Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION [204019]

Facility

$43.00

Service Code	HCPCS J9000
Hospital Revenue Code	250
Min. Negotiated Rate	$36.55
Max. Negotiated Rate	$41.71
Rate for Payer: Cash Price	$25.80
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: MDX Hawaii PPO	$41.71

DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION [204019]

Facility

$43.00

Service Code	HCPCS J9000
Hospital Revenue Code	636
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$41.71
Rate for Payer: Cash Price	$25.80
Rate for Payer: Cash Price	$25.80
Rate for Payer: Hawaii Medical Service Association ABD	$2.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.72
Rate for Payer: Hawaii Western Management Group Commercial	$40.85
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Kaiser Permanente Commercial	$27.09
Rate for Payer: Kaiser Permanente Medicaid	$21.93
Rate for Payer: MDX Hawaii PPO	$41.71
Rate for Payer: UnitedHealthcare Medicaid	$25.80
Rate for Payer: University Health Alliance Commercial	$31.34

DOXORUBICIN 20 MG/10 ML INTRAVENOUS SOLUTION [204020]

Facility

$61.00

Service Code	HCPCS J9000
Hospital Revenue Code	636
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$59.17
Rate for Payer: Cash Price	$36.60
Rate for Payer: Cash Price	$36.60
Rate for Payer: Hawaii Medical Service Association ABD	$2.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.72
Rate for Payer: Hawaii Western Management Group Commercial	$57.95
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: Kaiser Permanente Commercial	$38.43
Rate for Payer: Kaiser Permanente Medicaid	$31.11
Rate for Payer: MDX Hawaii PPO	$59.17
Rate for Payer: UnitedHealthcare Medicaid	$36.60
Rate for Payer: University Health Alliance Commercial	$44.46

DOXORUBICIN 20 MG/10 ML INTRAVENOUS SOLUTION [204020]

Facility

$61.00

Service Code	HCPCS J9000
Hospital Revenue Code	250
Min. Negotiated Rate	$51.85
Max. Negotiated Rate	$59.17
Rate for Payer: Cash Price	$36.60
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: MDX Hawaii PPO	$59.17

DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION [204018]

Facility

$74.00

Service Code	HCPCS J9000
Hospital Revenue Code	636
Min. Negotiated Rate	$2.72
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	$2.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.72
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

DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION [204018]

Facility

$74.00

Service Code	HCPCS J9000
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

DOXORUBICIN 50 MG INTRAVENOUS SOLUTION [2619]

Facility

$474.00

Service Code	HCPCS J9000
Hospital Revenue Code	250
Min. Negotiated Rate	$402.90
Max. Negotiated Rate	$459.78
Rate for Payer: Cash Price	$284.40
Rate for Payer: Health Management Network Commercial	$402.90
Rate for Payer: MDX Hawaii PPO	$459.78

DOXORUBICIN 50 MG INTRAVENOUS SOLUTION [2619]

Facility

$474.00

Service Code	HCPCS J9000
Hospital Revenue Code	636
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$459.78
Rate for Payer: Cash Price	$284.40
Rate for Payer: Cash Price	$284.40
Rate for Payer: Hawaii Medical Service Association ABD	$2.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.72
Rate for Payer: Hawaii Western Management Group Commercial	$450.30
Rate for Payer: Health Management Network Commercial	$402.90
Rate for Payer: Kaiser Permanente Commercial	$298.62
Rate for Payer: Kaiser Permanente Medicaid	$241.74
Rate for Payer: MDX Hawaii PPO	$459.78
Rate for Payer: UnitedHealthcare Medicaid	$284.40
Rate for Payer: University Health Alliance Commercial	$345.50

DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]

Facility

$4,042.00

Service Code	HCPCS Q2050
Hospital Revenue Code	250
Min. Negotiated Rate	$3,435.70
Max. Negotiated Rate	$3,920.74
Rate for Payer: Cash Price	$2,425.20
Rate for Payer: Cash Price	$853.20
Rate for Payer: Cash Price	$576.60
Rate for Payer: Health Management Network Commercial	$1,208.70
Rate for Payer: Health Management Network Commercial	$3,435.70
Rate for Payer: Health Management Network Commercial	$816.85
Rate for Payer: MDX Hawaii PPO	$932.17
Rate for Payer: MDX Hawaii PPO	$3,920.74
Rate for Payer: MDX Hawaii PPO	$1,379.34

DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]

