Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

BAR 11MMX500

Facility

$1,383.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$705.33
Max. Negotiated Rate	$1,341.51
Rate for Payer: Cash Price	$829.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,313.85
Rate for Payer: Health Management Network Commercial	$1,175.55
Rate for Payer: Kaiser Permanente Commercial	$871.29
Rate for Payer: Kaiser Permanente Medicaid	$705.33
Rate for Payer: MDX Hawaii PPO	$1,341.51
Rate for Payer: University Health Alliance Commercial	$1,008.07

BAR 11MMX500

Facility

$1,383.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$1,175.55
Max. Negotiated Rate	$1,341.51
Rate for Payer: Cash Price	$829.80
Rate for Payer: Health Management Network Commercial	$1,175.55
Rate for Payer: MDX Hawaii PPO	$1,341.51

BAR 11X350

Facility

$1,383.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,175.55
Max. Negotiated Rate	$1,341.51
Rate for Payer: Cash Price	$829.80
Rate for Payer: Health Management Network Commercial	$1,175.55
Rate for Payer: MDX Hawaii PPO	$1,341.51

BAR 11X350

Facility

$1,383.00

Hospital Revenue Code	272
Min. Negotiated Rate	$705.33
Max. Negotiated Rate	$1,341.51
Rate for Payer: Cash Price	$829.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,313.85
Rate for Payer: Health Management Network Commercial	$1,175.55
Rate for Payer: Kaiser Permanente Commercial	$871.29
Rate for Payer: Kaiser Permanente Medicaid	$705.33
Rate for Payer: MDX Hawaii PPO	$1,341.51
Rate for Payer: University Health Alliance Commercial	$1,008.07

BAR 250 4922-8-250

Facility

$1,279.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,087.15
Max. Negotiated Rate	$1,240.63
Rate for Payer: Cash Price	$767.40
Rate for Payer: Health Management Network Commercial	$1,087.15
Rate for Payer: MDX Hawaii PPO	$1,240.63

BAR 250 4922-8-250

Facility

$1,279.00

Hospital Revenue Code	272
Min. Negotiated Rate	$652.29
Max. Negotiated Rate	$1,240.63
Rate for Payer: Cash Price	$767.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,215.05
Rate for Payer: Health Management Network Commercial	$1,087.15
Rate for Payer: Kaiser Permanente Commercial	$805.77
Rate for Payer: Kaiser Permanente Medicaid	$652.29
Rate for Payer: MDX Hawaii PPO	$1,240.63
Rate for Payer: University Health Alliance Commercial	$932.26

BAR 300 4922-8-300

Facility

$1,312.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$669.12
Max. Negotiated Rate	$1,272.64
Rate for Payer: Cash Price	$787.20
Rate for Payer: Hawaii Western Management Group Commercial	$918.40
Rate for Payer: Health Management Network Commercial	$1,115.20
Rate for Payer: Kaiser Permanente Commercial	$826.56
Rate for Payer: Kaiser Permanente Medicaid	$669.12
Rate for Payer: MDX Hawaii PPO	$1,272.64
Rate for Payer: University Health Alliance Commercial	$734.72

BAR 300 4922-8-300

Facility

$1,312.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$734.72
Max. Negotiated Rate	$1,272.64
Rate for Payer: Cash Price	$787.20
Rate for Payer: Hawaii Western Management Group Commercial	$918.40
Rate for Payer: Health Management Network Commercial	$1,115.20
Rate for Payer: MDX Hawaii PPO	$1,272.64
Rate for Payer: University Health Alliance Commercial	$734.72

BAR 400 4922-8-400

Facility

$1,788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,519.80
Max. Negotiated Rate	$1,734.36
Rate for Payer: Cash Price	$1,072.80
Rate for Payer: Health Management Network Commercial	$1,519.80
Rate for Payer: MDX Hawaii PPO	$1,734.36

BAR 400 4922-8-400

Facility

$1,788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$911.88
Max. Negotiated Rate	$1,734.36
Rate for Payer: Cash Price	$1,072.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,698.60
Rate for Payer: Health Management Network Commercial	$1,519.80
Rate for Payer: Kaiser Permanente Commercial	$1,126.44
Rate for Payer: Kaiser Permanente Medicaid	$911.88
Rate for Payer: MDX Hawaii PPO	$1,734.36
Rate for Payer: University Health Alliance Commercial	$1,303.27

BARICITINIB 2 MG TABLET [160676]

