Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]

Facility

$1.00

Service Code	NDC 46122022171
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

GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]

Facility

$1.00

Service Code	NDC 46122022171
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

GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]

Facility

$1.00

Service Code	NDC 42511000000
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

GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]

Facility

$1.00

Service Code	NDC 42510000000
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

GLYCERIN (CHILD) RECTAL SUPPOSITORY [76974]

Facility

$1.00

Service Code	NDC 42512000000
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

GLYCERIN (CHILD) RECTAL SUPPOSITORY [76974]

Facility

$1.00

Service Code	NDC 46122022263
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

GLYCERIN (CHILD) RECTAL SUPPOSITORY [76974]

Facility

$1.00

Service Code	NDC 42512000000
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

GLYCERIN (CHILD) RECTAL SUPPOSITORY [76974]

Facility

$1.00

Service Code	NDC 46122022263
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

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$7.00

Service Code	HCPCS J1596
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$7.20
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: MDX Hawaii PPO	$11.64

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$12.00

Service Code	HCPCS J1596
Hospital Revenue Code	636
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$4.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.43
Rate for Payer: Hawaii Medical Service Association ABD	$0.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.43
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$7.56
Rate for Payer: Kaiser Permanente Commercial	$4.41
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: UnitedHealthcare Medicaid	$7.20
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: University Health Alliance Commercial	$8.75
Rate for Payer: University Health Alliance Commercial	$5.10

GORE DRYSEAL SHEATH 12FRX45CM

Facility

$2,271.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,158.21
Max. Negotiated Rate	$2,202.87
Rate for Payer: Cash Price	$1,362.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,157.45
Rate for Payer: Health Management Network Commercial	$1,930.35
Rate for Payer: Kaiser Permanente Commercial	$1,430.73
Rate for Payer: Kaiser Permanente Medicaid	$1,158.21
Rate for Payer: MDX Hawaii PPO	$2,202.87
Rate for Payer: University Health Alliance Commercial	$1,655.33

GORE DRYSEAL SHEATH 12FRX45CM

Facility

$2,271.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,930.35
Max. Negotiated Rate	$2,202.87
Rate for Payer: Cash Price	$1,362.60
Rate for Payer: Health Management Network Commercial	$1,930.35
Rate for Payer: MDX Hawaii PPO	$2,202.87

GORE DRYSEAL SHEATH 12FX33CM

Facility

$2,448.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$2,080.80
Max. Negotiated Rate	$2,374.56
Rate for Payer: Cash Price	$1,468.80
Rate for Payer: Health Management Network Commercial	$2,080.80
Rate for Payer: MDX Hawaii PPO	$2,374.56

GORE DRYSEAL SHEATH 12FX33CM

Facility

$2,448.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,248.48
Max. Negotiated Rate	$2,374.56
Rate for Payer: Cash Price	$1,468.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,325.60
Rate for Payer: Health Management Network Commercial	$2,080.80
Rate for Payer: Kaiser Permanente Commercial	$1,542.24
Rate for Payer: Kaiser Permanente Medicaid	$1,248.48
Rate for Payer: MDX Hawaii PPO	$2,374.56
Rate for Payer: University Health Alliance Commercial	$1,784.35

GORE DRYSEAL SHEATH 14FRX33CM

Facility

$1,548.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$789.48
Max. Negotiated Rate	$1,501.56
Rate for Payer: Cash Price	$928.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,470.60
Rate for Payer: Health Management Network Commercial	$1,315.80
Rate for Payer: Kaiser Permanente Commercial	$975.24
Rate for Payer: Kaiser Permanente Medicaid	$789.48
Rate for Payer: MDX Hawaii PPO	$1,501.56
Rate for Payer: University Health Alliance Commercial	$1,128.34

GORE DRYSEAL SHEATH 14FRX33CM

Facility

$1,548.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,315.80
Max. Negotiated Rate	$1,501.56
Rate for Payer: Cash Price	$928.80
Rate for Payer: Health Management Network Commercial	$1,315.80
Rate for Payer: MDX Hawaii PPO	$1,501.56

GORE DRYSEAL SHEATH 15FRX33CM

Facility

$2,448.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$2,080.80
Max. Negotiated Rate	$2,374.56
Rate for Payer: Cash Price	$1,468.80
Rate for Payer: Health Management Network Commercial	$2,080.80
Rate for Payer: MDX Hawaii PPO	$2,374.56

GORE DRYSEAL SHEATH 15FRX33CM

Facility

$2,448.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,248.48
Max. Negotiated Rate	$2,374.56
Rate for Payer: Cash Price	$1,468.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,325.60
Rate for Payer: Health Management Network Commercial	$2,080.80
Rate for Payer: Kaiser Permanente Commercial	$1,542.24
Rate for Payer: Kaiser Permanente Medicaid	$1,248.48
Rate for Payer: MDX Hawaii PPO	$2,374.56
Rate for Payer: University Health Alliance Commercial	$1,784.35

GORE DRYSEAL SHEATH 16FRX33CM

Facility

$2,400.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,280.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,749.36

GORE DRYSEAL SHEATH 16FRX33CM

Facility

$2,400.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$2,040.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00

GORE DRYSEAL SHEATH 18FRX28CM

Facility

$1,155.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$981.75
Max. Negotiated Rate	$1,120.35
Rate for Payer: Cash Price	$693.00
Rate for Payer: Health Management Network Commercial	$981.75
Rate for Payer: MDX Hawaii PPO	$1,120.35

GORE DRYSEAL SHEATH 18FRX28CM

Facility

$1,155.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$589.05
Max. Negotiated Rate	$1,120.35
Rate for Payer: Cash Price	$693.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,097.25
Rate for Payer: Health Management Network Commercial	$981.75
Rate for Payer: Kaiser Permanente Commercial	$727.65
Rate for Payer: Kaiser Permanente Medicaid	$589.05
Rate for Payer: MDX Hawaii PPO	$1,120.35
Rate for Payer: University Health Alliance Commercial	$841.88

GORE DRYSEAL SHEATH 18FRX33CM

Facility

$2,200.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,870.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: MDX Hawaii PPO	$2,134.00

GORE DRYSEAL SHEATH 18FRX33CM

Facility

$2,200.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,122.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,090.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$1,386.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: University Health Alliance Commercial	$1,603.58

GORE ERLY CANN GRFT ECH470045A

Facility

$2,960.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,657.60
Max. Negotiated Rate	$2,871.20
Rate for Payer: Cash Price	$1,776.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,072.00
Rate for Payer: Health Management Network Commercial	$2,516.00
Rate for Payer: MDX Hawaii PPO	$2,871.20
Rate for Payer: University Health Alliance Commercial	$1,657.60

Know your out-of-pocket cost for care.

All Charges