Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]

Facility

$30.00

Service Code	HCPCS J0640
Hospital Revenue Code	636
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Hawaii Medical Service Association ABD	$3.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.95
Rate for Payer: Hawaii Western Management Group Commercial	$28.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: UnitedHealthcare Medicaid	$18.00
Rate for Payer: University Health Alliance Commercial	$21.87

LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]

Facility

$30.00

Service Code	HCPCS J0640
Hospital Revenue Code	250
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: MDX Hawaii PPO	$29.10

LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT [13691]

Facility

$2,662.00

Service Code	HCPCS J1950
Hospital Revenue Code	250
Min. Negotiated Rate	$2,262.70
Max. Negotiated Rate	$2,582.14
Rate for Payer: Cash Price	$1,597.20
Rate for Payer: Health Management Network Commercial	$2,262.70
Rate for Payer: MDX Hawaii PPO	$2,582.14

LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT [13691]

Facility

$2,662.00

Service Code	HCPCS J1950
Hospital Revenue Code	636
Min. Negotiated Rate	$1,357.62
Max. Negotiated Rate	$2,582.14
Rate for Payer: AlohaCare Medicaid	$1,765.57
Rate for Payer: AlohaCare Medicare	$1,765.57
Rate for Payer: Cash Price	$1,597.20
Rate for Payer: Cash Price	$1,597.20
Rate for Payer: Devoted Health Medicare	$1,942.13
Rate for Payer: Hawaii Medical Service Association ABD	$1,737.10
Rate for Payer: Hawaii Medical Service Association Commercial	$2,206.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1,765.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,737.10
Rate for Payer: Hawaii Western Management Group Commercial	$2,528.90
Rate for Payer: Health Management Network Commercial	$2,262.70
Rate for Payer: Humana Medicare	$1,765.57
Rate for Payer: Kaiser Permanente Commercial	$1,677.06
Rate for Payer: Kaiser Permanente Medicaid	$1,357.62
Rate for Payer: Kaiser Permanente Medicare	$1,765.57
Rate for Payer: MDX Hawaii PPO	$2,582.14
Rate for Payer: Ohana Health Plan Medicaid	$1,942.13
Rate for Payer: Ohana Health Plan Medicare	$1,765.57
Rate for Payer: UnitedHealthcare Medicaid	$1,597.20
Rate for Payer: UnitedHealthcare Medicare	$1,765.57
Rate for Payer: University Health Alliance Commercial	$1,940.33

LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]

Facility

$814.00

Service Code	HCPCS J9217
Hospital Revenue Code	250
Min. Negotiated Rate	$691.90
Max. Negotiated Rate	$789.58
Rate for Payer: Cash Price	$488.40
Rate for Payer: Health Management Network Commercial	$691.90
Rate for Payer: MDX Hawaii PPO	$789.58

LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]

Facility

$814.00

Service Code	HCPCS J9217
Hospital Revenue Code	636
Min. Negotiated Rate	$155.42
Max. Negotiated Rate	$789.58
Rate for Payer: AlohaCare Medicaid	$176.20
Rate for Payer: AlohaCare Medicare	$176.20
Rate for Payer: Cash Price	$488.40
Rate for Payer: Cash Price	$488.40
Rate for Payer: Devoted Health Medicare	$193.82
Rate for Payer: Hawaii Medical Service Association ABD	$155.42
Rate for Payer: Hawaii Medical Service Association Commercial	$220.25
Rate for Payer: Hawaii Medical Service Association Medicare	$176.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$155.42
Rate for Payer: Hawaii Western Management Group Commercial	$773.30
Rate for Payer: Health Management Network Commercial	$691.90
Rate for Payer: Humana Medicare	$176.20
Rate for Payer: Kaiser Permanente Commercial	$512.82
Rate for Payer: Kaiser Permanente Medicaid	$415.14
Rate for Payer: Kaiser Permanente Medicare	$176.20
Rate for Payer: MDX Hawaii PPO	$789.58
Rate for Payer: Ohana Health Plan Medicaid	$193.82
Rate for Payer: Ohana Health Plan Medicare	$176.20
Rate for Payer: UnitedHealthcare Medicaid	$488.40
Rate for Payer: UnitedHealthcare Medicare	$176.20
Rate for Payer: University Health Alliance Commercial	$593.32

