Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN [94576]

Facility

$336.00

Service Code	HCPCS J2404
Hospital Revenue Code	250
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$325.92
Rate for Payer: Cash Price	$201.60
Rate for Payer: Health Management Network Commercial	$285.60
Rate for Payer: MDX Hawaii PPO	$325.92

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH [27862]

Facility

$8.00

Service Code	NDC 68001043390
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

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH [27862]

Facility

$8.00

Service Code	NDC 60505706200
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

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH [27862]

Facility

$8.00

Service Code	NDC 68001043390
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

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH [27862]

Facility

$8.00

Service Code	NDC 60505706200
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

NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]

Facility

$8.00

Service Code	NDC 68001043490
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

NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]

Facility

$9.00

Service Code	NDC 60505706300
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

NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]

Facility

$8.00

Service Code	NDC 68001043490
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

NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH [27863]

Facility

$9.00

Service Code	NDC 60505706300
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

NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]

Facility

$8.00

Service Code	NDC 68001043290
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

NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]

Facility

$8.00

Service Code	NDC 68001043290
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

NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]

Facility

$7.00

Service Code	NDC 60505706100
Hospital Revenue Code	637
Min. Negotiated Rate	$3.57
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$4.41
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: University Health Alliance Commercial	$5.10

NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]

Facility

$7.00

Service Code	NDC 60505706100
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: MDX Hawaii PPO	$6.79

NICOTINE (POLACRILEX) 4 MG BUCCAL MINI LOZENGE [119764]

Facility

$3.00

Service Code	NDC 46122071660
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

NIFEDIPINE 10 MG CAPSULE [5558]

Facility

$4.00

Service Code	NDC 69315021101
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

NIFEDIPINE 10 MG CAPSULE [5558]

Facility

$5.00

Service Code	NDC 00904722961
Hospital Revenue Code	637
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: University Health Alliance Commercial	$3.64

NIFEDIPINE 10 MG CAPSULE [5558]

Facility

$5.00

Service Code	NDC 00904722961
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$4.85

NIFEDIPINE 10 MG CAPSULE [5558]

Facility

$4.00

Service Code	NDC 69315021101
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

NIFEDIPINE 20 MG CAPSULE [5559]

Facility

$9.00

Service Code	NDC 69315021201
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

NIFEDIPINE 20 MG CAPSULE [5559]

Facility

$9.00

Service Code	NDC 69315021201
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

NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE [10719]

Facility

$5.00

Service Code	NDC 50742062001
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$4.85

NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE [10719]

Facility

$5.00

Service Code	NDC 50742062001
Hospital Revenue Code	637
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: University Health Alliance Commercial	$3.64

NIM EMG CONTACT TUBE 7.0MM

Facility

$1,481.00

Hospital Revenue Code	272
Min. Negotiated Rate	$755.31
Max. Negotiated Rate	$1,436.57
Rate for Payer: Cash Price	$888.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,406.95
Rate for Payer: Health Management Network Commercial	$1,258.85
Rate for Payer: Kaiser Permanente Commercial	$933.03
Rate for Payer: Kaiser Permanente Medicaid	$755.31
Rate for Payer: MDX Hawaii PPO	$1,436.57
Rate for Payer: University Health Alliance Commercial	$1,079.50

NIM EMG CONTACT TUBE 7.0MM

Facility

$1,481.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,258.85
Max. Negotiated Rate	$1,436.57
Rate for Payer: Cash Price	$888.60
Rate for Payer: Health Management Network Commercial	$1,258.85
Rate for Payer: MDX Hawaii PPO	$1,436.57

NIM ENDO-TRACH TUBE 6.0MM X 9.

Facility

$1,548.00

Hospital Revenue Code	272
Min. Negotiated Rate	$789.48
Max. Negotiated Rate	$1,501.56
Rate for Payer: Cash Price	$928.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,470.60
Rate for Payer: Health Management Network Commercial	$1,315.80
Rate for Payer: Kaiser Permanente Commercial	$975.24
Rate for Payer: Kaiser Permanente Medicaid	$789.48
Rate for Payer: MDX Hawaii PPO	$1,501.56
Rate for Payer: University Health Alliance Commercial	$1,128.34

Know your out-of-pocket cost for care.

All Charges