Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]

Facility

$24.00

Service Code	NDC 60687073411
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: MDX Hawaii PPO	$23.28

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]

Facility

$24.00

Service Code	NDC 68180029506
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: MDX Hawaii PPO	$23.28

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$24.00

Service Code	NDC 60687074511
Hospital Revenue Code	637
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$15.12
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: University Health Alliance Commercial	$17.49

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$24.00

Service Code	NDC 60687074501
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: MDX Hawaii PPO	$23.28

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$24.00

Service Code	NDC 60687074511
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: MDX Hawaii PPO	$23.28

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$24.00

Service Code	NDC 60687074501
Hospital Revenue Code	637
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$15.12
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: University Health Alliance Commercial	$17.49

DURASORB 10CM X 25CM PTM1025

Facility

$5,400.00

Hospital Revenue Code	278
Min. Negotiated Rate	$2,754.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: Kaiser Permanente Medicaid	$2,754.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

DURASORB 10CM X 25CM PTM1025

Facility

$5,400.00

Hospital Revenue Code	278
Min. Negotiated Rate	$3,024.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

DURASORB SIA 20X25 PTM2025

Facility

$12,800.00

Hospital Revenue Code	278
Min. Negotiated Rate	$7,168.00
Max. Negotiated Rate	$12,416.00
Rate for Payer: Cash Price	$7,680.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,960.00
Rate for Payer: Health Management Network Commercial	$10,880.00
Rate for Payer: MDX Hawaii PPO	$12,416.00
Rate for Payer: University Health Alliance Commercial	$7,168.00

DURASORB SIA 20X25 PTM2025

Facility

$12,800.00

Hospital Revenue Code	278
Min. Negotiated Rate	$6,528.00
Max. Negotiated Rate	$12,416.00
Rate for Payer: Cash Price	$7,680.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,960.00
Rate for Payer: Health Management Network Commercial	$10,880.00
Rate for Payer: Kaiser Permanente Commercial	$8,064.00
Rate for Payer: Kaiser Permanente Medicaid	$6,528.00
Rate for Payer: MDX Hawaii PPO	$12,416.00
Rate for Payer: University Health Alliance Commercial	$7,168.00

DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [139352]

Facility

$1,856.00

Service Code	HCPCS J9173
Hospital Revenue Code	250
Min. Negotiated Rate	$1,577.60
Max. Negotiated Rate	$1,800.32
Rate for Payer: Cash Price	$1,113.60
Rate for Payer: Cash Price	$4,638.60
Rate for Payer: Health Management Network Commercial	$1,577.60
Rate for Payer: Health Management Network Commercial	$6,571.35
Rate for Payer: MDX Hawaii PPO	$7,499.07
Rate for Payer: MDX Hawaii PPO	$1,800.32

DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [139352]

Facility

$1,856.00

Service Code	HCPCS J9173
Hospital Revenue Code	636
Min. Negotiated Rate	$85.25
Max. Negotiated Rate	$1,800.32
Rate for Payer: AlohaCare Medicaid	$86.15
Rate for Payer: AlohaCare Medicaid	$86.15
Rate for Payer: AlohaCare Medicare	$86.15
Rate for Payer: AlohaCare Medicare	$86.15
Rate for Payer: Cash Price	$1,113.60
Rate for Payer: Cash Price	$4,638.60
Rate for Payer: Cash Price	$1,113.60
Rate for Payer: Cash Price	$4,638.60
Rate for Payer: Devoted Health Medicare	$94.77
Rate for Payer: Devoted Health Medicare	$94.77
Rate for Payer: Hawaii Medical Service Association ABD	$85.25
Rate for Payer: Hawaii Medical Service Association ABD	$85.25
Rate for Payer: Hawaii Medical Service Association Commercial	$107.69
Rate for Payer: Hawaii Medical Service Association Commercial	$107.69
Rate for Payer: Hawaii Medical Service Association Medicare	$86.15
Rate for Payer: Hawaii Medical Service Association Medicare	$86.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$85.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$85.25
Rate for Payer: Hawaii Western Management Group Commercial	$7,344.45
Rate for Payer: Hawaii Western Management Group Commercial	$1,763.20
Rate for Payer: Health Management Network Commercial	$6,571.35
Rate for Payer: Health Management Network Commercial	$1,577.60
Rate for Payer: Humana Medicare	$86.15
Rate for Payer: Humana Medicare	$86.15
Rate for Payer: Kaiser Permanente Commercial	$4,870.53
Rate for Payer: Kaiser Permanente Commercial	$1,169.28
Rate for Payer: Kaiser Permanente Medicaid	$946.56
Rate for Payer: Kaiser Permanente Medicaid	$3,942.81
Rate for Payer: Kaiser Permanente Medicare	$86.15
Rate for Payer: Kaiser Permanente Medicare	$86.15
Rate for Payer: MDX Hawaii PPO	$7,499.07
Rate for Payer: MDX Hawaii PPO	$1,800.32
Rate for Payer: Ohana Health Plan Medicaid	$94.77
Rate for Payer: Ohana Health Plan Medicaid	$94.77
Rate for Payer: Ohana Health Plan Medicare	$86.15
Rate for Payer: Ohana Health Plan Medicare	$86.15
Rate for Payer: UnitedHealthcare Medicaid	$4,638.60
Rate for Payer: UnitedHealthcare Medicaid	$1,113.60
Rate for Payer: UnitedHealthcare Medicare	$86.15
Rate for Payer: UnitedHealthcare Medicare	$86.15
Rate for Payer: University Health Alliance Commercial	$1,352.84
Rate for Payer: University Health Alliance Commercial	$5,635.13

DUTASTERIDE 0.5 MG CAPSULE [34089]

