Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]

Facility

$8.00

Service Code	NDC 00904645061
Hospital Revenue Code	637
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: University Health Alliance Commercial	$5.83

ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]

Facility

$2.00

Service Code	NDC 60687079401
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$61.00

Service Code	NDC 67877045430
Hospital Revenue Code	637
Min. Negotiated Rate	$31.11
Max. Negotiated Rate	$59.17
Rate for Payer: Cash Price	$36.60
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: University Health Alliance Commercial	$44.46

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$20.00

Service Code	NDC 50268045012
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

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$20.00

Service Code	NDC 50268045012
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

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$61.00

Service Code	NDC 67877045430
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

ITRACONAZOLE 10 MG/ML ORAL SOLUTION [19928]

Facility

$551.00

Service Code	NDC 65162008774
Hospital Revenue Code	637
Min. Negotiated Rate	$281.01
Max. Negotiated Rate	$534.47
Rate for Payer: Cash Price	$330.60
Rate for Payer: Hawaii Western Management Group Commercial	$523.45
Rate for Payer: Health Management Network Commercial	$468.35
Rate for Payer: Kaiser Permanente Commercial	$347.13
Rate for Payer: Kaiser Permanente Medicaid	$281.01
Rate for Payer: MDX Hawaii PPO	$534.47
Rate for Payer: University Health Alliance Commercial	$401.62

ITRACONAZOLE 10 MG/ML ORAL SOLUTION [19928]

Facility

$551.00

Service Code	NDC 65162008774
Hospital Revenue Code	250
Min. Negotiated Rate	$468.35
Max. Negotiated Rate	$534.47
Rate for Payer: Cash Price	$330.60
Rate for Payer: Health Management Network Commercial	$468.35
Rate for Payer: MDX Hawaii PPO	$534.47

IVABRADINE 5 MG TABLET [128540]

Facility

$32.00

Service Code	NDC 55513080060
Hospital Revenue Code	250
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: MDX Hawaii PPO	$31.04

IVABRADINE 5 MG TABLET [128540]

Facility

$32.00

Service Code	NDC 55513080060
Hospital Revenue Code	637
Min. Negotiated Rate	$16.32
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Hawaii Western Management Group Commercial	$30.40
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Kaiser Permanente Commercial	$20.16
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: University Health Alliance Commercial	$23.32

IVERMECTIN 3 MG TABLET [25820]

Facility

$18.00

Service Code	NDC 42799080601
Hospital Revenue Code	250
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$17.46

IVERMECTIN 3 MG TABLET [25820]

Facility

$18.00

Service Code	NDC 42799080601
Hospital Revenue Code	637
Min. Negotiated Rate	$9.18
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$11.34
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: University Health Alliance Commercial	$13.12

IV PUSH EA ADDL SAME DRUG

Facility

$233.00

Service Code	HCPCS 96376
Hospital Charge Code	4509637601
Hospital Revenue Code	450
Min. Negotiated Rate	$146.79
Max. Negotiated Rate	$1,600.00
Rate for Payer: Cash Price	$139.80
Rate for Payer: Cash Price	$139.80
Rate for Payer: Cash Price	$139.80
Rate for Payer: Hawaii Medical Service Association ABD	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$221.35
Rate for Payer: Health Management Network Commercial	$198.05
Rate for Payer: Kaiser Permanente Commercial	$146.79
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: MDX Hawaii PPO	$226.01
Rate for Payer: University Health Alliance Commercial	$169.83

IV PUSH EA ADDL SAME DRUG

Facility

$233.00

Service Code	HCPCS 96376
Hospital Charge Code	4509637601
Hospital Revenue Code	450
Min. Negotiated Rate	$198.05
Max. Negotiated Rate	$226.01
Rate for Payer: Cash Price	$139.80
Rate for Payer: Health Management Network Commercial	$198.05
Rate for Payer: MDX Hawaii PPO	$226.01

