Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

VENLAFAXINE 25 MG TABLET [12203]

Facility

$8.00

Service Code	NDC 68084089695
Hospital Revenue Code	637
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
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: University Health Alliance Commercial	$5.83

VENLAFAXINE 75 MG TABLET [12206]

Facility

$8.00

Service Code	NDC 68001016000
Hospital Revenue Code	637
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
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: University Health Alliance Commercial	$5.83

VENLAFAXINE 75 MG TABLET [12206]

Facility

$8.00

Service Code	NDC 68001016000
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

VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]

Facility

$17.00

Service Code	NDC 68084071301
Hospital Revenue Code	637
Min. Negotiated Rate	$8.67
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$10.71
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: University Health Alliance Commercial	$12.39

VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]

Facility

$18.00

Service Code	NDC 65862069730
Hospital Revenue Code	250
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$17.46

VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]

Facility

$17.00

Service Code	NDC 68084071301
Hospital Revenue Code	250
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: MDX Hawaii PPO	$16.49

VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]

Facility

$18.00

Service Code	NDC 65862069730
Hospital Revenue Code	637
Min. Negotiated Rate	$9.18
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$11.34
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: University Health Alliance Commercial	$13.12

VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR [27857]

Facility

$14.00

Service Code	NDC 68084069811
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

VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR [27857]

Facility

$14.00

Service Code	NDC 68084069811
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

VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR [27857]

Facility

$14.00

Service Code	NDC 68084069801
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

VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR [27857]

Facility

$14.00

Service Code	NDC 68084069801
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

VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]

Facility

$15.00

Service Code	NDC 68084070901
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

VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]

Facility

$15.00

Service Code	NDC 68084070911
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

VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]

Facility

$15.00

Service Code	NDC 68084070911
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

VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]

Facility

$15.00

Service Code	NDC 68084070901
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

VENOVO VENOUS STENT 12X60

Facility

$7,000.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$3,570.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,900.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: Kaiser Permanente Commercial	$4,410.00
Rate for Payer: Kaiser Permanente Medicaid	$3,570.00
Rate for Payer: MDX Hawaii PPO	$6,790.00
Rate for Payer: University Health Alliance Commercial	$3,920.00

VENOVO VENOUS STENT 12X60

Facility

$7,000.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$3,920.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,900.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: MDX Hawaii PPO	$6,790.00
Rate for Payer: University Health Alliance Commercial	$3,920.00

VENOVO VENOUS STENT 14X60

Facility

$7,000.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$3,570.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,900.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: Kaiser Permanente Commercial	$4,410.00
Rate for Payer: Kaiser Permanente Medicaid	$3,570.00
Rate for Payer: MDX Hawaii PPO	$6,790.00
Rate for Payer: University Health Alliance Commercial	$3,920.00

VENOVO VENOUS STENT 14X60

Facility

$7,000.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$3,920.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,900.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: MDX Hawaii PPO	$6,790.00
Rate for Payer: University Health Alliance Commercial	$3,920.00

VENOVO VENOUS STENT 16X100

Facility

$7,000.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$3,570.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,900.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: Kaiser Permanente Commercial	$4,410.00
Rate for Payer: Kaiser Permanente Medicaid	$3,570.00
Rate for Payer: MDX Hawaii PPO	$6,790.00
Rate for Payer: University Health Alliance Commercial	$3,920.00

VENOVO VENOUS STENT 16X100

Facility

$7,000.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$3,920.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,900.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: MDX Hawaii PPO	$6,790.00
Rate for Payer: University Health Alliance Commercial	$3,920.00

VENOVO VENOUS STENT 16X120

Facility

$7,000.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$3,570.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,900.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: Kaiser Permanente Commercial	$4,410.00
Rate for Payer: Kaiser Permanente Medicaid	$3,570.00
Rate for Payer: MDX Hawaii PPO	$6,790.00
Rate for Payer: University Health Alliance Commercial	$3,920.00

VENOVO VENOUS STENT 16X120

Facility

$7,000.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$3,920.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,900.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: MDX Hawaii PPO	$6,790.00
Rate for Payer: University Health Alliance Commercial	$3,920.00

VENOVO VENOUS STENT 16X40

Facility

$7,000.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$3,920.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,900.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: MDX Hawaii PPO	$6,790.00
Rate for Payer: University Health Alliance Commercial	$3,920.00

VENOVO VENOUS STENT 16X40

Facility

$7,000.00

Service Code	HCPCS C1876
Hospital Revenue Code	278
Min. Negotiated Rate	$3,570.00
Max. Negotiated Rate	$6,790.00
Rate for Payer: Cash Price	$4,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,900.00
Rate for Payer: Health Management Network Commercial	$5,950.00
Rate for Payer: Kaiser Permanente Commercial	$4,410.00
Rate for Payer: Kaiser Permanente Medicaid	$3,570.00
Rate for Payer: MDX Hawaii PPO	$6,790.00
Rate for Payer: University Health Alliance Commercial	$3,920.00

Know your out-of-pocket cost for care.

All Charges