LEUPROLIDE ACETATE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]

Facility

$6,985.00

Service Code	HCPCS J1950
Hospital Revenue Code	636
Min. Negotiated Rate	$1,737.10
Max. Negotiated Rate	$6,775.45
Rate for Payer: AlohaCare Medicaid	$1,765.57
Rate for Payer: AlohaCare Medicare	$1,765.57
Rate for Payer: Cash Price	$4,191.00
Rate for Payer: Cash Price	$4,191.00
Rate for Payer: Devoted Health Medicare	$1,942.13
Rate for Payer: Hawaii Medical Service Association ABD	$1,737.10
Rate for Payer: Hawaii Medical Service Association Commercial	$2,206.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1,765.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,737.10
Rate for Payer: Hawaii Western Management Group Commercial	$6,635.75
Rate for Payer: Health Management Network Commercial	$5,937.25
Rate for Payer: Humana Medicare	$1,765.57
Rate for Payer: Kaiser Permanente Commercial	$4,400.55
Rate for Payer: Kaiser Permanente Medicaid	$3,562.35
Rate for Payer: Kaiser Permanente Medicare	$1,765.57
Rate for Payer: MDX Hawaii PPO	$6,775.45
Rate for Payer: Ohana Health Plan Medicaid	$1,942.13
Rate for Payer: Ohana Health Plan Medicare	$1,765.57
Rate for Payer: UnitedHealthcare Medicaid	$4,191.00
Rate for Payer: UnitedHealthcare Medicare	$1,765.57
Rate for Payer: University Health Alliance Commercial	$5,091.37

LEUPROLIDE ACETATE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]

Facility

$6,985.00

Service Code	HCPCS J1950
Hospital Revenue Code	250
Min. Negotiated Rate	$5,937.25
Max. Negotiated Rate	$6,775.45
Rate for Payer: Cash Price	$4,191.00
Rate for Payer: Health Management Network Commercial	$5,937.25
Rate for Payer: MDX Hawaii PPO	$6,775.45

LEUPROLIDE ACETATE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21045]

Facility

$8,227.00

Service Code	HCPCS J9217
Hospital Revenue Code	636
Min. Negotiated Rate	$155.42
Max. Negotiated Rate	$7,980.19
Rate for Payer: AlohaCare Medicaid	$176.20
Rate for Payer: AlohaCare Medicare	$176.20
Rate for Payer: Cash Price	$4,936.20
Rate for Payer: Cash Price	$4,936.20
Rate for Payer: Devoted Health Medicare	$193.82
Rate for Payer: Hawaii Medical Service Association ABD	$155.42
Rate for Payer: Hawaii Medical Service Association Commercial	$220.25
Rate for Payer: Hawaii Medical Service Association Medicare	$176.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$155.42
Rate for Payer: Hawaii Western Management Group Commercial	$7,815.65
Rate for Payer: Health Management Network Commercial	$6,992.95
Rate for Payer: Humana Medicare	$176.20
Rate for Payer: Kaiser Permanente Commercial	$5,183.01
Rate for Payer: Kaiser Permanente Medicaid	$4,195.77
Rate for Payer: Kaiser Permanente Medicare	$176.20
Rate for Payer: MDX Hawaii PPO	$7,980.19
Rate for Payer: Ohana Health Plan Medicaid	$193.82
Rate for Payer: Ohana Health Plan Medicare	$176.20
Rate for Payer: UnitedHealthcare Medicaid	$4,936.20
Rate for Payer: UnitedHealthcare Medicare	$176.20
Rate for Payer: University Health Alliance Commercial	$5,996.66

LEUPROLIDE ACETATE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21045]

Facility

$8,227.00

Service Code	HCPCS J9217
Hospital Revenue Code	250
Min. Negotiated Rate	$6,992.95
Max. Negotiated Rate	$7,980.19
Rate for Payer: Cash Price	$4,936.20
Rate for Payer: Health Management Network Commercial	$6,992.95
Rate for Payer: MDX Hawaii PPO	$7,980.19

LEUPROLIDE ACETATE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [33669]

Facility

$2,127.00

Service Code	HCPCS J9217
Hospital Revenue Code	250
Min. Negotiated Rate	$1,807.95
Max. Negotiated Rate	$2,063.19
Rate for Payer: Cash Price	$1,276.20
Rate for Payer: Health Management Network Commercial	$1,807.95
Rate for Payer: MDX Hawaii PPO	$2,063.19