Facility

$4,042.00

Service Code	HCPCS Q2050
Hospital Revenue Code	636
Min. Negotiated Rate	$71.86
Max. Negotiated Rate	$3,920.74
Rate for Payer: AlohaCare Medicaid	$71.86
Rate for Payer: AlohaCare Medicaid	$71.86
Rate for Payer: AlohaCare Medicaid	$71.86
Rate for Payer: AlohaCare Medicare	$71.86
Rate for Payer: AlohaCare Medicare	$71.86
Rate for Payer: AlohaCare Medicare	$71.86
Rate for Payer: Cash Price	$2,425.20
Rate for Payer: Cash Price	$853.20
Rate for Payer: Cash Price	$576.60
Rate for Payer: Cash Price	$576.60
Rate for Payer: Cash Price	$853.20
Rate for Payer: Cash Price	$2,425.20
Rate for Payer: Devoted Health Medicare	$79.05
Rate for Payer: Devoted Health Medicare	$79.05
Rate for Payer: Devoted Health Medicare	$79.05
Rate for Payer: Hawaii Medical Service Association ABD	$109.28
Rate for Payer: Hawaii Medical Service Association ABD	$109.28
Rate for Payer: Hawaii Medical Service Association ABD	$109.28
Rate for Payer: Hawaii Medical Service Association Commercial	$89.83
Rate for Payer: Hawaii Medical Service Association Commercial	$89.83
Rate for Payer: Hawaii Medical Service Association Commercial	$89.83
Rate for Payer: Hawaii Medical Service Association Medicare	$71.86
Rate for Payer: Hawaii Medical Service Association Medicare	$71.86
Rate for Payer: Hawaii Medical Service Association Medicare	$71.86
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.28
Rate for Payer: Hawaii Western Management Group Commercial	$912.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,350.90
Rate for Payer: Hawaii Western Management Group Commercial	$3,839.90
Rate for Payer: Health Management Network Commercial	$3,435.70
Rate for Payer: Health Management Network Commercial	$816.85
Rate for Payer: Health Management Network Commercial	$1,208.70
Rate for Payer: Humana Medicare	$71.86
Rate for Payer: Humana Medicare	$71.86
Rate for Payer: Humana Medicare	$71.86
Rate for Payer: Kaiser Permanente Commercial	$2,546.46
Rate for Payer: Kaiser Permanente Commercial	$895.86
Rate for Payer: Kaiser Permanente Commercial	$605.43
Rate for Payer: Kaiser Permanente Medicaid	$725.22
Rate for Payer: Kaiser Permanente Medicaid	$2,061.42
Rate for Payer: Kaiser Permanente Medicaid	$490.11
Rate for Payer: Kaiser Permanente Medicare	$71.86
Rate for Payer: Kaiser Permanente Medicare	$71.86
Rate for Payer: Kaiser Permanente Medicare	$71.86
Rate for Payer: MDX Hawaii PPO	$3,920.74
Rate for Payer: MDX Hawaii PPO	$1,379.34
Rate for Payer: MDX Hawaii PPO	$932.17
Rate for Payer: Ohana Health Plan Medicaid	$79.05
Rate for Payer: Ohana Health Plan Medicaid	$79.05
Rate for Payer: Ohana Health Plan Medicaid	$79.05
Rate for Payer: Ohana Health Plan Medicare	$71.86
Rate for Payer: Ohana Health Plan Medicare	$71.86
Rate for Payer: Ohana Health Plan Medicare	$71.86
Rate for Payer: UnitedHealthcare Medicaid	$853.20
Rate for Payer: UnitedHealthcare Medicaid	$2,425.20
Rate for Payer: UnitedHealthcare Medicaid	$576.60
Rate for Payer: UnitedHealthcare Medicare	$71.86
Rate for Payer: UnitedHealthcare Medicare	$71.86
Rate for Payer: UnitedHealthcare Medicare	$71.86
Rate for Payer: University Health Alliance Commercial	$2,946.21
Rate for Payer: University Health Alliance Commercial	$700.47
Rate for Payer: University Health Alliance Commercial	$1,036.50

DOXYCYCLINE 100 MG IN 100 ML NS ADD-A-VIAL (SIMPLE) [4080402]

Facility

$91.00

Service Code	HCPCS J1271
Hospital Revenue Code	250
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: MDX Hawaii PPO	$88.27

DOXYCYCLINE HYCLATE 100 MG/10ML IV (WET SOLR VIAL) [4302622]

Facility

$79.00

Service Code	NDC 63323013011
Hospital Revenue Code	250
Min. Negotiated Rate	$67.15
Max. Negotiated Rate	$76.63
Rate for Payer: Cash Price	$47.40
Rate for Payer: Cash Price	$94.80
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cash Price	$474.00
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: Health Management Network Commercial	$671.50
Rate for Payer: MDX Hawaii PPO	$76.63
Rate for Payer: MDX Hawaii PPO	$766.30
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: MDX Hawaii PPO	$153.26

