Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CEFDINIR SUSPENSION (OMNICEF) 250 MG/5 ML (100 ML) (TAKE HOME) [4080341]

Facility

$15.00

Service Code	NDC 00004080129
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

CEFEPIME 1 GRAM/50 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [163109]

Facility

$60.00

Service Code	HCPCS J0703
Hospital Revenue Code	636
Min. Negotiated Rate	$5.07
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Hawaii Medical Service Association ABD	$5.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.07
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: UnitedHealthcare Medicaid	$36.00
Rate for Payer: University Health Alliance Commercial	$43.73

CEFEPIME 1 GRAM/50 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [163109]

Facility

$60.00

Service Code	HCPCS J0703
Hospital Revenue Code	250
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: MDX Hawaii PPO	$58.20

CEFEPIME 1 GRAM SOLUTION FOR INJECTION [16369]

Facility

$51.00

Service Code	HCPCS J0692
Hospital Revenue Code	636
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cash Price	$30.60
Rate for Payer: Hawaii Medical Service Association ABD	$6.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.19
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$32.13
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: UnitedHealthcare Medicaid	$30.60
Rate for Payer: University Health Alliance Commercial	$37.17

CEFEPIME 1 GRAM SOLUTION FOR INJECTION [16369]

Facility

$51.00

Service Code	HCPCS J0692
Hospital Revenue Code	250
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: MDX Hawaii PPO	$49.47

CEFEPIME 2 GRAM/50 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [163115]

Facility

$90.00

Service Code	HCPCS J0703
Hospital Revenue Code	636
Min. Negotiated Rate	$5.07
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Hawaii Medical Service Association ABD	$5.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.07
Rate for Payer: Hawaii Western Management Group Commercial	$85.50
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$45.90
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: UnitedHealthcare Medicaid	$54.00
Rate for Payer: University Health Alliance Commercial	$65.60

CEFEPIME 2 GRAM/50 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [163115]

Facility

$90.00

Service Code	HCPCS J0703
Hospital Revenue Code	250
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$54.00
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: MDX Hawaii PPO	$87.30

CEFEPIME 2 GRAM SOLUTION FOR INJECTION [27311]

Facility

$101.00

Service Code	HCPCS J0692
Hospital Revenue Code	250
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$60.60
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: MDX Hawaii PPO	$97.97

CEFEPIME 2 GRAM SOLUTION FOR INJECTION [27311]

Facility

$101.00

Service Code	HCPCS J0692
Hospital Revenue Code	636
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$60.60
Rate for Payer: Cash Price	$60.60
Rate for Payer: Hawaii Medical Service Association ABD	$6.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.19
Rate for Payer: Hawaii Western Management Group Commercial	$95.95
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$63.63
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: UnitedHealthcare Medicaid	$60.60
Rate for Payer: University Health Alliance Commercial	$73.62

CEFEPIME HCL 1 G/10ML IJ (WET SOLR VIAL) [43016369]

Facility

$51.00

Service Code	HCPCS J0692
Hospital Revenue Code	250
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cash Price	$66.00
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: MDX Hawaii PPO	$106.70

CEFEPIME HCL 1 G/10ML IJ (WET SOLR VIAL) [43016369]

Facility

$110.00

Service Code	HCPCS J0692
Hospital Revenue Code	636
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$106.70
Rate for Payer: Cash Price	$66.00
Rate for Payer: Cash Price	$66.00
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cash Price	$30.60
Rate for Payer: Hawaii Medical Service Association ABD	$6.19
Rate for Payer: Hawaii Medical Service Association ABD	$6.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.19
Rate for Payer: Hawaii Western Management Group Commercial	$104.50
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: Kaiser Permanente Commercial	$32.13
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicaid	$56.10
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: MDX Hawaii PPO	$106.70
Rate for Payer: UnitedHealthcare Medicaid	$66.00
Rate for Payer: UnitedHealthcare Medicaid	$30.60
Rate for Payer: University Health Alliance Commercial	$80.18
Rate for Payer: University Health Alliance Commercial	$37.17

CEFEPIME HCL 2 G/20ML IV (WET SOLR VIAL) [43027311]

