Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PERMETHRIN 5% CREAM (ELIMITE) (60 GRAM) (TAKE HOME) [4080388]

Facility

$15.00

Service Code	NDC 00004080176
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

PERMETHRIN 5 % TOPICAL CREAM [10917]

Facility

$414.00

Service Code	NDC 21922002107
Hospital Revenue Code	637
Min. Negotiated Rate	$211.14
Max. Negotiated Rate	$401.58
Rate for Payer: Cash Price	$248.40
Rate for Payer: Hawaii Western Management Group Commercial	$393.30
Rate for Payer: Health Management Network Commercial	$351.90
Rate for Payer: Kaiser Permanente Commercial	$260.82
Rate for Payer: Kaiser Permanente Medicaid	$211.14
Rate for Payer: MDX Hawaii PPO	$401.58
Rate for Payer: University Health Alliance Commercial	$301.76

PERMETHRIN 5 % TOPICAL CREAM [10917]

Facility

$414.00

Service Code	NDC 21922002107
Hospital Revenue Code	250
Min. Negotiated Rate	$351.90
Max. Negotiated Rate	$401.58
Rate for Payer: Cash Price	$248.40
Rate for Payer: Health Management Network Commercial	$351.90
Rate for Payer: MDX Hawaii PPO	$401.58

PERPHENAZINE 2 MG TABLET [6157]

Facility

$7.00

Service Code	NDC 64980029001
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

PERSONA 10MM 42-5282-009-10

Facility

$2,520.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,411.20
Max. Negotiated Rate	$2,444.40
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,764.00
Rate for Payer: Health Management Network Commercial	$2,142.00
Rate for Payer: MDX Hawaii PPO	$2,444.40
Rate for Payer: University Health Alliance Commercial	$1,411.20

PERSONA 10MM 42-5282-009-10

Facility

$2,520.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,285.20
Max. Negotiated Rate	$2,444.40
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,764.00
Rate for Payer: Health Management Network Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Commercial	$1,587.60
Rate for Payer: Kaiser Permanente Medicaid	$1,285.20
Rate for Payer: MDX Hawaii PPO	$2,444.40
Rate for Payer: University Health Alliance Commercial	$1,411.20

PERSONA FEM CMT CCR NRW SZ10 L

Facility

$5,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,024.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

PERSONA FEM CMT CCR NRW SZ10 L

Facility

$5,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,754.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: Kaiser Permanente Medicaid	$2,754.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

PERSONA FEM CMT CCR NRW SZ10 R

Facility

$5,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,024.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

PERSONA FEM CMT CCR NRW SZ10 R

Facility

$5,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,754.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: Kaiser Permanente Medicaid	$2,754.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

PERSONA FEM CMT CCR NRW SZ11 L

Facility

$5,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,024.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

PERSONA FEM CMT CCR NRW SZ11 L

Facility

$5,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,754.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: Kaiser Permanente Medicaid	$2,754.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

PERSONA FEM CMT CCR NRW SZ11 R

Facility

$7,410.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,149.60
Max. Negotiated Rate	$7,187.70
Rate for Payer: Cash Price	$4,446.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,187.00
Rate for Payer: Health Management Network Commercial	$6,298.50
Rate for Payer: MDX Hawaii PPO	$7,187.70
Rate for Payer: University Health Alliance Commercial	$4,149.60

PERSONA FEM CMT CCR NRW SZ11 R

Facility

$7,410.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,779.10
Max. Negotiated Rate	$7,187.70
Rate for Payer: Cash Price	$4,446.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,187.00
Rate for Payer: Health Management Network Commercial	$6,298.50
Rate for Payer: Kaiser Permanente Commercial	$4,668.30
Rate for Payer: Kaiser Permanente Medicaid	$3,779.10
Rate for Payer: MDX Hawaii PPO	$7,187.70
Rate for Payer: University Health Alliance Commercial	$4,149.60

PERSONA FEM CMT CCR NRW SZ1 L

Facility

$5,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,024.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

PERSONA FEM CMT CCR NRW SZ1 L

Facility

$5,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,754.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: Kaiser Permanente Medicaid	$2,754.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

PERSONA FEM CMT CCR NRW SZ1 R

Facility

$15,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,855.84
Max. Negotiated Rate	$15,339.58
Rate for Payer: Cash Price	$9,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$11,069.80
Rate for Payer: Health Management Network Commercial	$13,441.90
Rate for Payer: MDX Hawaii PPO	$15,339.58
Rate for Payer: University Health Alliance Commercial	$8,855.84

PERSONA FEM CMT CCR NRW SZ1 R

Facility

$15,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,065.14
Max. Negotiated Rate	$15,339.58
Rate for Payer: Cash Price	$9,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$11,069.80
Rate for Payer: Health Management Network Commercial	$13,441.90
Rate for Payer: Kaiser Permanente Commercial	$9,962.82
Rate for Payer: Kaiser Permanente Medicaid	$8,065.14
Rate for Payer: MDX Hawaii PPO	$15,339.58
Rate for Payer: University Health Alliance Commercial	$8,855.84

PERSONA FEM CMT CCR NRW SZ2 L

Facility

$15,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,065.14
Max. Negotiated Rate	$15,339.58
Rate for Payer: Cash Price	$9,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$11,069.80
Rate for Payer: Health Management Network Commercial	$13,441.90
Rate for Payer: Kaiser Permanente Commercial	$9,962.82
Rate for Payer: Kaiser Permanente Medicaid	$8,065.14
Rate for Payer: MDX Hawaii PPO	$15,339.58
Rate for Payer: University Health Alliance Commercial	$8,855.84

PERSONA FEM CMT CCR NRW SZ2 L

Facility

$15,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,855.84
Max. Negotiated Rate	$15,339.58
Rate for Payer: Cash Price	$9,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$11,069.80
Rate for Payer: Health Management Network Commercial	$13,441.90
Rate for Payer: MDX Hawaii PPO	$15,339.58
Rate for Payer: University Health Alliance Commercial	$8,855.84

PERSONA FEM CMT CCR NRW SZ2 R

Facility

$15,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,065.14
Max. Negotiated Rate	$15,339.58
Rate for Payer: Cash Price	$9,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$11,069.80
Rate for Payer: Health Management Network Commercial	$13,441.90
Rate for Payer: Kaiser Permanente Commercial	$9,962.82
Rate for Payer: Kaiser Permanente Medicaid	$8,065.14
Rate for Payer: MDX Hawaii PPO	$15,339.58
Rate for Payer: University Health Alliance Commercial	$8,855.84

PERSONA FEM CMT CCR NRW SZ2 R

Facility

$15,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,855.84
Max. Negotiated Rate	$15,339.58
Rate for Payer: Cash Price	$9,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$11,069.80
Rate for Payer: Health Management Network Commercial	$13,441.90
Rate for Payer: MDX Hawaii PPO	$15,339.58
Rate for Payer: University Health Alliance Commercial	$8,855.84

PERSONA FEM CMT CCR NRW SZ3 L

Facility

$5,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,754.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: Kaiser Permanente Medicaid	$2,754.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

PERSONA FEM CMT CCR NRW SZ3 L

Facility

$5,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,024.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

PERSONA FEM CMT CCR NRW SZ3 R

Facility

$5,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,754.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Kaiser Permanente Commercial	$3,402.00
Rate for Payer: Kaiser Permanente Medicaid	$2,754.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

Know your out-of-pocket cost for care.

All Charges