Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

LINEZOLID 600 MG TABLET [28224]

Facility

$190.00

Service Code	NDC 60687030921
Hospital Revenue Code	637
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$184.30
Rate for Payer: Cash Price	$114.00
Rate for Payer: Hawaii Western Management Group Commercial	$180.50
Rate for Payer: Health Management Network Commercial	$161.50
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: Kaiser Permanente Medicaid	$96.90
Rate for Payer: MDX Hawaii PPO	$184.30
Rate for Payer: University Health Alliance Commercial	$138.49

LINEZOLID 600 MG TABLET [28224]

Facility

$276.00

Service Code	NDC 67877041984
Hospital Revenue Code	637
Min. Negotiated Rate	$140.76
Max. Negotiated Rate	$267.72
Rate for Payer: Cash Price	$165.60
Rate for Payer: Hawaii Western Management Group Commercial	$262.20
Rate for Payer: Health Management Network Commercial	$234.60
Rate for Payer: Kaiser Permanente Commercial	$173.88
Rate for Payer: Kaiser Permanente Medicaid	$140.76
Rate for Payer: MDX Hawaii PPO	$267.72
Rate for Payer: University Health Alliance Commercial	$201.18

LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK [131499]

Facility

$80.00

Service Code	HCPCS J2020
Hospital Revenue Code	250
Min. Negotiated Rate	$68.00
Max. Negotiated Rate	$77.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Health Management Network Commercial	$68.00
Rate for Payer: MDX Hawaii PPO	$77.60

LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK [131499]

Facility

$80.00

Service Code	HCPCS J2020
Hospital Revenue Code	636
Min. Negotiated Rate	$3.47
Max. Negotiated Rate	$77.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cash Price	$48.00
Rate for Payer: Hawaii Medical Service Association ABD	$3.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.47
Rate for Payer: Hawaii Western Management Group Commercial	$76.00
Rate for Payer: Health Management Network Commercial	$68.00
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$40.80
Rate for Payer: MDX Hawaii PPO	$77.60
Rate for Payer: UnitedHealthcare Medicaid	$48.00
Rate for Payer: University Health Alliance Commercial	$58.31

LIPASE-PROTEASE-AMYLASE (PORK) 15,000-47,000-63K UNIT CAPSULE,DEL REL [208816]

Facility

$22.00

Service Code	NDC 73562011101
Hospital Revenue Code	250
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: MDX Hawaii PPO	$21.34

LIPASE-PROTEASE-AMYLASE (PORK) 15,000-47,000-63K UNIT CAPSULE,DEL REL [208816]

Facility

$22.00

Service Code	NDC 73562011101
Hospital Revenue Code	637
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Kaiser Permanente Commercial	$13.86
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: University Health Alliance Commercial	$16.04

LIPASE-PROTEASE-AMYLASE(PORK)5,000-17,000-24,000 UNIT CAPSULE, DEL REL [151365]

Facility

$9.00

Service Code	NDC 73562011501
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

LIPASE-PROTEASE-AMYLASE(PORK)5,000-17,000-24,000 UNIT CAPSULE, DEL REL [151365]

Facility

$9.00

Service Code	NDC 73562011501
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: University Health Alliance Commercial	$6.56

LIPOASPIRATE WASH VIALITY-1400

Facility

$2,085.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,063.35
Max. Negotiated Rate	$2,022.45
Rate for Payer: Cash Price	$1,251.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,980.75
Rate for Payer: Health Management Network Commercial	$1,772.25
Rate for Payer: Kaiser Permanente Commercial	$1,313.55
Rate for Payer: Kaiser Permanente Medicaid	$1,063.35
Rate for Payer: MDX Hawaii PPO	$2,022.45
Rate for Payer: University Health Alliance Commercial	$1,519.76

LIPOASPIRATE WASH VIALITY-1400

Facility

$2,085.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,772.25
Max. Negotiated Rate	$2,022.45
Rate for Payer: Cash Price	$1,251.00
Rate for Payer: Health Management Network Commercial	$1,772.25
Rate for Payer: MDX Hawaii PPO	$2,022.45

LIPOFILTER CANISTER ASP-CAN-2S

Facility

$863.00

Hospital Revenue Code	272
Min. Negotiated Rate	$733.55
Max. Negotiated Rate	$837.11
Rate for Payer: Cash Price	$517.80
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: MDX Hawaii PPO	$837.11

LIPOFILTER CANISTER ASP-CAN-2S

Facility

$863.00

Hospital Revenue Code	272
Min. Negotiated Rate	$440.13
Max. Negotiated Rate	$837.11
Rate for Payer: Cash Price	$517.80
Rate for Payer: Hawaii Western Management Group Commercial	$819.85
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Kaiser Permanente Commercial	$543.69
Rate for Payer: Kaiser Permanente Medicaid	$440.13
Rate for Payer: MDX Hawaii PPO	$837.11
Rate for Payer: University Health Alliance Commercial	$629.04

LIPOTOWER BIOFILTER ASP-FLTR

Facility

$213.00

Hospital Revenue Code	272
Min. Negotiated Rate	$108.63
Max. Negotiated Rate	$206.61
Rate for Payer: Cash Price	$127.80
Rate for Payer: Hawaii Western Management Group Commercial	$202.35
Rate for Payer: Health Management Network Commercial	$181.05
Rate for Payer: Kaiser Permanente Commercial	$134.19
Rate for Payer: Kaiser Permanente Medicaid	$108.63
Rate for Payer: MDX Hawaii PPO	$206.61
Rate for Payer: University Health Alliance Commercial	$155.26

LIPOTOWER BIOFILTER ASP-FLTR

Facility

$213.00

Hospital Revenue Code	272
Min. Negotiated Rate	$181.05
Max. Negotiated Rate	$206.61
Rate for Payer: Cash Price	$127.80
Rate for Payer: Health Management Network Commercial	$181.05
Rate for Payer: MDX Hawaii PPO	$206.61

LISINOPRIL 10 MG TABLET [10449]

Facility

$1.00

Service Code	NDC 60687032501
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

LISINOPRIL 10 MG TABLET [10449]

Facility

$1.00

Service Code	NDC 00904679861
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

LISINOPRIL 10 MG TABLET [10449]

Facility

$1.00

Service Code	NDC 00904679861
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

LISINOPRIL 10 MG TABLET [10449]

Facility

$1.00

Service Code	NDC 60687032501
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

LISINOPRIL 20 MG TABLET [4526]

Facility

$1.00

Service Code	NDC 60687033301
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

LISINOPRIL 20 MG TABLET [4526]

Facility

$1.00

Service Code	NDC 60687033301
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

LISINOPRIL 20 MG TABLET [4526]

Facility

$1.00

Service Code	NDC 60687033311
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

LISINOPRIL 20 MG TABLET [4526]

Facility

$1.00

Service Code	NDC 60687033311
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

LISINOPRIL 2.5 MG TABLET [13089]

Facility

$3.00

Service Code	NDC 60687065611
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: University Health Alliance Commercial	$2.19

LISINOPRIL 2.5 MG TABLET [13089]

Facility

$3.00

Service Code	NDC 68001033200
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: University Health Alliance Commercial	$2.19

LISINOPRIL 2.5 MG TABLET [13089]

Facility

$3.00

Service Code	NDC 00591040501
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

Know your out-of-pocket cost for care.

All Charges