Facility

$19.00

Service Code	NDC 42806054930
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

DUTASTERIDE 0.5 MG CAPSULE [34089]

Facility

$19.00

Service Code	NDC 31722013130
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

DUTASTERIDE 0.5 MG CAPSULE [34089]

Facility

$19.00

Service Code	NDC 31722013130
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

DUTASTERIDE 0.5 MG CAPSULE [34089]

Facility

$19.00

Service Code	NDC 42806054930
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

DVR LCK MEDIUM L 131822060

Facility

$3,178.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,620.78
Max. Negotiated Rate	$3,082.66
Rate for Payer: Cash Price	$1,906.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,224.60
Rate for Payer: Health Management Network Commercial	$2,701.30
Rate for Payer: Kaiser Permanente Commercial	$2,002.14
Rate for Payer: Kaiser Permanente Medicaid	$1,620.78
Rate for Payer: MDX Hawaii PPO	$3,082.66
Rate for Payer: University Health Alliance Commercial	$1,779.68

DVR LCK MEDIUM L 131822060

Facility

$3,178.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,779.68
Max. Negotiated Rate	$3,082.66
Rate for Payer: Cash Price	$1,906.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,224.60
Rate for Payer: Health Management Network Commercial	$2,701.30
Rate for Payer: MDX Hawaii PPO	$3,082.66
Rate for Payer: University Health Alliance Commercial	$1,779.68

DVR LCK STANDARD L 131822050

Facility

$2,828.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,583.68
Max. Negotiated Rate	$2,743.16
Rate for Payer: Cash Price	$1,696.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,979.60
Rate for Payer: Health Management Network Commercial	$2,403.80
Rate for Payer: MDX Hawaii PPO	$2,743.16
Rate for Payer: University Health Alliance Commercial	$1,583.68

DVR LCK STANDARD L 131822050

Facility

$2,828.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,442.28
Max. Negotiated Rate	$2,743.16
Rate for Payer: Cash Price	$1,696.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,979.60
Rate for Payer: Health Management Network Commercial	$2,403.80
Rate for Payer: Kaiser Permanente Commercial	$1,781.64
Rate for Payer: Kaiser Permanente Medicaid	$1,442.28
Rate for Payer: MDX Hawaii PPO	$2,743.16
Rate for Payer: University Health Alliance Commercial	$1,583.68

DVR LOCK WIDE L 131823050

Facility

$2,913.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,631.28
Max. Negotiated Rate	$2,825.61
Rate for Payer: Cash Price	$1,747.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,039.10
Rate for Payer: Health Management Network Commercial	$2,476.05
Rate for Payer: MDX Hawaii PPO	$2,825.61
Rate for Payer: University Health Alliance Commercial	$1,631.28

DVR LOCK WIDE L 131823050

Facility

$2,913.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,485.63
Max. Negotiated Rate	$2,825.61
Rate for Payer: Cash Price	$1,747.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,039.10
Rate for Payer: Health Management Network Commercial	$2,476.05
Rate for Payer: Kaiser Permanente Commercial	$1,835.19
Rate for Payer: Kaiser Permanente Medicaid	$1,485.63
Rate for Payer: MDX Hawaii PPO	$2,825.61
Rate for Payer: University Health Alliance Commercial	$1,631.28

DYSEQUILIBRIUM

Facility

$13,030.84

Service Code	MSDRG 149
Min. Negotiated Rate	$8,548.89
Max. Negotiated Rate	$13,030.84
Rate for Payer: AlohaCare Medicare	$8,548.89
Rate for Payer: Devoted Health Medicare	$9,403.78
Rate for Payer: Hawaii Medical Service Association Commercial	$13,030.84
Rate for Payer: Hawaii Medical Service Association Medicare	$8,548.89
Rate for Payer: Humana Medicare	$8,548.89
Rate for Payer: Kaiser Permanente Commercial	$12,965.10
Rate for Payer: Kaiser Permanente Medicare	$8,548.89
Rate for Payer: Ohana Health Plan Medicare	$8,548.89
Rate for Payer: UnitedHealthcare Medicare	$8,548.89

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC

Facility

$36,204.87

Service Code	MSDRG 147
Min. Negotiated Rate	$14,462.36
Max. Negotiated Rate	$36,204.87
Rate for Payer: AlohaCare Medicare	$14,462.36
Rate for Payer: Devoted Health Medicare	$15,908.60
Rate for Payer: Hawaii Medical Service Association Commercial	$36,204.87
Rate for Payer: Hawaii Medical Service Association Medicare	$14,462.36
Rate for Payer: Humana Medicare	$14,462.36
Rate for Payer: Kaiser Permanente Commercial	$21,933.38
Rate for Payer: Kaiser Permanente Medicare	$14,462.36
Rate for Payer: Ohana Health Plan Medicare	$14,462.36
Rate for Payer: UnitedHealthcare Medicare	$14,462.36

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC

Facility

$36,525.15

Service Code	MSDRG 146
Min. Negotiated Rate	$24,083.85
Max. Negotiated Rate	$36,525.15
Rate for Payer: AlohaCare Medicare	$24,083.85
Rate for Payer: Devoted Health Medicare	$26,492.24
Rate for Payer: Hawaii Medical Service Association Commercial	$36,204.87
Rate for Payer: Hawaii Medical Service Association Medicare	$24,083.85
Rate for Payer: Humana Medicare	$24,083.85
Rate for Payer: Kaiser Permanente Commercial	$36,525.15
Rate for Payer: Kaiser Permanente Medicare	$24,083.85
Rate for Payer: Ohana Health Plan Medicare	$24,083.85
Rate for Payer: UnitedHealthcare Medicare	$24,083.85

Know your out-of-pocket cost for care.

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