Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GENTAMICIN 0.3 % EYE DROPS [3428]

Facility

$76.00

Service Code	NDC 61314063305
Hospital Revenue Code	637
Min. Negotiated Rate	$38.76
Max. Negotiated Rate	$73.72
Rate for Payer: Cash Price	$45.60
Rate for Payer: Hawaii Western Management Group Commercial	$72.20
Rate for Payer: Health Management Network Commercial	$64.60
Rate for Payer: Kaiser Permanente Commercial	$47.88
Rate for Payer: Kaiser Permanente Medicaid	$38.76
Rate for Payer: MDX Hawaii PPO	$73.72
Rate for Payer: University Health Alliance Commercial	$55.40

GENTAMICIN 0.3 % EYE DROPS [3428]

Facility

$76.00

Service Code	NDC 61314063305
Hospital Revenue Code	250
Min. Negotiated Rate	$64.60
Max. Negotiated Rate	$73.72
Rate for Payer: Cash Price	$45.60
Rate for Payer: Health Management Network Commercial	$64.60
Rate for Payer: MDX Hawaii PPO	$73.72

GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]

Facility

$53.00

Service Code	HCPCS J1580
Hospital Revenue Code	250
Min. Negotiated Rate	$45.05
Max. Negotiated Rate	$51.41
Rate for Payer: Cash Price	$31.80
Rate for Payer: Cash Price	$4.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Health Management Network Commercial	$45.05
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: MDX Hawaii PPO	$135.80
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: MDX Hawaii PPO	$51.41
Rate for Payer: MDX Hawaii PPO	$7.76

GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]

Facility

$20.00

Service Code	HCPCS J1580
Hospital Revenue Code	636
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$31.80
Rate for Payer: Cash Price	$31.80
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$84.00
Rate for Payer: Cash Price	$4.80
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$84.00
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Medical Service Association ABD	$2.62
Rate for Payer: Hawaii Medical Service Association ABD	$2.62
Rate for Payer: Hawaii Medical Service Association ABD	$2.62
Rate for Payer: Hawaii Medical Service Association ABD	$2.62
Rate for Payer: Hawaii Medical Service Association ABD	$2.62
Rate for Payer: Hawaii Medical Service Association ABD	$2.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.62
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Hawaii Western Management Group Commercial	$133.00
Rate for Payer: Hawaii Western Management Group Commercial	$19.00
Rate for Payer: Hawaii Western Management Group Commercial	$15.20
Rate for Payer: Hawaii Western Management Group Commercial	$50.35
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$45.05
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$13.23
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Commercial	$33.39
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Commercial	$10.08
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: Kaiser Permanente Medicaid	$10.20
Rate for Payer: Kaiser Permanente Medicaid	$8.16
Rate for Payer: Kaiser Permanente Medicaid	$71.40
Rate for Payer: Kaiser Permanente Medicaid	$27.03
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: MDX Hawaii PPO	$135.80
Rate for Payer: MDX Hawaii PPO	$51.41
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: UnitedHealthcare Medicaid	$4.80
Rate for Payer: UnitedHealthcare Medicaid	$12.00
Rate for Payer: UnitedHealthcare Medicaid	$9.60
Rate for Payer: UnitedHealthcare Medicaid	$12.60
Rate for Payer: UnitedHealthcare Medicaid	$84.00
Rate for Payer: UnitedHealthcare Medicaid	$31.80
Rate for Payer: University Health Alliance Commercial	$11.66
Rate for Payer: University Health Alliance Commercial	$15.31
Rate for Payer: University Health Alliance Commercial	$38.63
Rate for Payer: University Health Alliance Commercial	$5.83
Rate for Payer: University Health Alliance Commercial	$14.58
Rate for Payer: University Health Alliance Commercial	$102.05

GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION [3425]

Facility

$223.00

Service Code	HCPCS J1580
Hospital Revenue Code	250
Min. Negotiated Rate	$189.55
Max. Negotiated Rate	$216.31
Rate for Payer: Cash Price	$133.80
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: MDX Hawaii PPO	$216.31
Rate for Payer: MDX Hawaii PPO	$25.22

GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION [3425]

Facility

$223.00

Service Code	HCPCS J1580
Hospital Revenue Code	636
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$216.31
Rate for Payer: Cash Price	$133.80
Rate for Payer: Cash Price	$15.60
Rate for Payer: Cash Price	$133.80
Rate for Payer: Cash Price	$15.60
Rate for Payer: Hawaii Medical Service Association ABD	$2.62
Rate for Payer: Hawaii Medical Service Association ABD	$2.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.62
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Hawaii Western Management Group Commercial	$211.85
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Kaiser Permanente Commercial	$16.38
Rate for Payer: Kaiser Permanente Commercial	$140.49
Rate for Payer: Kaiser Permanente Medicaid	$113.73
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: MDX Hawaii PPO	$216.31
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: UnitedHealthcare Medicaid	$133.80
Rate for Payer: University Health Alliance Commercial	$162.54
Rate for Payer: University Health Alliance Commercial	$18.95