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]

Facility

$79.00

Service Code	HCPCS J1271
Hospital Revenue Code	250
Min. Negotiated Rate	$67.15
Max. Negotiated Rate	$76.63
Rate for Payer: Cash Price	$47.40
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: MDX Hawaii PPO	$76.63

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$20.00

Service Code	NDC 62584069311
Hospital Revenue Code	250
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: MDX Hawaii PPO	$19.40

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$20.00

Service Code	NDC 62584069311
Hospital Revenue Code	637
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Hawaii Western Management Group Commercial	$19.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$10.20
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: University Health Alliance Commercial	$14.58

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$20.00

Service Code	NDC 62584069321
Hospital Revenue Code	250
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: MDX Hawaii PPO	$19.40

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$20.00

Service Code	NDC 62584069321
Hospital Revenue Code	637
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Hawaii Western Management Group Commercial	$19.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$10.20
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: University Health Alliance Commercial	$14.58

DOXYCYCLINE HYCLATE TABLETS (VIBRAMYCIN) 100 MG (TAKE HOME) [4080357]

Facility

$15.00

Service Code	NDC 00004080145
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

DOXYCYCLINE HYCLATE TABLETS (VIBRAMYCIN) 100 MG (TAKE HOME) [4080357]

Facility

$15.00

Service Code	NDC 00004080145
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

DRAINAGE OF FINGER ABSCESS; SIMPLE

Facility

$2,837.00

Service Code	CPT 26010
Hospital Revenue Code	360
Min. Negotiated Rate	$96.86
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Devoted Health Medicare	$260.72
Rate for Payer: Hawaii Medical Service Association Commercial	$296.27
Rate for Payer: Hawaii Medical Service Association Medicare	$237.02
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicaid	$96.86
Rate for Payer: UnitedHealthcare Medicare	$237.02

DRAINAGE OF LYMPH NODE ABSCESS OR LYMPHADENITIS; SIMPLE

Facility

$4,289.34

Service Code	CPT 38300
Hospital Revenue Code	361
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$4,289.34
Rate for Payer: AlohaCare Medicaid	$3,431.47
Rate for Payer: AlohaCare Medicare	$3,431.47
Rate for Payer: Devoted Health Medicare	$3,774.62
Rate for Payer: Hawaii Medical Service Association Commercial	$4,289.34
Rate for Payer: Hawaii Medical Service Association Medicare	$3,431.47
Rate for Payer: Humana Medicare	$3,431.47
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,431.47
Rate for Payer: Ohana Health Plan Medicaid	$3,774.62
Rate for Payer: Ohana Health Plan Medicare	$3,431.47
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,431.47

DRAIN BLAKE FLAT 10MM

Facility

$111.00

Hospital Revenue Code	272
Min. Negotiated Rate	$56.61
Max. Negotiated Rate	$107.67
Rate for Payer: Cash Price	$66.60
Rate for Payer: Hawaii Western Management Group Commercial	$105.45
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: Kaiser Permanente Commercial	$69.93
Rate for Payer: Kaiser Permanente Medicaid	$56.61
Rate for Payer: MDX Hawaii PPO	$107.67
Rate for Payer: University Health Alliance Commercial	$80.91

DRAIN BLAKE FLAT 10MM

Facility

$111.00

Hospital Revenue Code	272
Min. Negotiated Rate	$94.35
Max. Negotiated Rate	$107.67
Rate for Payer: Cash Price	$66.60
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: MDX Hawaii PPO	$107.67

DRAIN BLAKE RND 10FR

Facility

$117.00

Hospital Revenue Code	272
Min. Negotiated Rate	$59.67
Max. Negotiated Rate	$113.49
Rate for Payer: Cash Price	$70.20
Rate for Payer: Hawaii Western Management Group Commercial	$111.15
Rate for Payer: Health Management Network Commercial	$99.45
Rate for Payer: Kaiser Permanente Commercial	$73.71
Rate for Payer: Kaiser Permanente Medicaid	$59.67
Rate for Payer: MDX Hawaii PPO	$113.49
Rate for Payer: University Health Alliance Commercial	$85.28

DRAIN BLAKE RND 10FR

Facility

$117.00

Hospital Revenue Code	272
Min. Negotiated Rate	$99.45
Max. Negotiated Rate	$113.49
Rate for Payer: Cash Price	$70.20
Rate for Payer: Health Management Network Commercial	$99.45
Rate for Payer: MDX Hawaii PPO	$113.49

Know your out-of-pocket cost for care.

All Charges