Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PENICILLIN VK TABLETS (VEETIDS) 500 MG (TAKE HOME) [4080387]

Facility

$15.00

Service Code	NDC 00004080175
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

PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]

Facility

$28.00

Service Code	NDC 00093412773
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

PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]

Facility

$28.00

Service Code	NDC 00093412773
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

PENICILLIN V POTASSIUM 250 MG TABLET [6092]

Facility

$3.00

Service Code	NDC 00143983701
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

PENICILLIN V POTASSIUM 250 MG TABLET [6092]

Facility

$3.00

Service Code	NDC 00143983701
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

PENICILLIN V POTASSIUM 500 MG TABLET [6093]

Facility

$3.00

Service Code	NDC 57237004101
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

PENICILLIN V POTASSIUM 500 MG TABLET [6093]

Facility

$3.00

Service Code	NDC 57237004101
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

PENIS PROCEDURES WITH CC/MCC

Facility

$40,142.47

Service Code	MSDRG 709
Min. Negotiated Rate	$25,552.10
Max. Negotiated Rate	$40,142.47
Rate for Payer: AlohaCare Medicare	$26,469.03
Rate for Payer: Devoted Health Medicare	$29,115.93
Rate for Payer: Hawaii Medical Service Association Commercial	$25,552.10
Rate for Payer: Hawaii Medical Service Association Medicare	$26,469.03
Rate for Payer: Humana Medicare	$26,469.03
Rate for Payer: Kaiser Permanente Commercial	$40,142.47
Rate for Payer: Kaiser Permanente Medicare	$26,469.03
Rate for Payer: Ohana Health Plan Medicare	$26,469.03
Rate for Payer: UnitedHealthcare Medicare	$26,469.03

PENIS PROCEDURES WITHOUT CC/MCC

Facility

$25,552.10

Service Code	MSDRG 710
Min. Negotiated Rate	$15,937.61
Max. Negotiated Rate	$25,552.10
Rate for Payer: AlohaCare Medicare	$15,937.61
Rate for Payer: Devoted Health Medicare	$17,531.37
Rate for Payer: Hawaii Medical Service Association Commercial	$25,552.10
Rate for Payer: Hawaii Medical Service Association Medicare	$15,937.61
Rate for Payer: Humana Medicare	$15,937.61
Rate for Payer: Kaiser Permanente Commercial	$24,170.70
Rate for Payer: Kaiser Permanente Medicare	$15,937.61
Rate for Payer: Ohana Health Plan Medicare	$15,937.61
Rate for Payer: UnitedHealthcare Medicare	$15,937.61

PENIS, TESTES & SCROTAL PROCEDURES

Facility

$6,431.45

Service Code	APR-DRG 4832
Min. Negotiated Rate	$6,431.45
Max. Negotiated Rate	$6,431.45
Rate for Payer: AlohaCare Medicaid	$6,431.45
Rate for Payer: Hawaii Medical Service Association ABD	$6,431.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,431.45
Rate for Payer: Kaiser Permanente Medicaid	$6,431.45
Rate for Payer: Ohana Health Plan Medicaid	$6,431.45
Rate for Payer: UnitedHealthcare Medicaid	$6,431.45

PENIS, TESTES & SCROTAL PROCEDURES

Facility

$17,766.72

Service Code	APR-DRG 4834
Min. Negotiated Rate	$17,766.72
Max. Negotiated Rate	$17,766.72
Rate for Payer: AlohaCare Medicaid	$17,766.72
Rate for Payer: Hawaii Medical Service Association ABD	$17,766.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17,766.72
Rate for Payer: Kaiser Permanente Medicaid	$17,766.72
Rate for Payer: Ohana Health Plan Medicaid	$17,766.72
Rate for Payer: UnitedHealthcare Medicaid	$17,766.72

PENIS, TESTES & SCROTAL PROCEDURES

Facility

$5,059.06

Service Code	APR-DRG 4831
Min. Negotiated Rate	$5,059.06
Max. Negotiated Rate	$5,059.06
Rate for Payer: AlohaCare Medicaid	$5,059.06
Rate for Payer: Hawaii Medical Service Association ABD	$5,059.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,059.06
Rate for Payer: Kaiser Permanente Medicaid	$5,059.06
Rate for Payer: Ohana Health Plan Medicaid	$5,059.06
Rate for Payer: UnitedHealthcare Medicaid	$5,059.06

PENIS, TESTES & SCROTAL PROCEDURES

Facility

$8,694.85

Service Code	APR-DRG 4833
Min. Negotiated Rate	$8,694.85
Max. Negotiated Rate	$8,694.85
Rate for Payer: AlohaCare Medicaid	$8,694.85
Rate for Payer: Hawaii Medical Service Association ABD	$8,694.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,694.85
Rate for Payer: Kaiser Permanente Medicaid	$8,694.85
Rate for Payer: Ohana Health Plan Medicaid	$8,694.85
Rate for Payer: UnitedHealthcare Medicaid	$8,694.85

PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]