GIA 60-3.8 LOADING GIA6038L

Facility

$208.00

Hospital Revenue Code	272
Min. Negotiated Rate	$106.08
Max. Negotiated Rate	$201.76
Rate for Payer: Cash Price	$124.80
Rate for Payer: Hawaii Western Management Group Commercial	$197.60
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Kaiser Permanente Commercial	$131.04
Rate for Payer: Kaiser Permanente Medicaid	$106.08
Rate for Payer: MDX Hawaii PPO	$201.76
Rate for Payer: University Health Alliance Commercial	$151.61

GIA 60-3.8 LOADING GIA6038L

Facility

$208.00

Hospital Revenue Code	272
Min. Negotiated Rate	$176.80
Max. Negotiated Rate	$201.76
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: MDX Hawaii PPO	$201.76

GIA 6-3.8 STAPLER GIA6038S

Facility

$358.00

Hospital Revenue Code	272
Min. Negotiated Rate	$182.58
Max. Negotiated Rate	$347.26
Rate for Payer: Cash Price	$214.80
Rate for Payer: Hawaii Western Management Group Commercial	$340.10
Rate for Payer: Health Management Network Commercial	$304.30
Rate for Payer: Kaiser Permanente Commercial	$225.54
Rate for Payer: Kaiser Permanente Medicaid	$182.58
Rate for Payer: MDX Hawaii PPO	$347.26
Rate for Payer: University Health Alliance Commercial	$260.95

GIA 6-3.8 STAPLER GIA6038S

Facility

$358.00

Hospital Revenue Code	272
Min. Negotiated Rate	$304.30
Max. Negotiated Rate	$347.26
Rate for Payer: Cash Price	$214.80
Rate for Payer: Health Management Network Commercial	$304.30
Rate for Payer: MDX Hawaii PPO	$347.26

GIA 80-3.8 STAPLER GIA8038S

Facility

$433.00

Hospital Revenue Code	272
Min. Negotiated Rate	$220.83
Max. Negotiated Rate	$420.01
Rate for Payer: Cash Price	$259.80
Rate for Payer: Hawaii Western Management Group Commercial	$411.35
Rate for Payer: Health Management Network Commercial	$368.05
Rate for Payer: Kaiser Permanente Commercial	$272.79
Rate for Payer: Kaiser Permanente Medicaid	$220.83
Rate for Payer: MDX Hawaii PPO	$420.01
Rate for Payer: University Health Alliance Commercial	$315.61

GIA 80-3.8 STAPLER GIA8038S

Facility

$433.00

Hospital Revenue Code	272
Min. Negotiated Rate	$368.05
Max. Negotiated Rate	$420.01
Rate for Payer: Cash Price	$259.80
Rate for Payer: Health Management Network Commercial	$368.05
Rate for Payer: MDX Hawaii PPO	$420.01

GIA 80-3.8 SULU GIA8038L

Facility

$241.00

Hospital Revenue Code	272
Min. Negotiated Rate	$122.91
Max. Negotiated Rate	$233.77
Rate for Payer: Cash Price	$144.60
Rate for Payer: Hawaii Western Management Group Commercial	$228.95
Rate for Payer: Health Management Network Commercial	$204.85
Rate for Payer: Kaiser Permanente Commercial	$151.83
Rate for Payer: Kaiser Permanente Medicaid	$122.91
Rate for Payer: MDX Hawaii PPO	$233.77
Rate for Payer: University Health Alliance Commercial	$175.66

GIA 80-3.8 SULU GIA8038L

Facility

$241.00

Hospital Revenue Code	272
Min. Negotiated Rate	$204.85
Max. Negotiated Rate	$233.77
Rate for Payer: Cash Price	$144.60
Rate for Payer: Health Management Network Commercial	$204.85
Rate for Payer: MDX Hawaii PPO	$233.77

GIA 80-4.8 RELOAD GIA 8048L

Facility

$281.00

Hospital Revenue Code	272
Min. Negotiated Rate	$143.31
Max. Negotiated Rate	$272.57
Rate for Payer: Cash Price	$168.60
Rate for Payer: Hawaii Western Management Group Commercial	$266.95
Rate for Payer: Health Management Network Commercial	$238.85
Rate for Payer: Kaiser Permanente Commercial	$177.03
Rate for Payer: Kaiser Permanente Medicaid	$143.31
Rate for Payer: MDX Hawaii PPO	$272.57
Rate for Payer: University Health Alliance Commercial	$204.82

