiated Rate	$94.09
Rate for Payer: Cash Price	$58.20
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: MDX Hawaii PPO	$94.09

VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION [164996]

Facility

$74.00

Service Code	HCPCS J3373
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$71.78
Rate for Payer: Cash Price	$44.40
Rate for Payer: Cash Price	$44.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Western Management Group Commercial	$70.30
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Kaiser Permanente Commercial	$46.62
Rate for Payer: Kaiser Permanente Medicaid	$37.74
Rate for Payer: MDX Hawaii PPO	$71.78
Rate for Payer: UnitedHealthcare Medicaid	$44.40
Rate for Payer: University Health Alliance Commercial	$53.94

VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION [164996]

Facility

$73.00

Service Code	HCPCS J3371
Hospital Revenue Code	636
Min. Negotiated Rate	$6.31
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$43.80
Rate for Payer: Cash Price	$43.80
Rate for Payer: Hawaii Medical Service Association ABD	$6.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.31
Rate for Payer: Hawaii Western Management Group Commercial	$69.35
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Kaiser Permanente Commercial	$45.99
Rate for Payer: Kaiser Permanente Medicaid	$37.23
Rate for Payer: MDX Hawaii PPO	$70.81
Rate for Payer: UnitedHealthcare Medicaid	$43.80
Rate for Payer: University Health Alliance Commercial	$53.21

VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION [164996]

Facility

$74.00

Service Code	HCPCS J3373
Hospital Revenue Code	250
Min. Negotiated Rate	$62.90
Max. Negotiated Rate	$71.78
Rate for Payer: Cash Price	$44.40
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: MDX Hawaii PPO	$71.78

VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION [164996]

Facility

$73.00

Service Code	HCPCS J3371
Hospital Revenue Code	250
Min. Negotiated Rate	$62.05
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$43.80
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: MDX Hawaii PPO	$70.81

VANCOMYCIN 1.75 GRAM/350 ML IN DILUENT COMBINATION IV PIGGYBACK [174639]

Facility

$110.00

Service Code	HCPCS J3375
Hospital Revenue Code	250
Min. Negotiated Rate	$93.50
Max. Negotiated Rate	$106.70
Rate for Payer: Cash Price	$66.00
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: MDX Hawaii PPO	$106.70

VANCOMYCIN 1.75 GRAM/350 ML IN DILUENT COMBINATION IV PIGGYBACK [174639]

Facility

$110.00

Service Code	HCPCS J3375
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$106.70
Rate for Payer: Cash Price	$66.00
Rate for Payer: Cash Price	$66.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.13
Rate for Payer: Hawaii Western Management Group Commercial	$104.50
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: Kaiser Permanente Medicaid	$56.10
Rate for Payer: MDX Hawaii PPO	$106.70
Rate for Payer: UnitedHealthcare Medicaid	$66.00
Rate for Payer: University Health Alliance Commercial	$80.18

VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK [166611]

Facility

$68.00

Service Code	HCPCS J3375
Hospital Revenue Code	250
Min. Negotiated Rate	$57.80
Max. Negotiated Rate	$65.96
Rate for Payer: Cash Price	$40.80
Rate for Payer: Health Management Network Commercial	$57.80
Rate for Payer: MDX Hawaii PPO	$65.96

VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK [166611]

Facility

$68.00

Service Code	HCPCS J3375
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$65.96
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cash Price	$40.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.13
Rate for Payer: Hawaii Western Management Group Commercial	$64.60
Rate for Payer: Health Management Network Commercial	$57.80
Rate for Payer: Kaiser Permanente Commercial	$42.84
Rate for Payer: Kaiser Permanente Medicaid	$34.68
Rate for Payer: MDX Hawaii PPO	$65.96
Rate for Payer: UnitedHealthcare Medicaid	$40.80
Rate for Payer: University Health Alliance Commercial	$49.57

VANCOMYCIN 25 MG/ML ORAL SOLUTION [160236]

Facility

$565.00

Service Code	NDC 65628020405
Hospital Revenue Code	250
Min. Negotiated Rate	$480.25
Max. Negotiated Rate	$548.05
Rate for Payer: Cash Price	$339.00
Rate for Payer: Health Management Network Commercial	$480.25
Rate for Payer: MDX Hawaii PPO	$548.05

VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK [168896]

Facility

$118.00

Service Code	HCPCS J3375
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$70.80
Rate for Payer: Cash Price	$70.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.13
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: UnitedHealthcare Medicaid	$70.80
Rate for Payer: University Health Alliance Commercial	$86.01

VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK [168896]

Facility

$118.00

Service Code	HCPCS J3375
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

Know your out-of-pocket cost for care.

All Charges