Facility

$101.00

Service Code	HCPCS J0692
Hospital Revenue Code	636
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$60.60
Rate for Payer: Cash Price	$60.60
Rate for Payer: Hawaii Medical Service Association ABD	$6.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.19
Rate for Payer: Hawaii Western Management Group Commercial	$95.95
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$63.63
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: UnitedHealthcare Medicaid	$60.60
Rate for Payer: University Health Alliance Commercial	$73.62

CEFEPIME HCL 2 G/20ML IV (WET SOLR VIAL) [43027311]

Facility

$101.00

Service Code	HCPCS J0692
Hospital Revenue Code	250
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$60.60
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: MDX Hawaii PPO	$97.97

CEFOXITIN 2 G IN 100 ML NS ADD-A-VIAL (SIMPLE) [4080121]

Facility

$44.00

Service Code	HCPCS J0694
Hospital Revenue Code	250
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$42.68
Rate for Payer: Cash Price	$26.40
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: MDX Hawaii PPO	$42.68

CEFOXITIN 2 G IN 100 ML NS ADD-A-VIAL (SIMPLE) [4080121]

Facility

$44.00

Service Code	HCPCS J0694
Hospital Revenue Code	636
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$42.68
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cash Price	$26.40
Rate for Payer: Hawaii Medical Service Association ABD	$5.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.13
Rate for Payer: Hawaii Western Management Group Commercial	$41.80
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: Kaiser Permanente Commercial	$27.72
Rate for Payer: Kaiser Permanente Medicaid	$22.44
Rate for Payer: MDX Hawaii PPO	$42.68
Rate for Payer: UnitedHealthcare Medicaid	$26.40
Rate for Payer: University Health Alliance Commercial	$32.07

CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION [9463]

Facility

$30.00

Service Code	HCPCS J0694
Hospital Revenue Code	636
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Hawaii Medical Service Association ABD	$5.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.13
Rate for Payer: Hawaii Western Management Group Commercial	$28.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: UnitedHealthcare Medicaid	$18.00
Rate for Payer: University Health Alliance Commercial	$21.87

CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION [9463]

Facility

$30.00

Service Code	HCPCS J0694
Hospital Revenue Code	250
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: MDX Hawaii PPO	$29.10

CEFOXITIN SODIUM 2 G/20ML IV (WET SOLR VIAL) [4309463]

Facility

$30.00

Service Code	HCPCS J0694
Hospital Revenue Code	250
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: MDX Hawaii PPO	$29.10

CEFOXITIN SODIUM 2 G/20ML IV (WET SOLR VIAL) [4309463]

Facility

$30.00

Service Code	HCPCS J0694
Hospital Revenue Code	636
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Hawaii Medical Service Association ABD	$5.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.13
Rate for Payer: Hawaii Western Management Group Commercial	$28.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: UnitedHealthcare Medicaid	$18.00
Rate for Payer: University Health Alliance Commercial	$21.87

CEFTAROLINE FOSAMIL 400 MG/20ML IV (WET SOLR VIAL) [430107670]

Facility

$464.00

Service Code	HCPCS J0712
Hospital Revenue Code	636
Min. Negotiated Rate	$4.24
Max. Negotiated Rate	$450.08
Rate for Payer: AlohaCare Medicaid	$4.25
Rate for Payer: AlohaCare Medicare	$4.25
Rate for Payer: Cash Price	$278.40
Rate for Payer: Cash Price	$278.40
Rate for Payer: Devoted Health Medicare	$4.67
Rate for Payer: Hawaii Medical Service Association ABD	$4.24
Rate for Payer: Hawaii Medical Service Association Commercial	$5.31
Rate for Payer: Hawaii Medical Service Association Medicare	$4.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.24
Rate for Payer: Hawaii Western Management Group Commercial	$440.80
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Humana Medicare	$4.25
Rate for Payer: Kaiser Permanente Commercial	$292.32
Rate for Payer: Kaiser Permanente Medicaid	$236.64
Rate for Payer: Kaiser Permanente Medicare	$4.25
Rate for Payer: MDX Hawaii PPO	$450.08
Rate for Payer: Ohana Health Plan Medicaid	$4.67
Rate for Payer: Ohana Health Plan Medicare	$4.25
Rate for Payer: UnitedHealthcare Medicaid	$278.40
Rate for Payer: UnitedHealthcare Medicare	$4.25
Rate for Payer: University Health Alliance Commercial	$338.21