Facility

$271.00

Service Code	HCPCS J2545
Hospital Revenue Code	250
Min. Negotiated Rate	$230.35
Max. Negotiated Rate	$262.87
Rate for Payer: Cash Price	$162.60
Rate for Payer: Cash Price	$101.40
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Health Management Network Commercial	$230.35
Rate for Payer: MDX Hawaii PPO	$262.87
Rate for Payer: MDX Hawaii PPO	$163.93

PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]

Facility

$169.00

Service Code	HCPCS J2545
Hospital Revenue Code	636
Min. Negotiated Rate	$82.37
Max. Negotiated Rate	$163.93
Rate for Payer: Cash Price	$101.40
Rate for Payer: Cash Price	$101.40
Rate for Payer: Cash Price	$162.60
Rate for Payer: Cash Price	$162.60
Rate for Payer: Hawaii Medical Service Association ABD	$82.37
Rate for Payer: Hawaii Medical Service Association ABD	$82.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$82.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$82.37
Rate for Payer: Hawaii Western Management Group Commercial	$160.55
Rate for Payer: Hawaii Western Management Group Commercial	$257.45
Rate for Payer: Health Management Network Commercial	$230.35
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Kaiser Permanente Commercial	$170.73
Rate for Payer: Kaiser Permanente Commercial	$106.47
Rate for Payer: Kaiser Permanente Medicaid	$86.19
Rate for Payer: Kaiser Permanente Medicaid	$138.21
Rate for Payer: MDX Hawaii PPO	$262.87
Rate for Payer: MDX Hawaii PPO	$163.93
Rate for Payer: UnitedHealthcare Medicaid	$101.40
Rate for Payer: UnitedHealthcare Medicaid	$162.60
Rate for Payer: University Health Alliance Commercial	$197.53
Rate for Payer: University Health Alliance Commercial	$123.18

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [21300]

Facility

$4.00

Service Code	NDC 60505003306
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

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [21300]

Facility

$4.00

Service Code	NDC 60505003306
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

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [21300]

Facility

$2.00

Service Code	NDC 00904544861
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [21300]

Facility

$2.00

Service Code	NDC 00904544861
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

PENUMBRA ENGINE

Facility

$4,500.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$2,295.00
Max. Negotiated Rate	$4,365.00
Rate for Payer: Cash Price	$2,700.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.00
Rate for Payer: Health Management Network Commercial	$3,825.00
Rate for Payer: Kaiser Permanente Commercial	$2,835.00
Rate for Payer: Kaiser Permanente Medicaid	$2,295.00
Rate for Payer: MDX Hawaii PPO	$4,365.00
Rate for Payer: University Health Alliance Commercial	$3,280.05

PENUMBRA ENGINE

Facility

$4,500.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$3,825.00
Max. Negotiated Rate	$4,365.00
Rate for Payer: Cash Price	$2,700.00
Rate for Payer: Health Management Network Commercial	$3,825.00
Rate for Payer: MDX Hawaii PPO	$4,365.00

PENUMBRA ENGINE CANISTER

Facility

$1,260.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$1,071.00
Max. Negotiated Rate	$1,222.20
Rate for Payer: Cash Price	$756.00
Rate for Payer: Health Management Network Commercial	$1,071.00
Rate for Payer: MDX Hawaii PPO	$1,222.20

PENUMBRA ENGINE CANISTER

Facility

$1,260.00

Service Code	HCPCS C1887
Hospital Revenue Code	272
Min. Negotiated Rate	$642.60
Max. Negotiated Rate	$1,222.20
Rate for Payer: Cash Price	$756.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,197.00
Rate for Payer: Health Management Network Commercial	$1,071.00
Rate for Payer: Kaiser Permanente Commercial	$793.80
Rate for Payer: Kaiser Permanente Medicaid	$642.60
Rate for Payer: MDX Hawaii PPO	$1,222.20
Rate for Payer: University Health Alliance Commercial	$918.41

PEPTIC ULCER & GASTRITIS

Facility

$4,125.65

Service Code	APR-DRG 2412
Min. Negotiated Rate	$4,125.65
Max. Negotiated Rate	$4,125.65
Rate for Payer: AlohaCare Medicaid	$4,125.65
Rate for Payer: Hawaii Medical Service Association ABD	$4,125.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,125.65
Rate for Payer: Kaiser Permanente Medicaid	$4,125.65
Rate for Payer: Ohana Health Plan Medicaid	$4,125.65
Rate for Payer: UnitedHealthcare Medicaid	$4,125.65

PEPTIC ULCER & GASTRITIS

Facility

$6,035.52

Service Code	APR-DRG 2413
Min. Negotiated Rate	$6,035.52
Max. Negotiated Rate	$6,035.52
Rate for Payer: AlohaCare Medicaid	$6,035.52
Rate for Payer: Hawaii Medical Service Association ABD	$6,035.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,035.52
Rate for Payer: Kaiser Permanente Medicaid	$6,035.52
Rate for Payer: Ohana Health Plan Medicaid	$6,035.52
Rate for Payer: UnitedHealthcare Medicaid	$6,035.52

Know your out-of-pocket cost for care.

All Charges