Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION [96982]

Facility

$27.00

Service Code	HCPCS J9100
Hospital Revenue Code	250
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: MDX Hawaii PPO	$26.19

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$14.00

Service Code	NDC 00597036082
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: MDX Hawaii PPO	$13.58

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$14.00

Service Code	NDC 00597036082
Hospital Revenue Code	637
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$8.82
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: University Health Alliance Commercial	$10.20

DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]

Facility

$14.00

Service Code	NDC 00597035556
Hospital Revenue Code	637
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$8.82
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: University Health Alliance Commercial	$10.20

DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]

Facility

$14.00

Service Code	NDC 00597035556
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: MDX Hawaii PPO	$13.58

DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]

Facility

$38.00

Service Code	HCPCS J9130
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

DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]

Facility

$38.00

Service Code	HCPCS J9130
Hospital Revenue Code	636
Min. Negotiated Rate	$3.82
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	$3.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.82
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

DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]

Facility

$36.00

Service Code	HCPCS J9130
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$34.92

DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]

Facility

$36.00

Service Code	HCPCS J9130
Hospital Revenue Code	636
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Hawaii Medical Service Association ABD	$3.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.82
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$22.68
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: UnitedHealthcare Medicaid	$21.60
Rate for Payer: University Health Alliance Commercial	$26.24

DALBAVANCIN 500 MG INTRAVENOUS SOLUTION [126244]

Facility

$2,635.00

Service Code	HCPCS J0875
Hospital Revenue Code	636
Min. Negotiated Rate	$15.00
Max. Negotiated Rate	$2,555.95
Rate for Payer: AlohaCare Medicaid	$15.00
Rate for Payer: AlohaCare Medicare	$15.00
Rate for Payer: Cash Price	$1,581.00
Rate for Payer: Cash Price	$1,581.00
Rate for Payer: Devoted Health Medicare	$16.50
Rate for Payer: Hawaii Medical Service Association ABD	$15.55
Rate for Payer: Hawaii Medical Service Association Commercial	$18.75
Rate for Payer: Hawaii Medical Service Association Medicare	$15.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.55
Rate for Payer: Hawaii Western Management Group Commercial	$2,503.25
Rate for Payer: Health Management Network Commercial	$2,239.75
Rate for Payer: Humana Medicare	$15.00
Rate for Payer: Kaiser Permanente Commercial	$1,660.05
Rate for Payer: Kaiser Permanente Medicaid	$1,343.85
Rate for Payer: Kaiser Permanente Medicare	$15.00
Rate for Payer: MDX Hawaii PPO	$2,555.95
Rate for Payer: Ohana Health Plan Medicaid	$16.50
Rate for Payer: Ohana Health Plan Medicare	$15.00
Rate for Payer: UnitedHealthcare Medicaid	$1,581.00
Rate for Payer: UnitedHealthcare Medicare	$15.00
Rate for Payer: University Health Alliance Commercial	$1,920.65

DALBAVANCIN 500 MG INTRAVENOUS SOLUTION [126244]

Facility

$2,635.00

Service Code	HCPCS J0875
Hospital Revenue Code	250
Min. Negotiated Rate	$2,239.75
Max. Negotiated Rate	$2,555.95
Rate for Payer: Cash Price	$1,581.00
Rate for Payer: Health Management Network Commercial	$2,239.75
Rate for Payer: MDX Hawaii PPO	$2,555.95

DALBAVANCIN HCL 500 MG/25ML IV (WET SOLR VIAL) [430126244]

Facility

$3,805.00

Service Code	HCPCS J0875
Hospital Revenue Code	250
Min. Negotiated Rate	$3,234.25
Max. Negotiated Rate	$3,690.85
Rate for Payer: Cash Price	$2,283.00
Rate for Payer: Cash Price	$1,581.00
Rate for Payer: Cash Price	$4,143.00
Rate for Payer: Health Management Network Commercial	$2,239.75
Rate for Payer: Health Management Network Commercial	$3,234.25
Rate for Payer: Health Management Network Commercial	$5,869.25
Rate for Payer: MDX Hawaii PPO	$6,697.85
Rate for Payer: MDX Hawaii PPO	$3,690.85
Rate for Payer: MDX Hawaii PPO	$2,555.95

DALBAVANCIN HCL 500 MG/25ML IV (WET SOLR VIAL) [430126244]

