Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

LOPERAMIDE 2 MG CAPSULE [4560]

Facility

$4.00

Service Code	NDC 51079069001
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.92

LOPERAMIDE 2 MG CAPSULE [4560]

Facility

$4.00

Service Code	NDC 60687022901
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.92

LORAZEPAM 1 MG TABLET [4573]

Facility

$1.00

Service Code	NDC 00904600861
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

LORAZEPAM 1 MG TABLET [4573]

Facility

$3.00

Service Code	NDC 69315090501
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

LORAZEPAM 1 MG TABLET [4573]

Facility

$1.00

Service Code	NDC 00904600861
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

LORAZEPAM 1 MG TABLET [4573]

Facility

$1.00

Service Code	NDC 60687063801
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

LORAZEPAM 1 MG TABLET [4573]

Facility

$1.00

Service Code	NDC 60687063801
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

LORAZEPAM 1 MG TABLET [4573]

Facility

$3.00

Service Code	NDC 69315090501
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

LORAZEPAM 2 MG/ML INJECTION SOLUTION [10467]

Facility

$3.00

Service Code	HCPCS J2060
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$6.60
Rate for Payer: Hawaii Medical Service Association ABD	$1.32
Rate for Payer: Hawaii Medical Service Association ABD	$1.32
Rate for Payer: Hawaii Medical Service Association ABD	$1.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.32
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: UnitedHealthcare Medicaid	$6.60
Rate for Payer: University Health Alliance Commercial	$2.19
Rate for Payer: University Health Alliance Commercial	$8.02
Rate for Payer: University Health Alliance Commercial	$4.37

LORAZEPAM 2 MG/ML INJECTION SOLUTION [10467]

Facility

$6.00

Service Code	HCPCS J2060
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: MDX Hawaii PPO	$2.91

LORAZEPAM 2 MG/ML INJECTION SYRINGE [201439]

Facility

$16.00

Service Code	HCPCS J2060
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$9.60
Rate for Payer: Hawaii Medical Service Association ABD	$1.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.32
Rate for Payer: Hawaii Western Management Group Commercial	$15.20
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Kaiser Permanente Commercial	$10.08
Rate for Payer: Kaiser Permanente Medicaid	$8.16
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: UnitedHealthcare Medicaid	$9.60
Rate for Payer: University Health Alliance Commercial	$11.66

LORAZEPAM 2 MG/ML INJECTION SYRINGE [201439]

Facility

$16.00

Service Code	HCPCS J2060
Hospital Revenue Code	250
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: MDX Hawaii PPO	$15.52

LORAZEPAM TABLETS (ATIVAN) 1 MG (TAKE HOME) [4080370]

Facility

$15.00

Service Code	NDC 00004080158
Hospital Revenue Code	253
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$9.45
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: University Health Alliance Commercial	$10.93

LORAZEPAM TABLETS (ATIVAN) 1 MG (TAKE HOME) [4080370]

Facility

$15.00

Service Code	NDC 00004080158
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: MDX Hawaii PPO	$14.55

LOSARTAN 100 MG TABLET [22588]

Facility

$11.00

Service Code	NDC 68084034801
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: MDX Hawaii PPO	$10.67

LOSARTAN 100 MG TABLET [22588]

Facility

$11.00

Service Code	NDC 68084034801
Hospital Revenue Code	637
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: University Health Alliance Commercial	$8.02

LOSARTAN 100 MG TABLET [22588]

Facility

$11.00

Service Code	NDC 68084034811
Hospital Revenue Code	637
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: University Health Alliance Commercial	$8.02

LOSARTAN 100 MG TABLET [22588]

Facility

$11.00

Service Code	NDC 68084034811
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: MDX Hawaii PPO	$10.67

LOSARTAN 25 MG TABLET [14823]

Facility

$6.00

Service Code	NDC 68084034611
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

LOSARTAN 25 MG TABLET [14823]

Facility

$6.00

Service Code	NDC 68084034601
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

LOSARTAN 25 MG TABLET [14823]

Facility

$6.00

Service Code	NDC 68084034601
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

LOSARTAN 25 MG TABLET [14823]

Facility

$6.00

Service Code	NDC 68084034611
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

LOSARTAN 50 MG TABLET [14824]

Facility

$8.00

Service Code	NDC 68084034711
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

LOSARTAN 50 MG TABLET [14824]

Facility

$8.00

Service Code	NDC 68084034701
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

LOSARTAN 50 MG TABLET [14824]

Facility

$8.00

Service Code	NDC 68084034711
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

Know your out-of-pocket cost for care.

All Charges