Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PROJECTION SMT RND 10721-235MP

Facility

$2,685.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,503.60
Max. Negotiated Rate	$2,604.45
Rate for Payer: Cash Price	$1,611.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,879.50
Rate for Payer: Health Management Network Commercial	$2,282.25
Rate for Payer: MDX Hawaii PPO	$2,604.45
Rate for Payer: University Health Alliance Commercial	$1,503.60

PROLENE 6-0 C-1 36" DA 8706H

Facility

$290.00

Hospital Revenue Code	272
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$281.30
Rate for Payer: Cash Price	$174.00
Rate for Payer: Hawaii Western Management Group Commercial	$275.50
Rate for Payer: Health Management Network Commercial	$246.50
Rate for Payer: Kaiser Permanente Commercial	$182.70
Rate for Payer: Kaiser Permanente Medicaid	$147.90
Rate for Payer: MDX Hawaii PPO	$281.30
Rate for Payer: University Health Alliance Commercial	$211.38

PROLENE 6-0 C-1 36" DA 8706H

Facility

$290.00

Hospital Revenue Code	272
Min. Negotiated Rate	$246.50
Max. Negotiated Rate	$281.30
Rate for Payer: Cash Price	$174.00
Rate for Payer: Health Management Network Commercial	$246.50
Rate for Payer: MDX Hawaii PPO	$281.30

PR OMENTAL FLAP INTRA-ABDOMINAL

Professional

Both

$578.00

Service Code	HCPCS 49905
Min. Negotiated Rate	$292.24
Max. Negotiated Rate	$491.30
Rate for Payer: AlohaCare Medicaid	$338.46
Rate for Payer: AlohaCare Medicare	$301.34
Rate for Payer: Cash Price	$346.80
Rate for Payer: Cash Price	$346.80
Rate for Payer: Devoted Health Medicare	$331.47
Rate for Payer: Hawaii Medical Service Association Medicare	$301.34
Rate for Payer: Hawaii Western Management Group Commercial	$292.24
Rate for Payer: Health Management Network Commercial	$491.30
Rate for Payer: Kaiser Permanente Commercial	$361.61
Rate for Payer: Kaiser Permanente Medicaid	$361.61
Rate for Payer: Kaiser Permanente Medicare	$361.61
Rate for Payer: Ohana Health Plan Medicaid	$338.46
Rate for Payer: Ohana Health Plan Medicare	$301.34
Rate for Payer: UnitedHealthcare Medicaid	$338.46
Rate for Payer: UnitedHealthcare Medicare	$301.34

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

$40.00

Service Code	NDC 31722004031
Hospital Revenue Code	637
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Hawaii Western Management Group Commercial	$38.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$20.40
Rate for Payer: MDX Hawaii PPO	$38.80
Rate for Payer: University Health Alliance Commercial	$29.16

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

$45.00

Service Code	NDC 00713053612
Hospital Revenue Code	637
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$27.00
Rate for Payer: Hawaii Western Management Group Commercial	$42.75
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$28.35
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: University Health Alliance Commercial	$32.80

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

$40.00

Service Code	NDC 31722004031
Hospital Revenue Code	250
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: MDX Hawaii PPO	$38.80

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

$45.00

Service Code	NDC 00713053612
Hospital Revenue Code	250
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$27.00
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: MDX Hawaii PPO	$43.65

PROMETHAZINE 12.5 MG TABLET [6621]

Facility

$2.00

Service Code	HCPCS Q0169
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

PROMETHAZINE 12.5 MG TABLET [6621]

Facility

$2.00

Service Code	HCPCS Q0169
Hospital Revenue Code	636
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: UnitedHealthcare Medicaid	$1.20
Rate for Payer: University Health Alliance Commercial	$1.46

PROMETHAZINE 25 MG/ML INJECTION SOLUTION [6618]

Facility

$8.00

Service Code	HCPCS J2550
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$7.76

PROMETHAZINE 25 MG/ML INJECTION SOLUTION [6618]

Facility

$8.00

Service Code	HCPCS J2550
Hospital Revenue Code	636
Min. Negotiated Rate	$2.87
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Medical Service Association ABD	$2.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.87
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: UnitedHealthcare Medicaid	$4.80
Rate for Payer: University Health Alliance Commercial	$5.83

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

$45.00

Service Code	NDC 00713052606
Hospital Revenue Code	250
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$27.00
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: MDX Hawaii PPO	$43.65

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

$45.00

Service Code	NDC 00713052612
Hospital Revenue Code	637
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$27.00
Rate for Payer: Hawaii Western Management Group Commercial	$42.75
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$28.35
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: University Health Alliance Commercial	$32.80

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

$45.00

Service Code	NDC 00713052606
Hospital Revenue Code	637
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$27.00
Rate for Payer: Hawaii Western Management Group Commercial	$42.75
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$28.35
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: University Health Alliance Commercial	$32.80

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

$45.00

Service Code	NDC 00713052612
Hospital Revenue Code	250
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$27.00
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: MDX Hawaii PPO	$43.65

PROMETHAZINE 25 MG TABLET [6622]

Facility

$2.00

Service Code	HCPCS Q0169
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

PROMETHAZINE 25 MG TABLET [6622]

Facility

$2.00

Service Code	HCPCS Q0169
Hospital Revenue Code	636
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: UnitedHealthcare Medicaid	$1.20
Rate for Payer: University Health Alliance Commercial	$1.46

PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [97609]

Facility

$119.00

Service Code	NDC 27808005102
Hospital Revenue Code	637
Min. Negotiated Rate	$60.69
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Hawaii Western Management Group Commercial	$113.05
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Kaiser Permanente Commercial	$74.97
Rate for Payer: Kaiser Permanente Medicaid	$60.69
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: University Health Alliance Commercial	$86.74

PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [97609]

Facility

$119.00

Service Code	NDC 27808005102
Hospital Revenue Code	250
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: MDX Hawaii PPO	$115.43

PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [97609]

Facility

$114.00

Service Code	NDC 00116402316
Hospital Revenue Code	250
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$68.40
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: MDX Hawaii PPO	$110.58

PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [97609]

Facility

$114.00

Service Code	NDC 00116402316
Hospital Revenue Code	637
Min. Negotiated Rate	$58.14
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$68.40
Rate for Payer: Hawaii Western Management Group Commercial	$108.30
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$71.82
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: University Health Alliance Commercial	$83.09

PROMETHAZINE SUPPOSITORIES (PHENERGAN) 25 MG (TAKE HOME) [4080393]

Facility

$15.00

Service Code	NDC 00004080181
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

PROMETHAZINE SUPPOSITORIES (PHENERGAN) 25 MG (TAKE HOME) [4080393]

Facility

$15.00

Service Code	NDC 00004080181
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

PROMETHAZINE TABLETS (PHENERGAN) 25 MG (TAKE HOME) [4080392]

Facility

$15.00

Service Code	HCPCS Q0169
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

Know your out-of-pocket cost for care.

All Charges