CEFTAROLINE FOSAMIL 400 MG/20ML IV (WET SOLR VIAL) [430107670]

Facility

$464.00

Service Code	HCPCS J0712
Hospital Revenue Code	250
Min. Negotiated Rate	$394.40
Max. Negotiated Rate	$450.08
Rate for Payer: Cash Price	$278.40
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: MDX Hawaii PPO	$450.08

CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION [107670]

Facility

$464.00

Service Code	HCPCS J0712
Hospital Revenue Code	636
Min. Negotiated Rate	$4.24
Max. Negotiated Rate	$450.08
Rate for Payer: AlohaCare Medicaid	$4.25
Rate for Payer: AlohaCare Medicare	$4.25
Rate for Payer: Cash Price	$278.40
Rate for Payer: Cash Price	$278.40
Rate for Payer: Devoted Health Medicare	$4.67
Rate for Payer: Hawaii Medical Service Association ABD	$4.24
Rate for Payer: Hawaii Medical Service Association Commercial	$5.31
Rate for Payer: Hawaii Medical Service Association Medicare	$4.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.24
Rate for Payer: Hawaii Western Management Group Commercial	$440.80
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Humana Medicare	$4.25
Rate for Payer: Kaiser Permanente Commercial	$292.32
Rate for Payer: Kaiser Permanente Medicaid	$236.64
Rate for Payer: Kaiser Permanente Medicare	$4.25
Rate for Payer: MDX Hawaii PPO	$450.08
Rate for Payer: Ohana Health Plan Medicaid	$4.67
Rate for Payer: Ohana Health Plan Medicare	$4.25
Rate for Payer: UnitedHealthcare Medicaid	$278.40
Rate for Payer: UnitedHealthcare Medicare	$4.25
Rate for Payer: University Health Alliance Commercial	$338.21

CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION [107670]

Facility

$464.00

Service Code	HCPCS J0712
Hospital Revenue Code	250
Min. Negotiated Rate	$394.40
Max. Negotiated Rate	$450.08
Rate for Payer: Cash Price	$278.40
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: MDX Hawaii PPO	$450.08

CEFTAROLINE FOSAMIL 600 MG/20ML IV (WET SOLR VIAL) [430107671]

Facility

$464.00

Service Code	HCPCS J0712
Hospital Revenue Code	250
Min. Negotiated Rate	$394.40
Max. Negotiated Rate	$450.08
Rate for Payer: Cash Price	$278.40
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: MDX Hawaii PPO	$450.08

CEFTAROLINE FOSAMIL 600 MG/20ML IV (WET SOLR VIAL) [430107671]

Facility

$464.00

Service Code	HCPCS J0712
Hospital Revenue Code	636
Min. Negotiated Rate	$4.24
Max. Negotiated Rate	$450.08
Rate for Payer: AlohaCare Medicaid	$4.25
Rate for Payer: AlohaCare Medicare	$4.25
Rate for Payer: Cash Price	$278.40
Rate for Payer: Cash Price	$278.40
Rate for Payer: Devoted Health Medicare	$4.67
Rate for Payer: Hawaii Medical Service Association ABD	$4.24
Rate for Payer: Hawaii Medical Service Association Commercial	$5.31
Rate for Payer: Hawaii Medical Service Association Medicare	$4.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.24
Rate for Payer: Hawaii Western Management Group Commercial	$440.80
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Humana Medicare	$4.25
Rate for Payer: Kaiser Permanente Commercial	$292.32
Rate for Payer: Kaiser Permanente Medicaid	$236.64
Rate for Payer: Kaiser Permanente Medicare	$4.25
Rate for Payer: MDX Hawaii PPO	$450.08
Rate for Payer: Ohana Health Plan Medicaid	$4.67
Rate for Payer: Ohana Health Plan Medicare	$4.25
Rate for Payer: UnitedHealthcare Medicaid	$278.40
Rate for Payer: UnitedHealthcare Medicare	$4.25
Rate for Payer: University Health Alliance Commercial	$338.21

Know your out-of-pocket cost for care.

All Charges