Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

POST STRAIGHT 11MM 4922-2-120

Facility

$594.00

Hospital Revenue Code	278
Min. Negotiated Rate	$332.64
Max. Negotiated Rate	$576.18
Rate for Payer: Cash Price	$356.40
Rate for Payer: Hawaii Western Management Group Commercial	$415.80
Rate for Payer: Health Management Network Commercial	$504.90
Rate for Payer: MDX Hawaii PPO	$576.18
Rate for Payer: University Health Alliance Commercial	$332.64

POST STRAIGHT 11MM 4922-2-120

Facility

$594.00

Hospital Revenue Code	278
Min. Negotiated Rate	$302.94
Max. Negotiated Rate	$576.18
Rate for Payer: Cash Price	$356.40
Rate for Payer: Hawaii Western Management Group Commercial	$415.80
Rate for Payer: Health Management Network Commercial	$504.90
Rate for Payer: Kaiser Permanente Commercial	$374.22
Rate for Payer: Kaiser Permanente Medicaid	$302.94
Rate for Payer: MDX Hawaii PPO	$576.18
Rate for Payer: University Health Alliance Commercial	$332.64

POTAS AND SOD CITRATE-CITRIC ACID 550 MG-500 MG-334 MG/5 ML ORAL SOLN [11057]

Facility

$118.00

Service Code	NDC 67716000000
Hospital Revenue Code	250
Min. Negotiated Rate	$100.30
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$70.80
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: MDX Hawaii PPO	$114.46

POTAS AND SOD CITRATE-CITRIC ACID 550 MG-500 MG-334 MG/5 ML ORAL SOLN [11057]

Facility

$118.00

Service Code	NDC 67716000000
Hospital Revenue Code	637
Min. Negotiated Rate	$60.18
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$70.80
Rate for Payer: Hawaii Western Management Group Commercial	$112.10
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Kaiser Permanente Commercial	$74.34
Rate for Payer: Kaiser Permanente Medicaid	$60.18
Rate for Payer: MDX Hawaii PPO	$114.46
Rate for Payer: University Health Alliance Commercial	$86.01

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [6420]

Facility

$23.00

Service Code	NDC 00409818301
Hospital Revenue Code	250
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: MDX Hawaii PPO	$22.31

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [6420]

Facility

$23.00

Service Code	NDC 00409818311
Hospital Revenue Code	250
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: MDX Hawaii PPO	$22.31

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [6420]

Facility

$23.00

Service Code	NDC 51754200104
Hospital Revenue Code	250
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: MDX Hawaii PPO	$22.31

POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK [11074]

Facility

$21.00

Service Code	HCPCS J3480
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$12.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
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: UnitedHealthcare Medicaid	$12.60
Rate for Payer: University Health Alliance Commercial	$15.31

POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK [11074]

Facility

$21.00

Service Code	HCPCS J3480
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

POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV [9799]

Facility

$42.00

Service Code	NDC 00264763400
Hospital Revenue Code	258
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: MDX Hawaii PPO	$40.74

POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV [9799]

Facility

$42.00

Service Code	NDC 00264763400
Hospital Revenue Code	258
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$26.46
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: University Health Alliance Commercial	$30.61

POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK [11076]

Facility

$18.00

Service Code	HCPCS J3480
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$12.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$13.23
Rate for Payer: Kaiser Permanente Commercial	$11.34
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: UnitedHealthcare Medicaid	$12.60
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: University Health Alliance Commercial	$13.12
Rate for Payer: University Health Alliance Commercial	$15.31

POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK [11076]

Facility

$18.00

Service Code	HCPCS J3480
Hospital Revenue Code	250
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: MDX Hawaii PPO	$20.37

POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN [36046]

Facility

$32.00

Service Code	HCPCS J3480
Hospital Revenue Code	258
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$19.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$30.40
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$13.23
Rate for Payer: Kaiser Permanente Commercial	$20.16
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: UnitedHealthcare Medicaid	$0.13
Rate for Payer: UnitedHealthcare Medicaid	$0.13
Rate for Payer: University Health Alliance Commercial	$15.31
Rate for Payer: University Health Alliance Commercial	$23.32

POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN [36046]

Facility

$21.00

Service Code	HCPCS J3480
Hospital Revenue Code	258
Min. Negotiated Rate	$17.85
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$19.20
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: MDX Hawaii PPO	$31.04

POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [11081]

Facility

$25.00

Service Code	HCPCS J3480
Hospital Revenue Code	258
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cash Price	$27.60
Rate for Payer: Cash Price	$27.60
Rate for Payer: Cash Price	$15.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$43.70
Rate for Payer: Hawaii Western Management Group Commercial	$23.75
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Kaiser Permanente Commercial	$28.98
Rate for Payer: Kaiser Permanente Commercial	$15.75
Rate for Payer: Kaiser Permanente Medicaid	$23.46
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: MDX Hawaii PPO	$44.62
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: UnitedHealthcare Medicaid	$0.13
Rate for Payer: UnitedHealthcare Medicaid	$0.13
Rate for Payer: University Health Alliance Commercial	$18.22
Rate for Payer: University Health Alliance Commercial	$33.53

POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [11081]

Facility

$25.00

Service Code	HCPCS J3480
Hospital Revenue Code	258
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cash Price	$27.60
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: MDX Hawaii PPO	$44.62

POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION [9791]

Facility

$42.00

Service Code	HCPCS J3480
Hospital Revenue Code	258
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cash Price	$25.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$26.46
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: UnitedHealthcare Medicaid	$0.13
Rate for Payer: University Health Alliance Commercial	$30.61

POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION [9791]

Facility

$42.00

Service Code	HCPCS J3480
Hospital Revenue Code	258
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: MDX Hawaii PPO	$40.74

POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS [9795]

Facility

$25.00

Service Code	NDC 00264765200
Hospital Revenue Code	258
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: MDX Hawaii PPO	$24.25

POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS [9795]

Facility

$25.00

Service Code	NDC 00264765200
Hospital Revenue Code	258
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Hawaii Western Management Group Commercial	$23.75
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$15.75
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: University Health Alliance Commercial	$18.22

POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS [9795]

Facility

$46.00

Service Code	NDC 00338080304
Hospital Revenue Code	258
Min. Negotiated Rate	$39.10
Max. Negotiated Rate	$44.62
Rate for Payer: Cash Price	$27.60
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: MDX Hawaii PPO	$44.62

POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS [9795]

Facility

$46.00

Service Code	NDC 00338080304
Hospital Revenue Code	258
Min. Negotiated Rate	$23.46
Max. Negotiated Rate	$44.62
Rate for Payer: Cash Price	$27.60
Rate for Payer: Hawaii Western Management Group Commercial	$43.70
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Kaiser Permanente Commercial	$28.98
Rate for Payer: Kaiser Permanente Medicaid	$23.46
Rate for Payer: MDX Hawaii PPO	$44.62
Rate for Payer: University Health Alliance Commercial	$33.53

POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV [9801]

Facility

$21.00

Service Code	NDC 00264763500
Hospital Revenue Code	258
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

POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV [9801]

Facility

$25.00

Service Code	NDC 00338067104
Hospital Revenue Code	258
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Hawaii Western Management Group Commercial	$23.75
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$15.75
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: University Health Alliance Commercial	$18.22

Know your out-of-pocket cost for care.

All Charges