Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

VANCOMYCIN 500 MG/100 ML IN DILUENT COMBINATION IV PIGGYBACK [170119]

Facility

$38.00

Service Code	HCPCS J3375
Hospital Revenue Code	250
Min. Negotiated Rate	$32.30
Max. Negotiated Rate	$36.86
Rate for Payer: Cash Price	$22.80
Rate for Payer: Health Management Network Commercial	$32.30
Rate for Payer: MDX Hawaii PPO	$36.86

VANCOMYCIN 500 MG/100 ML IN DILUENT COMBINATION IV PIGGYBACK [170119]

Facility

$38.00

Service Code	HCPCS J3375
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$36.86
Rate for Payer: Cash Price	$22.80
Rate for Payer: Cash Price	$22.80
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	$36.10
Rate for Payer: Health Management Network Commercial	$32.30
Rate for Payer: Kaiser Permanente Commercial	$23.94
Rate for Payer: Kaiser Permanente Medicaid	$19.38
Rate for Payer: MDX Hawaii PPO	$36.86
Rate for Payer: UnitedHealthcare Medicaid	$22.80
Rate for Payer: University Health Alliance Commercial	$27.70

VANCOMYCIN 500 MG INTRAVENOUS SOLUTION [8443]

Facility

$30.00

Service Code	HCPCS J3373
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$18.00
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	$28.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: UnitedHealthcare Medicaid	$18.00
Rate for Payer: University Health Alliance Commercial	$21.87

VANCOMYCIN 500 MG INTRAVENOUS SOLUTION [8443]

Facility

$30.00

Service Code	HCPCS J3373
Hospital Revenue Code	250
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: MDX Hawaii PPO	$29.10

VANCOMYCIN 750 MG/150 ML IN DILUENT COMBINATION IV PIGGYBACK [174637]

Facility

$51.00

Service Code	HCPCS J3375
Hospital Revenue Code	250
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: MDX Hawaii PPO	$49.47

VANCOMYCIN 750 MG/150 ML IN DILUENT COMBINATION IV PIGGYBACK [174637]

Facility

$51.00

Service Code	HCPCS J3375
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cash Price	$30.60
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	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$32.13
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: UnitedHealthcare Medicaid	$30.60
Rate for Payer: University Health Alliance Commercial	$37.17

VANCOMYCIN 750 MG INTRAVENOUS SOLUTION [97371]

Facility

$30.00

Service Code	HCPCS J3373
Hospital Revenue Code	250
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$17.40
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: MDX Hawaii PPO	$28.13

VANCOMYCIN 750 MG INTRAVENOUS SOLUTION [97371]

Facility

$29.00

Service Code	HCPCS J3373
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$17.40
Rate for Payer: Cash Price	$17.40
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$18.00
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 Non-ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Western Management Group Commercial	$27.55
Rate for Payer: Hawaii Western Management Group Commercial	$28.50
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$18.27
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$14.79
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: MDX Hawaii PPO	$28.13
Rate for Payer: UnitedHealthcare Medicaid	$17.40
Rate for Payer: UnitedHealthcare Medicaid	$18.00
Rate for Payer: University Health Alliance Commercial	$21.14
Rate for Payer: University Health Alliance Commercial	$21.87

VANCOMYCIN HCL 10 G/100ML IV (WET SOLR VIAL) [43011627]

Facility

$386.00

Service Code	HCPCS J3376
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 HCL 10 G/100ML IV (WET SOLR VIAL) [43011627]

Facility

$386.00

Service Code	HCPCS J3376
Hospital Revenue Code	636
Min. Negotiated Rate	$196.86
Max. Negotiated Rate	$374.42
Rate for Payer: Cash Price	$231.60
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 HCL 1.5 G/30ML IV (WET SOLR VIAL) [430164996]

Facility

$86.00

Service Code	HCPCS J3370
Hospital Revenue Code	636
Min. Negotiated Rate	$8.20
Max. Negotiated Rate	$83.42
Rate for Payer: Cash Price	$51.60
Rate for Payer: Cash Price	$44.40
Rate for Payer: Cash Price	$44.40
Rate for Payer: Cash Price	$51.60
Rate for Payer: Hawaii Medical Service Association ABD	$8.20
Rate for Payer: Hawaii Medical Service Association ABD	$8.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.20
Rate for Payer: Hawaii Western Management Group Commercial	$70.30
Rate for Payer: Hawaii Western Management Group Commercial	$81.70
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Kaiser Permanente Commercial	$54.18
Rate for Payer: Kaiser Permanente Commercial	$46.62
Rate for Payer: Kaiser Permanente Medicaid	$37.74
Rate for Payer: Kaiser Permanente Medicaid	$43.86
Rate for Payer: MDX Hawaii PPO	$71.78
Rate for Payer: MDX Hawaii PPO	$83.42
Rate for Payer: UnitedHealthcare Medicaid	$44.40
Rate for Payer: UnitedHealthcare Medicaid	$51.60
Rate for Payer: University Health Alliance Commercial	$53.94
Rate for Payer: University Health Alliance Commercial	$62.69

