Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [174455]

Facility

$11,633.00

Service Code	HCPCS J9316
Hospital Revenue Code	250
Min. Negotiated Rate	$9,888.05
Max. Negotiated Rate	$11,284.01
Rate for Payer: Cash Price	$6,979.80
Rate for Payer: Health Management Network Commercial	$9,888.05
Rate for Payer: MDX Hawaii PPO	$11,284.01

PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [174455]

Facility

$11,633.00

Service Code	HCPCS J9316
Hospital Revenue Code	636
Min. Negotiated Rate	$60.23
Max. Negotiated Rate	$11,284.01
Rate for Payer: AlohaCare Medicaid	$60.23
Rate for Payer: AlohaCare Medicare	$60.23
Rate for Payer: Cash Price	$6,979.80
Rate for Payer: Cash Price	$6,979.80
Rate for Payer: Devoted Health Medicare	$66.25
Rate for Payer: Hawaii Medical Service Association ABD	$63.39
Rate for Payer: Hawaii Medical Service Association Commercial	$75.29
Rate for Payer: Hawaii Medical Service Association Medicare	$60.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$63.39
Rate for Payer: Hawaii Western Management Group Commercial	$11,051.35
Rate for Payer: Health Management Network Commercial	$9,888.05
Rate for Payer: Humana Medicare	$60.23
Rate for Payer: Kaiser Permanente Commercial	$7,328.79
Rate for Payer: Kaiser Permanente Medicaid	$5,932.83
Rate for Payer: Kaiser Permanente Medicare	$60.23
Rate for Payer: MDX Hawaii PPO	$11,284.01
Rate for Payer: Ohana Health Plan Medicaid	$66.25
Rate for Payer: Ohana Health Plan Medicare	$60.23
Rate for Payer: UnitedHealthcare Medicaid	$6,979.80
Rate for Payer: UnitedHealthcare Medicare	$60.23
Rate for Payer: University Health Alliance Commercial	$8,479.29

PHENAZOPYRIDINE 100 MG TABLET [6193]

Facility

$10.00

Service Code	NDC 65162068110
Hospital Revenue Code	637
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: University Health Alliance Commercial	$7.29

PHENAZOPYRIDINE 100 MG TABLET [6193]

Facility

$10.00

Service Code	NDC 65162068110
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: MDX Hawaii PPO	$9.70

PHENAZOPYRIDINE 200 MG TABLET [6194]

Facility

$14.00

Service Code	NDC 65162068210
Hospital Revenue Code	637
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$8.82
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: University Health Alliance Commercial	$10.20

PHENAZOPYRIDINE 200 MG TABLET [6194]

Facility

$14.00

Service Code	NDC 65162068210
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: MDX Hawaii PPO	$13.58

PHENAZOPYRIDINE TABLETS (PYRIDIUM) 200 MG (TAKE HOME) [4080389]

Facility

$15.00

Service Code	NDC 00004080177
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

PHENAZOPYRIDINE TABLETS (PYRIDIUM) 200 MG (TAKE HOME) [4080389]

Facility

$15.00

Service Code	NDC 00004080177
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

PHENOBARBITAL 32.4 MG TABLET [6217]

Facility

$2.00

Service Code	NDC 00904657561
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

PHENOBARBITAL 32.4 MG TABLET [6217]

Facility

$2.00

Service Code	NDC 00904657561
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

PHENOBARBITAL 32.4 MG TABLET [6217]

Facility

$3.00

Service Code	NDC 63739029410
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

PHENOBARBITAL 32.4 MG TABLET [6217]

Facility

$3.00

Service Code	NDC 63739029410
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

PHENOBARBITAL 64.8 MG TABLET [6219]

Facility

$3.00

Service Code	NDC 16571066701
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

PHENOBARBITAL 64.8 MG TABLET [6219]

Facility

$3.00

Service Code	NDC 16571066701
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

PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION [6221]

Facility

$136.00

Service Code	HCPCS J2560
Hospital Revenue Code	636
Min. Negotiated Rate	$27.36
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Hawaii Medical Service Association ABD	$27.36
Rate for Payer: Hawaii Medical Service Association ABD	$27.36
Rate for Payer: Hawaii Medical Service Association ABD	$27.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27.36
Rate for Payer: Hawaii Western Management Group Commercial	$129.20
Rate for Payer: Hawaii Western Management Group Commercial	$855.00
Rate for Payer: Hawaii Western Management Group Commercial	$427.50
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: Kaiser Permanente Commercial	$85.68
Rate for Payer: Kaiser Permanente Commercial	$283.50
Rate for Payer: Kaiser Permanente Commercial	$567.00
Rate for Payer: Kaiser Permanente Medicaid	$459.00
Rate for Payer: Kaiser Permanente Medicaid	$69.36
Rate for Payer: Kaiser Permanente Medicaid	$229.50
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: UnitedHealthcare Medicaid	$270.00
Rate for Payer: UnitedHealthcare Medicaid	$540.00
Rate for Payer: UnitedHealthcare Medicaid	$81.60
Rate for Payer: University Health Alliance Commercial	$328.00
Rate for Payer: University Health Alliance Commercial	$656.01
Rate for Payer: University Health Alliance Commercial	$99.13

PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION [6221]