GIA 80-4.8 RELOAD GIA 8048L

Facility

$281.00

Hospital Revenue Code	272
Min. Negotiated Rate	$238.85
Max. Negotiated Rate	$272.57
Rate for Payer: Cash Price	$168.60
Rate for Payer: Health Management Network Commercial	$238.85
Rate for Payer: MDX Hawaii PPO	$272.57

GIA 80-4.8 STAPLER GIA8048S

Facility

$495.00

Hospital Revenue Code	272
Min. Negotiated Rate	$252.45
Max. Negotiated Rate	$480.15
Rate for Payer: Cash Price	$297.00
Rate for Payer: Hawaii Western Management Group Commercial	$470.25
Rate for Payer: Health Management Network Commercial	$420.75
Rate for Payer: Kaiser Permanente Commercial	$311.85
Rate for Payer: Kaiser Permanente Medicaid	$252.45
Rate for Payer: MDX Hawaii PPO	$480.15
Rate for Payer: University Health Alliance Commercial	$360.81

GIA 80-4.8 STAPLER GIA8048S

Facility

$495.00

Hospital Revenue Code	272
Min. Negotiated Rate	$420.75
Max. Negotiated Rate	$480.15
Rate for Payer: Cash Price	$297.00
Rate for Payer: Health Management Network Commercial	$420.75
Rate for Payer: MDX Hawaii PPO	$480.15

GIA ENDO 30VAS/MED SIG30AVM

Facility

$559.00

Hospital Revenue Code	272
Min. Negotiated Rate	$475.15
Max. Negotiated Rate	$542.23
Rate for Payer: Cash Price	$335.40
Rate for Payer: Health Management Network Commercial	$475.15
Rate for Payer: MDX Hawaii PPO	$542.23

GIA ENDO 30VAS/MED SIG30AVM

Facility

$559.00

Hospital Revenue Code	272
Min. Negotiated Rate	$285.09
Max. Negotiated Rate	$542.23
Rate for Payer: Cash Price	$335.40
Rate for Payer: Hawaii Western Management Group Commercial	$531.05
Rate for Payer: Health Management Network Commercial	$475.15
Rate for Payer: Kaiser Permanente Commercial	$352.17
Rate for Payer: Kaiser Permanente Medicaid	$285.09
Rate for Payer: MDX Hawaii PPO	$542.23
Rate for Payer: University Health Alliance Commercial	$407.46

GIA ENDO 45MEDIUM EGIA45AVMGIA

Facility

$555.00

Hospital Revenue Code	272
Min. Negotiated Rate	$471.75
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$333.00
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: MDX Hawaii PPO	$538.35

GIA ENDO 45MEDIUM EGIA45AVMGIA

Facility

$555.00

Hospital Revenue Code	272
Min. Negotiated Rate	$283.05
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$333.00
Rate for Payer: Hawaii Western Management Group Commercial	$527.25
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: Kaiser Permanente Commercial	$349.65
Rate for Payer: Kaiser Permanente Medicaid	$283.05
Rate for Payer: MDX Hawaii PPO	$538.35
Rate for Payer: University Health Alliance Commercial	$404.54

GIA ENDO 45MED/THK EGIA45AMT

Facility

$555.00

Hospital Revenue Code	272
Min. Negotiated Rate	$283.05
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$333.00
Rate for Payer: Hawaii Western Management Group Commercial	$527.25
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: Kaiser Permanente Commercial	$349.65
Rate for Payer: Kaiser Permanente Medicaid	$283.05
Rate for Payer: MDX Hawaii PPO	$538.35
Rate for Payer: University Health Alliance Commercial	$404.54

GIA ENDO 45MED/THK EGIA45AMT

Facility

$555.00

Hospital Revenue Code	272
Min. Negotiated Rate	$471.75
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$333.00
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: MDX Hawaii PPO	$538.35

GIA ENDO 60MEDIUM EGIA60AVM

Facility

$705.00

Hospital Revenue Code	272
Min. Negotiated Rate	$359.55
Max. Negotiated Rate	$683.85
Rate for Payer: Kaiser Permanente Medicaid	$359.55
Rate for Payer: Cash Price	$423.00
Rate for Payer: Hawaii Western Management Group Commercial	$669.75
Rate for Payer: Health Management Network Commercial	$599.25
Rate for Payer: Kaiser Permanente Commercial	$444.15
Rate for Payer: MDX Hawaii PPO	$683.85
Rate for Payer: University Health Alliance Commercial	$513.87

Know your out-of-pocket cost for care.

All Charges