LEUPROLIDE ACETATE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [33669]

Facility

$2,127.00

Service Code	HCPCS J9217
Hospital Revenue Code	636
Min. Negotiated Rate	$155.42
Max. Negotiated Rate	$2,063.19
Rate for Payer: AlohaCare Medicaid	$176.20
Rate for Payer: AlohaCare Medicare	$176.20
Rate for Payer: Cash Price	$1,276.20
Rate for Payer: Cash Price	$1,276.20
Rate for Payer: Devoted Health Medicare	$193.82
Rate for Payer: Hawaii Medical Service Association ABD	$155.42
Rate for Payer: Hawaii Medical Service Association Commercial	$220.25
Rate for Payer: Hawaii Medical Service Association Medicare	$176.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$155.42
Rate for Payer: Hawaii Western Management Group Commercial	$2,020.65
Rate for Payer: Health Management Network Commercial	$1,807.95
Rate for Payer: Humana Medicare	$176.20
Rate for Payer: Kaiser Permanente Commercial	$1,340.01
Rate for Payer: Kaiser Permanente Medicaid	$1,084.77
Rate for Payer: Kaiser Permanente Medicare	$176.20
Rate for Payer: MDX Hawaii PPO	$2,063.19
Rate for Payer: Ohana Health Plan Medicaid	$193.82
Rate for Payer: Ohana Health Plan Medicare	$176.20
Rate for Payer: UnitedHealthcare Medicaid	$1,276.20
Rate for Payer: UnitedHealthcare Medicare	$176.20
Rate for Payer: University Health Alliance Commercial	$1,550.37

LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE [40801]

Facility

$3,753.00

Service Code	HCPCS J9217
Hospital Revenue Code	636
Min. Negotiated Rate	$155.42
Max. Negotiated Rate	$3,640.41
Rate for Payer: AlohaCare Medicaid	$176.20
Rate for Payer: AlohaCare Medicare	$176.20
Rate for Payer: Cash Price	$2,251.80
Rate for Payer: Cash Price	$2,251.80
Rate for Payer: Devoted Health Medicare	$193.82
Rate for Payer: Hawaii Medical Service Association ABD	$155.42
Rate for Payer: Hawaii Medical Service Association Commercial	$220.25
Rate for Payer: Hawaii Medical Service Association Medicare	$176.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$155.42
Rate for Payer: Hawaii Western Management Group Commercial	$3,565.35
Rate for Payer: Health Management Network Commercial	$3,190.05
Rate for Payer: Humana Medicare	$176.20
Rate for Payer: Kaiser Permanente Commercial	$2,364.39
Rate for Payer: Kaiser Permanente Medicaid	$1,914.03
Rate for Payer: Kaiser Permanente Medicare	$176.20
Rate for Payer: MDX Hawaii PPO	$3,640.41
Rate for Payer: Ohana Health Plan Medicaid	$193.82
Rate for Payer: Ohana Health Plan Medicare	$176.20
Rate for Payer: UnitedHealthcare Medicaid	$2,251.80
Rate for Payer: UnitedHealthcare Medicare	$176.20
Rate for Payer: University Health Alliance Commercial	$2,735.56

LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE [40801]

Facility

$3,753.00

Service Code	HCPCS J9217
Hospital Revenue Code	250
Min. Negotiated Rate	$3,190.05
Max. Negotiated Rate	$3,640.41
Rate for Payer: Cash Price	$2,251.80
Rate for Payer: Health Management Network Commercial	$3,190.05
Rate for Payer: MDX Hawaii PPO	$3,640.41

LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT [110751]

Facility

$15,954.00

Service Code	HCPCS J9217
Hospital Revenue Code	250
Min. Negotiated Rate	$13,560.90
Max. Negotiated Rate	$15,475.38
Rate for Payer: Cash Price	$9,572.40
Rate for Payer: Health Management Network Commercial	$13,560.90
Rate for Payer: MDX Hawaii PPO	$15,475.38

LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT [110751]

