Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

DOCUSATE SODIUM 100 MG CAPSULE [2087]

Facility

$1.00

Service Code	NDC 60687012901
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

DOCUSATE SODIUM 100 MG CAPSULE [2087]

Facility

$1.00

Service Code	NDC 00904718361
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

DOCUSATE SODIUM 100 MG CAPSULE [2087]

Facility

$1.00

Service Code	NDC 60687012901
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

DOCUSATE SODIUM 100 MG CAPSULE [2087]

Facility

$1.00

Service Code	NDC 60687012911
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

DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [2569]

Facility

$8.00

Service Code	NDC 00121187010
Hospital Revenue Code	637
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: University Health Alliance Commercial	$5.83

DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [2569]

Facility

$8.00

Service Code	NDC 00121187000
Hospital Revenue Code	637
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: University Health Alliance Commercial	$5.83

DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [2569]

Facility

$8.00

Service Code	NDC 00121187010
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$7.76

DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [2569]

Facility

$8.00

Service Code	NDC 00121187000
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$7.76

DOFETILIDE 125 MCG CAPSULE [26965]

Facility

$19.00

Service Code	NDC 00904668108
Hospital Revenue Code	250
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: MDX Hawaii PPO	$18.43

DOFETILIDE 125 MCG CAPSULE [26965]

Facility

$19.00

Service Code	NDC 00904668108
Hospital Revenue Code	637
Min. Negotiated Rate	$9.69
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$11.97
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: University Health Alliance Commercial	$13.85

DOFETILIDE 125 MCG CAPSULE [26965]

Facility

$30.00

Service Code	NDC 72205003960
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

DOFETILIDE 125 MCG CAPSULE [26965]

Facility

$30.00

Service Code	NDC 72205003960
Hospital Revenue Code	637
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
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: University Health Alliance Commercial	$21.87

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$30.00

Service Code	NDC 72205004060
Hospital Revenue Code	637
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
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: University Health Alliance Commercial	$21.87

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$30.00

Service Code	NDC 72205004060
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

DOLUTEGRAVIR 50 MG TABLET [122784]

Facility

$187.00

Service Code	NDC 49702022813
Hospital Revenue Code	250
Min. Negotiated Rate	$158.95
Max. Negotiated Rate	$181.39
Rate for Payer: Cash Price	$112.20
Rate for Payer: Health Management Network Commercial	$158.95
Rate for Payer: MDX Hawaii PPO	$181.39

DOLUTEGRAVIR 50 MG TABLET [122784]

Facility

$187.00

Service Code	NDC 49702022813
Hospital Revenue Code	637
Min. Negotiated Rate	$95.37
Max. Negotiated Rate	$181.39
Rate for Payer: Cash Price	$112.20
Rate for Payer: Hawaii Western Management Group Commercial	$177.65
Rate for Payer: Health Management Network Commercial	$158.95
Rate for Payer: Kaiser Permanente Commercial	$117.81
Rate for Payer: Kaiser Permanente Medicaid	$95.37
Rate for Payer: MDX Hawaii PPO	$181.39
Rate for Payer: University Health Alliance Commercial	$136.30

DOME CENTRIC AS 01.04227.005

Facility

$987.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$552.72
Max. Negotiated Rate	$957.39
Rate for Payer: Cash Price	$592.20
Rate for Payer: Hawaii Western Management Group Commercial	$690.90
Rate for Payer: Health Management Network Commercial	$838.95
Rate for Payer: MDX Hawaii PPO	$957.39
Rate for Payer: University Health Alliance Commercial	$552.72

DOME CENTRIC AS 01.04227.005

Facility

$987.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$503.37
Max. Negotiated Rate	$957.39
Rate for Payer: Cash Price	$592.20
Rate for Payer: Hawaii Western Management Group Commercial	$690.90
Rate for Payer: Health Management Network Commercial	$838.95
Rate for Payer: Kaiser Permanente Commercial	$621.81
Rate for Payer: Kaiser Permanente Medicaid	$503.37
Rate for Payer: MDX Hawaii PPO	$957.39
Rate for Payer: University Health Alliance Commercial	$552.72

DONEPEZIL 10 MG TABLET [18787]

Facility

$1.00

Service Code	NDC 00904647861
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

DONEPEZIL 10 MG TABLET [18787]

Facility

$1.00

Service Code	NDC 00904647861
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

DONEPEZIL 5 MG TABLET [18786]

Facility

$1.00

Service Code	NDC 00904647761
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

DONEPEZIL 5 MG TABLET [18786]

Facility

$3.00

Service Code	NDC 60687029201
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: University Health Alliance Commercial	$2.19

DONEPEZIL 5 MG TABLET [18786]

Facility

$3.00

Service Code	NDC 60687029201
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

DONEPEZIL 5 MG TABLET [18786]

Facility

$1.00

Service Code	NDC 00904647761
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

DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14845]

Facility

$63.00

Service Code	HCPCS J1265
Hospital Revenue Code	636
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cash Price	$42.00
Rate for Payer: Cash Price	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.66
Rate for Payer: Hawaii Medical Service Association ABD	$0.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.66
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.66
Rate for Payer: Hawaii Western Management Group Commercial	$59.85
Rate for Payer: Hawaii Western Management Group Commercial	$66.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: Kaiser Permanente Commercial	$39.69
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: Kaiser Permanente Medicaid	$35.70
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: MDX Hawaii PPO	$67.90
Rate for Payer: UnitedHealthcare Medicaid	$42.00
Rate for Payer: UnitedHealthcare Medicaid	$37.80
Rate for Payer: University Health Alliance Commercial	$45.92
Rate for Payer: University Health Alliance Commercial	$51.02

Know your out-of-pocket cost for care.

All Charges