Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

DIAZEPAM 2 MG TABLET [2404]

Facility

$1.00

Service Code	NDC 00378027101
Hospital Revenue Code	637
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: University Health Alliance Commercial	$0.73

DIAZEPAM 2 MG TABLET [2404]

Facility

$1.00

Service Code	NDC 00378027101
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: MDX Hawaii PPO	$0.97

DIAZEPAM 2 MG TABLET [2404]

Facility

$1.00

Service Code	NDC 51079028401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: MDX Hawaii PPO	$0.97

DIAZEPAM 2 MG TABLET [2404]

Facility

$1.00

Service Code	NDC 00172392560
Hospital Revenue Code	637
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: University Health Alliance Commercial	$0.73

DIAZEPAM 2 MG TABLET [2404]

Facility

$1.00

Service Code	NDC 51079028420
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: MDX Hawaii PPO	$0.97

DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION [114047]

Facility

$17.00

Service Code	NDC 68094075062
Hospital Revenue Code	637
Min. Negotiated Rate	$8.67
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$10.71
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: University Health Alliance Commercial	$12.39

DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION [114047]

Facility

$17.00

Service Code	NDC 68094075062
Hospital Revenue Code	250
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: MDX Hawaii PPO	$16.49

DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION [114047]

Facility

$17.00

Service Code	NDC 60687075540
Hospital Revenue Code	637
Min. Negotiated Rate	$8.67
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$10.71
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: University Health Alliance Commercial	$12.39

DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION [114047]

Facility

$17.00

Service Code	NDC 60687075540
Hospital Revenue Code	250
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: MDX Hawaii PPO	$16.49

DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT [87867]

Facility

$274.00

Service Code	NDC 68682065220
Hospital Revenue Code	250
Min. Negotiated Rate	$232.90
Max. Negotiated Rate	$265.78
Rate for Payer: Cash Price	$164.40
Rate for Payer: Health Management Network Commercial	$232.90
Rate for Payer: MDX Hawaii PPO	$265.78

DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT [87867]

Facility

$274.00

Service Code	NDC 68682065220
Hospital Revenue Code	637
Min. Negotiated Rate	$139.74
Max. Negotiated Rate	$265.78
Rate for Payer: Cash Price	$164.40
Rate for Payer: Hawaii Western Management Group Commercial	$260.30
Rate for Payer: Health Management Network Commercial	$232.90
Rate for Payer: Kaiser Permanente Commercial	$172.62
Rate for Payer: Kaiser Permanente Medicaid	$139.74
Rate for Payer: MDX Hawaii PPO	$265.78
Rate for Payer: University Health Alliance Commercial	$199.72

DIAZEPAM 5 MG/ML INJECTION SYRINGE [131534]

Facility

$101.00

Service Code	HCPCS J3360
Hospital Revenue Code	636
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$60.60
Rate for Payer: Cash Price	$44.40
Rate for Payer: Cash Price	$44.40
Rate for Payer: Cash Price	$60.60
Rate for Payer: Hawaii Medical Service Association ABD	$6.17
Rate for Payer: Hawaii Medical Service Association ABD	$6.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.17
Rate for Payer: Hawaii Western Management Group Commercial	$95.95
Rate for Payer: Hawaii Western Management Group Commercial	$70.30
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$46.62
Rate for Payer: Kaiser Permanente Commercial	$63.63
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicaid	$37.74
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: MDX Hawaii PPO	$71.78
Rate for Payer: UnitedHealthcare Medicaid	$44.40
Rate for Payer: UnitedHealthcare Medicaid	$60.60
Rate for Payer: University Health Alliance Commercial	$73.62
Rate for Payer: University Health Alliance Commercial	$53.94

DIAZEPAM 5 MG/ML INJECTION SYRINGE [131534]

Facility

$101.00

Service Code	HCPCS J3360
Hospital Revenue Code	250
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$60.60
Rate for Payer: Cash Price	$44.40
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: MDX Hawaii PPO	$71.78
Rate for Payer: MDX Hawaii PPO	$97.97

DIAZEPAM 5 MG TABLET [2405]

Facility

$2.00

Service Code	NDC 51079028520
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

DIAZEPAM 5 MG TABLET [2405]

Facility

$2.00

Service Code	NDC 51079028501
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

DIAZEPAM 5 MG TABLET [2405]

Facility

$2.00

Service Code	NDC 51079028520
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

DIAZEPAM 5 MG TABLET [2405]

Facility

$2.00

Service Code	NDC 51079028501
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

DIAZEPAM TABLETS (VALIUM) 5 MG (TAKE HOME) [4080353]

Facility

$15.00

Service Code	NDC 00004080141
Hospital Revenue Code	253
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

DIAZEPAM TABLETS (VALIUM) 5 MG (TAKE HOME) [4080353]

Facility

$15.00

Service Code	NDC 00004080141
Hospital Revenue Code	253
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$9.45
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: University Health Alliance Commercial	$10.93

DICYCLOMINE 10 MG/5 ML ORAL SOLUTION [42119]

Facility

$211.00

Service Code	NDC 00054062263
Hospital Revenue Code	250
Min. Negotiated Rate	$179.35
Max. Negotiated Rate	$204.67
Rate for Payer: Cash Price	$126.60
Rate for Payer: Health Management Network Commercial	$179.35
Rate for Payer: MDX Hawaii PPO	$204.67

DICYCLOMINE 10 MG/5 ML ORAL SOLUTION [42119]

Facility

$211.00

Service Code	NDC 00603116158
Hospital Revenue Code	250
Min. Negotiated Rate	$179.35
Max. Negotiated Rate	$204.67
Rate for Payer: Cash Price	$126.60
Rate for Payer: Health Management Network Commercial	$179.35
Rate for Payer: MDX Hawaii PPO	$204.67

DICYCLOMINE 10 MG/5 ML ORAL SOLUTION [42119]

Facility

$211.00

Service Code	NDC 00603116158
Hospital Revenue Code	637
Min. Negotiated Rate	$107.61
Max. Negotiated Rate	$204.67
Rate for Payer: Cash Price	$126.60
Rate for Payer: Hawaii Western Management Group Commercial	$200.45
Rate for Payer: Health Management Network Commercial	$179.35
Rate for Payer: Kaiser Permanente Commercial	$132.93
Rate for Payer: Kaiser Permanente Medicaid	$107.61
Rate for Payer: MDX Hawaii PPO	$204.67
Rate for Payer: University Health Alliance Commercial	$153.80

DICYCLOMINE 10 MG/5 ML ORAL SOLUTION [42119]

Facility

$211.00

Service Code	NDC 00054062263
Hospital Revenue Code	637
Min. Negotiated Rate	$107.61
Max. Negotiated Rate	$204.67
Rate for Payer: Cash Price	$126.60
Rate for Payer: Hawaii Western Management Group Commercial	$200.45
Rate for Payer: Health Management Network Commercial	$179.35
Rate for Payer: Kaiser Permanente Commercial	$132.93
Rate for Payer: Kaiser Permanente Medicaid	$107.61
Rate for Payer: MDX Hawaii PPO	$204.67
Rate for Payer: University Health Alliance Commercial	$153.80

DICYCLOMINE 10 MG/5 ML ORAL SYRINGE [4080572]

Facility

$6.00

Service Code	NDC 00004080073
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

DICYCLOMINE 10 MG/5 ML ORAL SYRINGE [4080572]

Facility

$6.00

Service Code	NDC 00004080073
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

Know your out-of-pocket cost for care.

All Charges