Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

OLANZAPINE 20 MG TABLET [28158]

Facility

$102.00

Service Code	NDC 68084052901
Hospital Revenue Code	637
Min. Negotiated Rate	$52.02
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$61.20
Rate for Payer: Hawaii Western Management Group Commercial	$96.90
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Kaiser Permanente Commercial	$64.26
Rate for Payer: Kaiser Permanente Medicaid	$52.02
Rate for Payer: MDX Hawaii PPO	$98.94
Rate for Payer: University Health Alliance Commercial	$74.35

OLANZAPINE 20 MG TABLET [28158]

Facility

$102.00

Service Code	NDC 68084052911
Hospital Revenue Code	250
Min. Negotiated Rate	$86.70
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$61.20
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: MDX Hawaii PPO	$98.94

OLANZAPINE 20 MG TABLET [28158]

Facility

$102.00

Service Code	NDC 68084052901
Hospital Revenue Code	250
Min. Negotiated Rate	$86.70
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$61.20
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: MDX Hawaii PPO	$98.94

OLANZAPINE 20 MG TABLET [28158]

Facility

$100.00

Service Code	NDC 55111016830
Hospital Revenue Code	637
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$97.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Hawaii Western Management Group Commercial	$95.00
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$63.00
Rate for Payer: Kaiser Permanente Medicaid	$51.00
Rate for Payer: MDX Hawaii PPO	$97.00
Rate for Payer: University Health Alliance Commercial	$72.89

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$28.00

Service Code	NDC 60505311000
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: MDX Hawaii PPO	$27.16

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$28.00

Service Code	NDC 60505311000
Hospital Revenue Code	637
Min. Negotiated Rate	$14.28
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$17.64
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: University Health Alliance Commercial	$20.41

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$36.00

Service Code	NDC 64380017202
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$34.92

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$36.00

Service Code	NDC 64380017201
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$34.92

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$36.00

Service Code	NDC 64380017201
Hospital Revenue Code	637
Min. Negotiated Rate	$18.36
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$22.68
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: University Health Alliance Commercial	$26.24

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$36.00

Service Code	NDC 64380017202
Hospital Revenue Code	637
Min. Negotiated Rate	$18.36
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$22.68
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: University Health Alliance Commercial	$26.24

OLANZAPINE 5 MG TABLET [17936]

Facility

$34.00

Service Code	NDC 60505311100
Hospital Revenue Code	250
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$20.40
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: MDX Hawaii PPO	$32.98

OLANZAPINE 5 MG TABLET [17936]

Facility

$34.00

Service Code	NDC 60505311100
Hospital Revenue Code	637
Min. Negotiated Rate	$17.34
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$20.40
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$21.42
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: University Health Alliance Commercial	$24.78

OLANZAPINE 5 MG TABLET [17936]

Facility

$33.00

Service Code	NDC 68084072301
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: MDX Hawaii PPO	$32.01

OLANZAPINE 5 MG TABLET [17936]

Facility

$33.00

Service Code	NDC 68084072301
Hospital Revenue Code	637
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$20.79
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: University Health Alliance Commercial	$24.05

OLMESARTAN 20 MG TABLET [32762]

Facility

$21.00

Service Code	NDC 68462043730
Hospital Revenue Code	250
Min. Negotiated Rate	$17.85
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: MDX Hawaii PPO	$20.37

OLMESARTAN 20 MG TABLET [32762]

Facility

$21.00

Service Code	NDC 68462043730
Hospital Revenue Code	637
Min. Negotiated Rate	$10.71
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$13.23
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: University Health Alliance Commercial	$15.31

OLMESARTAN 5 MG TABLET [32761]

Facility

$18.00

Service Code	NDC 33342017807
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

OLMESARTAN 5 MG TABLET [32761]

Facility

$20.00

Service Code	NDC 68462043630
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

OLMESARTAN 5 MG TABLET [32761]

Facility

$20.00

Service Code	NDC 68462043630
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

OLMESARTAN 5 MG TABLET [32761]

Facility

$18.00

Service Code	NDC 33342017807
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

OLYMPUS AIR WATER VALVE MH-438

Facility

$2,660.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,356.60
Max. Negotiated Rate	$2,580.20
Rate for Payer: Cash Price	$1,596.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,527.00
Rate for Payer: Health Management Network Commercial	$2,261.00
Rate for Payer: Kaiser Permanente Commercial	$1,675.80
Rate for Payer: Kaiser Permanente Medicaid	$1,356.60
Rate for Payer: MDX Hawaii PPO	$2,580.20
Rate for Payer: University Health Alliance Commercial	$1,938.87

OLYMPUS AIR WATER VALVE MH-438

Facility

$2,660.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,261.00
Max. Negotiated Rate	$2,580.20
Rate for Payer: Cash Price	$1,596.00
Rate for Payer: Health Management Network Commercial	$2,261.00
Rate for Payer: MDX Hawaii PPO	$2,580.20

OMNIFIT HIPCSTEM#10 #6098-1040

Facility

$10,332.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,785.92
Max. Negotiated Rate	$10,022.04
Rate for Payer: Cash Price	$6,199.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,232.40
Rate for Payer: Health Management Network Commercial	$8,782.20
Rate for Payer: MDX Hawaii PPO	$10,022.04
Rate for Payer: University Health Alliance Commercial	$5,785.92

OMNIFIT HIPCSTEM#10 #6098-1040

Facility

$10,332.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,269.32
Max. Negotiated Rate	$10,022.04
Rate for Payer: Cash Price	$6,199.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,232.40
Rate for Payer: Health Management Network Commercial	$8,782.20
Rate for Payer: Kaiser Permanente Commercial	$6,509.16
Rate for Payer: Kaiser Permanente Medicaid	$5,269.32
Rate for Payer: MDX Hawaii PPO	$10,022.04
Rate for Payer: University Health Alliance Commercial	$5,785.92

OMNIFIT HIPCSTEM#11 6098-1140

Facility

$10,032.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,617.92
Max. Negotiated Rate	$9,731.04
Rate for Payer: Cash Price	$6,019.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,022.40
Rate for Payer: Health Management Network Commercial	$8,527.20
Rate for Payer: MDX Hawaii PPO	$9,731.04
Rate for Payer: University Health Alliance Commercial	$5,617.92

Know your out-of-pocket cost for care.

All Charges