Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [105634]

Facility

$14.00

Service Code	NDC 00409812601
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

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]

Facility

$15.00

Service Code	HCPCS J0665
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
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: UnitedHealthcare Medicaid	$9.00
Rate for Payer: University Health Alliance Commercial	$10.93

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]

Facility

$15.00

Service Code	HCPCS J0665
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

BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [1223]

Facility

$59.00

Service Code	HCPCS J0665
Hospital Revenue Code	250
Min. Negotiated Rate	$50.15
Max. Negotiated Rate	$57.23
Rate for Payer: Cash Price	$35.40
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: MDX Hawaii PPO	$57.23

BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [1223]

Facility

$59.00

Service Code	HCPCS J0665
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$57.23
Rate for Payer: Cash Price	$35.40
Rate for Payer: Cash Price	$35.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$56.05
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Kaiser Permanente Commercial	$37.17
Rate for Payer: Kaiser Permanente Medicaid	$30.09
Rate for Payer: MDX Hawaii PPO	$57.23
Rate for Payer: UnitedHealthcare Medicaid	$35.40
Rate for Payer: University Health Alliance Commercial	$43.01

BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [105639]

Facility

$10.00

Service Code	HCPCS J0665
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$18.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$9.70

BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [105639]

Facility

$11.00

Service Code	HCPCS J0665
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$7.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$17.64
Rate for Payer: Kaiser Permanente Commercial	$7.56
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Commercial	$19.53
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: UnitedHealthcare Medicaid	$16.80
Rate for Payer: UnitedHealthcare Medicaid	$7.20
Rate for Payer: UnitedHealthcare Medicaid	$6.60
Rate for Payer: UnitedHealthcare Medicaid	$6.00
Rate for Payer: UnitedHealthcare Medicaid	$18.60
Rate for Payer: University Health Alliance Commercial	$22.60
Rate for Payer: University Health Alliance Commercial	$7.29
Rate for Payer: University Health Alliance Commercial	$8.75
Rate for Payer: University Health Alliance Commercial	$8.02
Rate for Payer: University Health Alliance Commercial	$20.41

BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]

Facility

$12.00

Service Code	HCPCS J0665
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$7.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$8.19
Rate for Payer: Kaiser Permanente Commercial	$7.56
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: UnitedHealthcare Medicaid	$7.20
Rate for Payer: UnitedHealthcare Medicaid	$7.80
Rate for Payer: UnitedHealthcare Medicaid	$6.60
Rate for Payer: University Health Alliance Commercial	$8.02
Rate for Payer: University Health Alliance Commercial	$8.75
Rate for Payer: University Health Alliance Commercial	$9.48

BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]

Facility

$13.00

Service Code	HCPCS J0665
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$10.67

BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]

Facility

$21.00

Service Code	HCPCS J0665
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$87.00
Rate for Payer: Cash Price	$87.00
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$12.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$137.75
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$17.64
Rate for Payer: Kaiser Permanente Commercial	$13.23
Rate for Payer: Kaiser Permanente Commercial	$91.35
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: UnitedHealthcare Medicaid	$12.60
Rate for Payer: UnitedHealthcare Medicaid	$16.80
Rate for Payer: UnitedHealthcare Medicaid	$87.00
Rate for Payer: University Health Alliance Commercial	$105.69
Rate for Payer: University Health Alliance Commercial	$15.31
Rate for Payer: University Health Alliance Commercial	$20.41

BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]

Facility

$28.00

Service Code	HCPCS J0665
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$87.00
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: MDX Hawaii PPO	$140.65

BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION [122185]

Facility

$13.00

Service Code	HCPCS J0665
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: MDX Hawaii PPO	$12.61

BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION [122185]

Facility

$13.00

Service Code	HCPCS J0665
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$7.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$8.19
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: UnitedHealthcare Medicaid	$7.80
Rate for Payer: University Health Alliance Commercial	$9.48

BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]

Facility

$11.00

Service Code	NDC 60687062665
Hospital Revenue Code	637
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: University Health Alliance Commercial	$8.02

BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]

Facility

$11.00

Service Code	NDC 60687062611
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: MDX Hawaii PPO	$10.67

BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]

Facility

$11.00

Service Code	NDC 60687062665
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: MDX Hawaii PPO	$10.67

BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]

Facility

$11.00

Service Code	NDC 60687062611
Hospital Revenue Code	637
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: University Health Alliance Commercial	$8.02

BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]

Facility

$15.00

Service Code	NDC 60687063711
Hospital Revenue Code	637
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

BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]

Facility

$15.00

Service Code	NDC 60687063765
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

BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]

Facility

$15.00

Service Code	NDC 60687063765
Hospital Revenue Code	637
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

BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]

Facility

$15.00

Service Code	NDC 60687063711
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

BUPROPION HCL 75 MG TABLET [9322]

Facility

$6.00

Service Code	NDC 00904663561
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

BUPROPION HCL 75 MG TABLET [9322]

Facility

$5.00

Service Code	NDC 60687034001
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$4.85

BUPROPION HCL 75 MG TABLET [9322]

Facility

$5.00

Service Code	NDC 60687034001
Hospital Revenue Code	637
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: University Health Alliance Commercial	$3.64

BUPROPION HCL 75 MG TABLET [9322]

Facility

$6.00

Service Code	NDC 00904663561
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

Know your out-of-pocket cost for care.

All Charges