Facility

$15,954.00

Service Code	HCPCS J9217
Hospital Revenue Code	636
Min. Negotiated Rate	$155.42
Max. Negotiated Rate	$15,475.38
Rate for Payer: AlohaCare Medicaid	$176.20
Rate for Payer: AlohaCare Medicare	$176.20
Rate for Payer: Cash Price	$9,572.40
Rate for Payer: Cash Price	$9,572.40
Rate for Payer: Devoted Health Medicare	$193.82
Rate for Payer: Hawaii Medical Service Association ABD	$155.42
Rate for Payer: Hawaii Medical Service Association Commercial	$220.25
Rate for Payer: Hawaii Medical Service Association Medicare	$176.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$155.42
Rate for Payer: Hawaii Western Management Group Commercial	$15,156.30
Rate for Payer: Health Management Network Commercial	$13,560.90
Rate for Payer: Humana Medicare	$176.20
Rate for Payer: Kaiser Permanente Commercial	$10,051.02
Rate for Payer: Kaiser Permanente Medicaid	$8,136.54
Rate for Payer: Kaiser Permanente Medicare	$176.20
Rate for Payer: MDX Hawaii PPO	$15,475.38
Rate for Payer: Ohana Health Plan Medicaid	$193.82
Rate for Payer: Ohana Health Plan Medicare	$176.20
Rate for Payer: UnitedHealthcare Medicaid	$9,572.40
Rate for Payer: UnitedHealthcare Medicare	$176.20
Rate for Payer: University Health Alliance Commercial	$11,628.87

LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION [24915]

Facility

$21.00

Service Code	HCPCS J7614
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$4.80
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Commercial	$13.23
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: UnitedHealthcare Medicaid	$12.60
Rate for Payer: UnitedHealthcare Medicaid	$4.80
Rate for Payer: University Health Alliance Commercial	$5.83
Rate for Payer: University Health Alliance Commercial	$15.31

LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION [24915]

Facility

$8.00

Service Code	HCPCS J7614
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: MDX Hawaii PPO	$7.76

LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]

Facility

$8.00

Service Code	HCPCS J7614
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.09
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: UnitedHealthcare Medicaid	$4.80
Rate for Payer: University Health Alliance Commercial	$5.83

LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]

Facility

$8.00

Service Code	HCPCS J7614
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$7.76

LEVALBUTEROL HFA 45 MCG/ACTUATION AEROSOL INHALER [43472]

Facility

$258.00

Service Code	NDC 00591292754
Hospital Revenue Code	250
Min. Negotiated Rate	$219.30
Max. Negotiated Rate	$250.26
Rate for Payer: Cash Price	$154.80
Rate for Payer: Health Management Network Commercial	$219.30
Rate for Payer: MDX Hawaii PPO	$250.26

LEVALBUTEROL HFA 45 MCG/ACTUATION AEROSOL INHALER [43472]

Facility

$258.00

Service Code	NDC 00591292754
Hospital Revenue Code	637
Min. Negotiated Rate	$131.58
Max. Negotiated Rate	$250.26
Rate for Payer: Cash Price	$154.80
Rate for Payer: Hawaii Western Management Group Commercial	$245.10
Rate for Payer: Health Management Network Commercial	$219.30
Rate for Payer: Kaiser Permanente Commercial	$162.54
Rate for Payer: Kaiser Permanente Medicaid	$131.58
Rate for Payer: MDX Hawaii PPO	$250.26
Rate for Payer: University Health Alliance Commercial	$188.06

LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [113476]

Facility

$126.00

Service Code	HCPCS J1953
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cash Price	$75.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.05
Rate for Payer: Hawaii Western Management Group Commercial	$119.70
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$79.38
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: UnitedHealthcare Medicaid	$75.60
Rate for Payer: University Health Alliance Commercial	$91.84

LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [113476]

Facility

$126.00

Service Code	HCPCS J1953
Hospital Revenue Code	250
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: MDX Hawaii PPO	$122.22

LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK [113475]

Facility

$78.00

Service Code	HCPCS J1953
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cash Price	$46.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.05
Rate for Payer: Hawaii Western Management Group Commercial	$74.10
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Kaiser Permanente Commercial	$49.14
Rate for Payer: Kaiser Permanente Medicaid	$39.78
Rate for Payer: MDX Hawaii PPO	$75.66
Rate for Payer: UnitedHealthcare Medicaid	$46.80
Rate for Payer: University Health Alliance Commercial	$56.85

Know your out-of-pocket cost for care.

All Charges