Facility

$450.00

Service Code	HCPCS J2560
Hospital Revenue Code	250
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$540.00
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Health Management Network Commercial	$765.00
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: MDX Hawaii PPO	$873.00
Rate for Payer: MDX Hawaii PPO	$131.92

PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [36976]

Facility

$12.00

Service Code	NDC 00536122858
Hospital Revenue Code	250
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.20
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: MDX Hawaii PPO	$11.64

PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [36976]

Facility

$12.00

Service Code	NDC 00536122858
Hospital Revenue Code	637
Min. Negotiated Rate	$6.12
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.20
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$7.56
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: University Health Alliance Commercial	$8.75

PHENTOLAMINE 5 MG INJECTION SOLUTION [10947]

Facility

$756.00

Service Code	HCPCS J2760
Hospital Revenue Code	250
Min. Negotiated Rate	$642.60
Max. Negotiated Rate	$733.32
Rate for Payer: Cash Price	$453.60
Rate for Payer: Cash Price	$529.20
Rate for Payer: Health Management Network Commercial	$749.70
Rate for Payer: Health Management Network Commercial	$642.60
Rate for Payer: MDX Hawaii PPO	$733.32
Rate for Payer: MDX Hawaii PPO	$855.54

PHENTOLAMINE 5 MG INJECTION SOLUTION [10947]

Facility

$756.00

Service Code	HCPCS J2760
Hospital Revenue Code	636
Min. Negotiated Rate	$257.45
Max. Negotiated Rate	$733.32
Rate for Payer: AlohaCare Medicaid	$257.45
Rate for Payer: AlohaCare Medicaid	$257.45
Rate for Payer: AlohaCare Medicare	$257.45
Rate for Payer: AlohaCare Medicare	$257.45
Rate for Payer: Cash Price	$453.60
Rate for Payer: Cash Price	$529.20
Rate for Payer: Cash Price	$453.60
Rate for Payer: Cash Price	$529.20
Rate for Payer: Devoted Health Medicare	$283.19
Rate for Payer: Devoted Health Medicare	$283.19
Rate for Payer: Hawaii Medical Service Association ABD	$436.51
Rate for Payer: Hawaii Medical Service Association ABD	$436.51
Rate for Payer: Hawaii Medical Service Association Commercial	$321.81
Rate for Payer: Hawaii Medical Service Association Commercial	$321.81
Rate for Payer: Hawaii Medical Service Association Medicare	$257.45
Rate for Payer: Hawaii Medical Service Association Medicare	$257.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$436.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$436.51
Rate for Payer: Hawaii Western Management Group Commercial	$718.20
Rate for Payer: Hawaii Western Management Group Commercial	$837.90
Rate for Payer: Health Management Network Commercial	$749.70
Rate for Payer: Health Management Network Commercial	$642.60
Rate for Payer: Humana Medicare	$257.45
Rate for Payer: Humana Medicare	$257.45
Rate for Payer: Kaiser Permanente Commercial	$476.28
Rate for Payer: Kaiser Permanente Commercial	$555.66
Rate for Payer: Kaiser Permanente Medicaid	$385.56
Rate for Payer: Kaiser Permanente Medicaid	$449.82
Rate for Payer: Kaiser Permanente Medicare	$257.45
Rate for Payer: Kaiser Permanente Medicare	$257.45
Rate for Payer: MDX Hawaii PPO	$733.32
Rate for Payer: MDX Hawaii PPO	$855.54
Rate for Payer: Ohana Health Plan Medicaid	$283.19
Rate for Payer: Ohana Health Plan Medicaid	$283.19
Rate for Payer: Ohana Health Plan Medicare	$257.45
Rate for Payer: Ohana Health Plan Medicare	$257.45
Rate for Payer: UnitedHealthcare Medicaid	$453.60
Rate for Payer: UnitedHealthcare Medicaid	$529.20
Rate for Payer: UnitedHealthcare Medicare	$257.45
Rate for Payer: UnitedHealthcare Medicare	$257.45
Rate for Payer: University Health Alliance Commercial	$551.05
Rate for Payer: University Health Alliance Commercial	$642.89

PHENYLEPHRINE 0.5 % NASAL SPRAY [6244]

Facility

$15.00

Service Code	NDC 00225080547
Hospital Revenue Code	250
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

PHENYLEPHRINE 10 % EYE DROPS [19636]

Facility

$150.00

Service Code	NDC 70756061430
Hospital Revenue Code	637
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$90.00
Rate for Payer: Hawaii Western Management Group Commercial	$142.50
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Kaiser Permanente Commercial	$94.50
Rate for Payer: Kaiser Permanente Medicaid	$76.50
Rate for Payer: MDX Hawaii PPO	$145.50
Rate for Payer: University Health Alliance Commercial	$109.33

PHENYLEPHRINE 10 % EYE DROPS [19636]

Facility

$150.00

Service Code	NDC 70756061430
Hospital Revenue Code	250
Min. Negotiated Rate	$127.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$90.00
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: MDX Hawaii PPO	$145.50

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [127358]

Facility

$4.00

Service Code	HCPCS J2371
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: MDX Hawaii PPO	$3.88

PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE [132408]

Facility

$2.00

Service Code	HCPCS J2371
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

Know your out-of-pocket cost for care.

All Charges