Facility

$3,805.00

Service Code	HCPCS J0875
Hospital Revenue Code	636
Min. Negotiated Rate	$15.00
Max. Negotiated Rate	$3,690.85
Rate for Payer: AlohaCare Medicaid	$15.00
Rate for Payer: AlohaCare Medicaid	$15.00
Rate for Payer: AlohaCare Medicaid	$15.00
Rate for Payer: AlohaCare Medicare	$15.00
Rate for Payer: AlohaCare Medicare	$15.00
Rate for Payer: AlohaCare Medicare	$15.00
Rate for Payer: Cash Price	$2,283.00
Rate for Payer: Cash Price	$1,581.00
Rate for Payer: Cash Price	$4,143.00
Rate for Payer: Cash Price	$4,143.00
Rate for Payer: Cash Price	$1,581.00
Rate for Payer: Cash Price	$2,283.00
Rate for Payer: Devoted Health Medicare	$16.50
Rate for Payer: Devoted Health Medicare	$16.50
Rate for Payer: Devoted Health Medicare	$16.50
Rate for Payer: Hawaii Medical Service Association ABD	$15.55
Rate for Payer: Hawaii Medical Service Association ABD	$15.55
Rate for Payer: Hawaii Medical Service Association ABD	$15.55
Rate for Payer: Hawaii Medical Service Association Commercial	$18.75
Rate for Payer: Hawaii Medical Service Association Commercial	$18.75
Rate for Payer: Hawaii Medical Service Association Commercial	$18.75
Rate for Payer: Hawaii Medical Service Association Medicare	$15.00
Rate for Payer: Hawaii Medical Service Association Medicare	$15.00
Rate for Payer: Hawaii Medical Service Association Medicare	$15.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.55
Rate for Payer: Hawaii Western Management Group Commercial	$6,559.75
Rate for Payer: Hawaii Western Management Group Commercial	$2,503.25
Rate for Payer: Hawaii Western Management Group Commercial	$3,614.75
Rate for Payer: Health Management Network Commercial	$3,234.25
Rate for Payer: Health Management Network Commercial	$5,869.25
Rate for Payer: Health Management Network Commercial	$2,239.75
Rate for Payer: Humana Medicare	$15.00
Rate for Payer: Humana Medicare	$15.00
Rate for Payer: Humana Medicare	$15.00
Rate for Payer: Kaiser Permanente Commercial	$2,397.15
Rate for Payer: Kaiser Permanente Commercial	$1,660.05
Rate for Payer: Kaiser Permanente Commercial	$4,350.15
Rate for Payer: Kaiser Permanente Medicaid	$1,343.85
Rate for Payer: Kaiser Permanente Medicaid	$1,940.55
Rate for Payer: Kaiser Permanente Medicaid	$3,521.55
Rate for Payer: Kaiser Permanente Medicare	$15.00
Rate for Payer: Kaiser Permanente Medicare	$15.00
Rate for Payer: Kaiser Permanente Medicare	$15.00
Rate for Payer: MDX Hawaii PPO	$3,690.85
Rate for Payer: MDX Hawaii PPO	$2,555.95
Rate for Payer: MDX Hawaii PPO	$6,697.85
Rate for Payer: Ohana Health Plan Medicaid	$16.50
Rate for Payer: Ohana Health Plan Medicaid	$16.50
Rate for Payer: Ohana Health Plan Medicaid	$16.50
Rate for Payer: Ohana Health Plan Medicare	$15.00
Rate for Payer: Ohana Health Plan Medicare	$15.00
Rate for Payer: Ohana Health Plan Medicare	$15.00
Rate for Payer: UnitedHealthcare Medicaid	$1,581.00
Rate for Payer: UnitedHealthcare Medicaid	$2,283.00
Rate for Payer: UnitedHealthcare Medicaid	$4,143.00
Rate for Payer: UnitedHealthcare Medicare	$15.00
Rate for Payer: UnitedHealthcare Medicare	$15.00
Rate for Payer: UnitedHealthcare Medicare	$15.00
Rate for Payer: University Health Alliance Commercial	$2,773.46
Rate for Payer: University Health Alliance Commercial	$5,033.05
Rate for Payer: University Health Alliance Commercial	$1,920.65

DANTROLENE 250 MG INTRAVENOUS SUSPENSION [126579]

Facility

$4,478.00

Service Code	NDC 42367054032
Hospital Revenue Code	250
Min. Negotiated Rate	$3,806.30
Max. Negotiated Rate	$4,343.66
Rate for Payer: Cash Price	$2,686.80
Rate for Payer: Health Management Network Commercial	$3,806.30
Rate for Payer: MDX Hawaii PPO	$4,343.66

DANTROLENE 25 MG CAPSULE [9718]

Facility

$4.00

Service Code	NDC 49884036201
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

DANTROLENE 25 MG CAPSULE [9718]

Facility

$9.00

Service Code	NDC 50268021715
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

DANTROLENE 25 MG CAPSULE [9718]

Facility

$4.00

Service Code	NDC 49884036201
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

DANTROLENE 25 MG CAPSULE [9718]

Facility

$9.00

Service Code	NDC 50268021715
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: University Health Alliance Commercial	$6.56

DAPSONE 100 MG TABLET [2131]

Facility

$11.00

Service Code	NDC 64980056603
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: MDX Hawaii PPO	$10.67

DAPSONE 100 MG TABLET [2131]

Facility

$11.00

Service Code	NDC 70954013610
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: MDX Hawaii PPO	$10.67

DAPSONE 100 MG TABLET [2131]

Facility

$11.00

Service Code	NDC 64980056603
Hospital Revenue Code	637
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: University Health Alliance Commercial	$8.02

DAPSONE 100 MG TABLET [2131]

Facility

$11.00

Service Code	NDC 70954013610
Hospital Revenue Code	637
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: University Health Alliance Commercial	$8.02

DAPTOMYCIN 500 MG/10ML IV (WET SOLR VIAL) [43036989]

Facility

$31.00

Service Code	HCPCS J0878
Hospital Revenue Code	250
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$54.00
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: MDX Hawaii PPO	$87.30

DAPTOMYCIN 500 MG/10ML IV (WET SOLR VIAL) [43036989]

Facility

$90.00

Service Code	HCPCS J0878
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$54.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.91
Rate for Payer: Hawaii Medical Service Association ABD	$0.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.91
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Hawaii Western Management Group Commercial	$85.50
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Commercial	$19.53
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicaid	$45.90
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: UnitedHealthcare Medicaid	$18.60
Rate for Payer: UnitedHealthcare Medicaid	$54.00
Rate for Payer: University Health Alliance Commercial	$22.60
Rate for Payer: University Health Alliance Commercial	$65.60

DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]

Facility

$90.00

Service Code	HCPCS J0878
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.91
Rate for Payer: Hawaii Western Management Group Commercial	$85.50
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$45.90
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: UnitedHealthcare Medicaid	$54.00
Rate for Payer: University Health Alliance Commercial	$65.60

Know your out-of-pocket cost for care.

All Charges