IV PUSH EA ADDL SAME DRUG

Facility

$303.00

Service Code	HCPCS 96376
Hospital Charge Code	9409637610
Hospital Revenue Code	940
Min. Negotiated Rate	$154.53
Max. Negotiated Rate	$293.91
Rate for Payer: Cash Price	$181.80
Rate for Payer: Hawaii Western Management Group Commercial	$287.85
Rate for Payer: Health Management Network Commercial	$257.55
Rate for Payer: Kaiser Permanente Commercial	$190.89
Rate for Payer: Kaiser Permanente Medicaid	$154.53
Rate for Payer: MDX Hawaii PPO	$293.91
Rate for Payer: University Health Alliance Commercial	$220.86

IV PUSH EA ADDL SAME DRUG

Facility

$303.00

Service Code	HCPCS 96376
Hospital Charge Code	9409637610
Hospital Revenue Code	940
Min. Negotiated Rate	$257.55
Max. Negotiated Rate	$293.91
Rate for Payer: Cash Price	$181.80
Rate for Payer: Health Management Network Commercial	$257.55
Rate for Payer: MDX Hawaii PPO	$293.91

J-TUBE FEEDING TUBE #0200-12LV

Facility

$536.00

Service Code	HCPCS B4087
Hospital Revenue Code	272
Min. Negotiated Rate	$455.60
Max. Negotiated Rate	$519.92
Rate for Payer: Cash Price	$321.60
Rate for Payer: Health Management Network Commercial	$455.60
Rate for Payer: MDX Hawaii PPO	$519.92

J-TUBE FEEDING TUBE #0200-12LV

Facility

$536.00

Service Code	HCPCS B4087
Hospital Revenue Code	272
Min. Negotiated Rate	$38.22
Max. Negotiated Rate	$519.92
Rate for Payer: Cash Price	$321.60
Rate for Payer: Cash Price	$321.60
Rate for Payer: Hawaii Western Management Group Commercial	$509.20
Rate for Payer: Health Management Network Commercial	$455.60
Rate for Payer: Kaiser Permanente Commercial	$337.68
Rate for Payer: Kaiser Permanente Medicaid	$273.36
Rate for Payer: MDX Hawaii PPO	$519.92
Rate for Payer: UnitedHealthcare Medicaid	$38.22
Rate for Payer: University Health Alliance Commercial	$390.69

KETAMINE 100 MG/ML INJECTION SOLUTION [4237]

Facility

$54.00

Service Code	NDC 00143950901
Hospital Revenue Code	250
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$32.40
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$52.38

KETAMINE 100 MG/ML INJECTION SOLUTION [4237]

Facility

$54.00

Service Code	NDC 00143950910
Hospital Revenue Code	250
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$32.40
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$52.38

KETAMINE 100 MG/ML INJECTION SOLUTION [4237]

Facility

$35.00

Service Code	NDC 00409205105
Hospital Revenue Code	250
Min. Negotiated Rate	$29.75
Max. Negotiated Rate	$33.95
Rate for Payer: Cash Price	$21.00
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: MDX Hawaii PPO	$33.95

KETAMINE 10 MG/ML INJECTION SOLUTION [4236]

Facility

$84.00

Service Code	NDC 42023011310
Hospital Revenue Code	250
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$50.40
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: MDX Hawaii PPO	$81.48

KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLOR,ISO-OSMOTIC INJ SYRINGE [162740]

Facility

$25.00

Service Code	NDC 71266908004
Hospital Revenue Code	250
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: MDX Hawaii PPO	$24.25

KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLOR,ISO-OSMOTIC INJ SYRINGE [162740]

Facility

$25.00

Service Code	NDC 71266908002
Hospital Revenue Code	250
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: MDX Hawaii PPO	$24.25

KETAMINE 50 MG/ML INJECTION SOLUTION [4238]

Facility

$27.00

Service Code	NDC 00143950810
Hospital Revenue Code	250
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$32.40
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: MDX Hawaii PPO	$52.38

Know your out-of-pocket cost for care.

All Charges