VANCOMYCIN HCL 1.5 G/30ML IV (WET SOLR VIAL) [430164996]

Facility

$74.00

Service Code	HCPCS J3370
Hospital Revenue Code	250
Min. Negotiated Rate	$62.90
Max. Negotiated Rate	$71.78
Rate for Payer: Cash Price	$44.40
Rate for Payer: Cash Price	$51.60
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: MDX Hawaii PPO	$83.42
Rate for Payer: MDX Hawaii PPO	$71.78

VANCOMYCIN HCL 1 G/20ML IV (WET SOLR VIAL) [430162638]

Facility

$49.00

Service Code	HCPCS J3373
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$47.53
Rate for Payer: Cash Price	$29.40
Rate for Payer: Cash Price	$29.40
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$3.60
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 Western Management Group Commercial	$46.55
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$30.87
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicaid	$24.99
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
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: UnitedHealthcare Medicaid	$29.40
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: UnitedHealthcare Medicaid	$3.00
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: University Health Alliance Commercial	$4.37
Rate for Payer: University Health Alliance Commercial	$2.19
Rate for Payer: University Health Alliance Commercial	$35.72
Rate for Payer: University Health Alliance Commercial	$3.64

VANCOMYCIN HCL 1 G/20ML IV (WET SOLR VIAL) [430162638]

Facility

$49.00

Service Code	HCPCS J3373
Hospital Revenue Code	250
Min. Negotiated Rate	$41.65
Max. Negotiated Rate	$47.53
Rate for Payer: Cash Price	$29.40
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: MDX Hawaii PPO	$47.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: MDX Hawaii PPO	$5.82

VANCOMYCIN HCL 500 MG/10ML IV (WET SOLR VIAL) [4308443]

Facility

$30.00

Service Code	HCPCS J3373
Hospital Revenue Code	250
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: MDX Hawaii PPO	$29.10

VANCOMYCIN HCL 500 MG/10ML IV (WET SOLR VIAL) [4308443]

Facility

$30.00

Service Code	HCPCS J3373
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$18.00
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	$28.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: UnitedHealthcare Medicaid	$18.00
Rate for Payer: University Health Alliance Commercial	$21.87

VANCOMYCIN HCL 750 MG/15ML IV (WET SOLR VIAL) [43097371]

Facility

$29.00

Service Code	HCPCS J3373
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$17.40
Rate for Payer: Cash Price	$17.40
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	$27.55
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Kaiser Permanente Commercial	$18.27
Rate for Payer: Kaiser Permanente Medicaid	$14.79
Rate for Payer: MDX Hawaii PPO	$28.13
Rate for Payer: UnitedHealthcare Medicaid	$17.40
Rate for Payer: University Health Alliance Commercial	$21.14

VANCOMYCIN HCL 750 MG/15ML IV (WET SOLR VIAL) [43097371]

Facility

$29.00

Service Code	HCPCS J3373
Hospital Revenue Code	250
Min. Negotiated Rate	$24.65
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$17.40
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: MDX Hawaii PPO	$28.13

VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP [113088]

Facility

$346.00

Service Code	NDC 00006482701
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

VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP [113088]

Facility

$346.00

Service Code	NDC 00006482700
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

VAS DILATR 12X20 G03929

Facility

$104.00

Hospital Revenue Code	272
Min. Negotiated Rate	$53.04
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$62.40
Rate for Payer: Hawaii Western Management Group Commercial	$98.80
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$65.52
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: University Health Alliance Commercial	$75.81

VAS DILATR 12X20 G03929

Facility

$104.00

Hospital Revenue Code	272
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: MDX Hawaii PPO	$100.88

VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)

Facility

$5,160.40

Service Code	CPT 55250
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$2,469.46
Rate for Payer: AlohaCare Medicare	$2,469.46
Rate for Payer: Devoted Health Medicare	$2,716.41
Rate for Payer: Hawaii Medical Service Association Commercial	$3,086.82
Rate for Payer: Hawaii Medical Service Association Medicare	$2,469.46
Rate for Payer: Humana Medicare	$2,469.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,469.46
Rate for Payer: Ohana Health Plan Medicaid	$2,716.41
Rate for Payer: Ohana Health Plan Medicare	$2,469.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,469.46
Rate for Payer: University Health Alliance Commercial	$5,160.40

VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION [210483]

Facility

$103.00

Service Code	HCPCS J2598
Hospital Revenue Code	636
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$61.80
Rate for Payer: Cash Price	$61.80
Rate for Payer: Hawaii Medical Service Association ABD	$1.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$97.85
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Kaiser Permanente Commercial	$64.89
Rate for Payer: Kaiser Permanente Medicaid	$52.53
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: UnitedHealthcare Medicaid	$61.80
Rate for Payer: University Health Alliance Commercial	$75.08

VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION [210483]

Facility

$103.00

Service Code	HCPCS J2598
Hospital Revenue Code	250
Min. Negotiated Rate	$87.55
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$61.80
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: MDX Hawaii PPO	$99.91

Know your out-of-pocket cost for care.

All Charges