Facility

$167.00

Service Code	NDC 00002418230
Hospital Revenue Code	637
Min. Negotiated Rate	$85.17
Max. Negotiated Rate	$161.99
Rate for Payer: Cash Price	$100.20
Rate for Payer: Hawaii Western Management Group Commercial	$158.65
Rate for Payer: Health Management Network Commercial	$141.95
Rate for Payer: Kaiser Permanente Commercial	$105.21
Rate for Payer: Kaiser Permanente Medicaid	$85.17
Rate for Payer: MDX Hawaii PPO	$161.99
Rate for Payer: University Health Alliance Commercial	$121.73

BARICITINIB 2 MG TABLET [160676]

Facility

$167.00

Service Code	NDC 00002418230
Hospital Revenue Code	250
Min. Negotiated Rate	$141.95
Max. Negotiated Rate	$161.99
Rate for Payer: Cash Price	$100.20
Rate for Payer: Health Management Network Commercial	$141.95
Rate for Payer: MDX Hawaii PPO	$161.99

BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [97296]

Facility

$1.00

Service Code	NDC 32909016755
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

BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [97296]

Facility

$1.00

Service Code	NDC 32909016755
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

BARIUM SULFATE 2 % (W/V) ORAL SUSPENSION [18299]

Facility

$19.00

Service Code	NDC 32909074603
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

BARIUM SULFATE 2 % (W/V) ORAL SUSPENSION [18299]

Facility

$19.00

Service Code	NDC 32909074603
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

BARIUM SULFATE 40 % (W/V), 29 % (W/W) (1,500 CPS) ORAL SUSPENSION [209049]

Facility

$151.00

Service Code	NDC 32909012107
Hospital Revenue Code	637
Min. Negotiated Rate	$77.01
Max. Negotiated Rate	$146.47
Rate for Payer: Cash Price	$90.60
Rate for Payer: Hawaii Western Management Group Commercial	$143.45
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Kaiser Permanente Commercial	$95.13
Rate for Payer: Kaiser Permanente Medicaid	$77.01
Rate for Payer: MDX Hawaii PPO	$146.47
Rate for Payer: University Health Alliance Commercial	$110.06

BARIUM SULFATE 40 % (W/V), 29 % (W/W) (1,500 CPS) ORAL SUSPENSION [209049]

Facility

$151.00

Service Code	NDC 32909012107
Hospital Revenue Code	250
Min. Negotiated Rate	$128.35
Max. Negotiated Rate	$146.47
Rate for Payer: Cash Price	$90.60
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: MDX Hawaii PPO	$146.47

BARIUM SULFATE 40 % (W/V), 30% (W/W) ORAL PASTE [104159]

Facility

$132.00

Service Code	NDC 32909012522
Hospital Revenue Code	250
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$79.20
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: MDX Hawaii PPO	$128.04

BARIUM SULFATE 40 % (W/V), 30% (W/W) ORAL PASTE [104159]

Facility

$132.00

Service Code	NDC 32909012522
Hospital Revenue Code	637
Min. Negotiated Rate	$67.32
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$79.20
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$83.16
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: University Health Alliance Commercial	$96.21

BARIUM SULFATE 40 % (W/V), 30 % (W/W) ORAL SUSPENSION [39786]

Facility

$48.00

Service Code	NDC 32909011600
Hospital Revenue Code	250
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$28.80
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: MDX Hawaii PPO	$46.56

BARIUM SULFATE 40 % (W/V), 30 % (W/W) ORAL SUSPENSION [39786]

Facility

$48.00

Service Code	NDC 32909011600
Hospital Revenue Code	637
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$28.80
Rate for Payer: Hawaii Western Management Group Commercial	$45.60
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$30.24
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: University Health Alliance Commercial	$34.99

BARIUM SULFATE 700 MG TABLET [100992]

Facility

$12.00

Service Code	NDC 10361077831
Hospital Revenue Code	250
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.20
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: MDX Hawaii PPO	$11.64

BARIUM SULFATE 700 MG TABLET [100992]

Facility

$12.00

Service Code	NDC 10361077831
Hospital Revenue Code	637
Min. Negotiated Rate	$6.12
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.20
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$7.56
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: University Health Alliance Commercial	$8.75

BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]

Facility

$21.00

Service Code	NDC 32909075003
Hospital Revenue Code	637
Min. Negotiated Rate	$10.71
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$13.23
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: University Health Alliance Commercial	$15.31

Know your out-of-pocket cost for care.

All Charges