Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION [107671]

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 600 MG INTRAVENOUS SOLUTION [107671]

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

CEFTAZIDIME 1 G/10ML IJ (WET SOLR VIAL) [4309474]

Facility

$25.00

Service Code	HCPCS J0713
Hospital Revenue Code	250
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: MDX Hawaii PPO	$24.25

CEFTAZIDIME 1 G/10ML IJ (WET SOLR VIAL) [4309474]

Facility

$19.00

Service Code	HCPCS J0713
Hospital Revenue Code	636
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Cash Price	$11.40
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cash Price	$15.00
Rate for Payer: Hawaii Medical Service Association ABD	$2.09
Rate for Payer: Hawaii Medical Service Association ABD	$2.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.09
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
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	$16.15
Rate for Payer: Kaiser Permanente Commercial	$15.75
Rate for Payer: Kaiser Permanente Commercial	$11.97
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: UnitedHealthcare Medicaid	$11.40
Rate for Payer: UnitedHealthcare Medicaid	$15.00
Rate for Payer: University Health Alliance Commercial	$18.22
Rate for Payer: University Health Alliance Commercial	$13.85

CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION [9474]

Facility

$19.00

Service Code	HCPCS J0713
Hospital Revenue Code	250
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: MDX Hawaii PPO	$18.43

CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION [9474]

Facility

$19.00

Service Code	HCPCS J0713
Hospital Revenue Code	636
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Cash Price	$11.40
Rate for Payer: Hawaii Medical Service Association ABD	$2.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.09
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$11.97
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: UnitedHealthcare Medicaid	$11.40
Rate for Payer: University Health Alliance Commercial	$13.85

CEFTAZIDIME-AVIBACTAM 2.5 G/12ML IV (WET SOLR VIAL) [430128163]

Facility

$748.00

Service Code	HCPCS J0714
Hospital Revenue Code	250
Min. Negotiated Rate	$635.80
Max. Negotiated Rate	$725.56
Rate for Payer: Cash Price	$448.80
Rate for Payer: Cash Price	$169.20
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Health Management Network Commercial	$635.80
Rate for Payer: MDX Hawaii PPO	$273.54
Rate for Payer: MDX Hawaii PPO	$725.56

CEFTAZIDIME-AVIBACTAM 2.5 G/12ML IV (WET SOLR VIAL) [430128163]

Facility

$282.00

Service Code	HCPCS J0714
Hospital Revenue Code	636
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$273.54
Rate for Payer: AlohaCare Medicaid	$104.75
Rate for Payer: AlohaCare Medicaid	$104.75
Rate for Payer: AlohaCare Medicare	$104.75
Rate for Payer: AlohaCare Medicare	$104.75
Rate for Payer: Cash Price	$169.20
Rate for Payer: Cash Price	$448.80
Rate for Payer: Cash Price	$169.20
Rate for Payer: Cash Price	$448.80
Rate for Payer: Devoted Health Medicare	$115.22
Rate for Payer: Devoted Health Medicare	$115.22
Rate for Payer: Hawaii Medical Service Association ABD	$104.95
Rate for Payer: Hawaii Medical Service Association ABD	$104.95
Rate for Payer: Hawaii Medical Service Association Commercial	$130.94
Rate for Payer: Hawaii Medical Service Association Commercial	$130.94
Rate for Payer: Hawaii Medical Service Association Medicare	$104.75
Rate for Payer: Hawaii Medical Service Association Medicare	$104.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$104.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$104.95
Rate for Payer: Hawaii Western Management Group Commercial	$267.90
Rate for Payer: Hawaii Western Management Group Commercial	$710.60
Rate for Payer: Health Management Network Commercial	$635.80
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Humana Medicare	$104.75
Rate for Payer: Humana Medicare	$104.75
Rate for Payer: Kaiser Permanente Commercial	$177.66
Rate for Payer: Kaiser Permanente Commercial	$471.24
Rate for Payer: Kaiser Permanente Medicaid	$143.82
Rate for Payer: Kaiser Permanente Medicaid	$381.48
Rate for Payer: Kaiser Permanente Medicare	$104.75
Rate for Payer: Kaiser Permanente Medicare	$104.75
Rate for Payer: MDX Hawaii PPO	$273.54
Rate for Payer: MDX Hawaii PPO	$725.56
Rate for Payer: Ohana Health Plan Medicaid	$115.22
Rate for Payer: Ohana Health Plan Medicaid	$115.22
Rate for Payer: Ohana Health Plan Medicare	$104.75
Rate for Payer: Ohana Health Plan Medicare	$104.75
Rate for Payer: UnitedHealthcare Medicaid	$169.20
Rate for Payer: UnitedHealthcare Medicaid	$448.80
Rate for Payer: UnitedHealthcare Medicare	$104.75
Rate for Payer: UnitedHealthcare Medicare	$104.75
Rate for Payer: University Health Alliance Commercial	$205.55
Rate for Payer: University Health Alliance Commercial	$545.22

CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION [128163]

Facility

$748.00

Service Code	HCPCS J0714
Hospital Revenue Code	250
Min. Negotiated Rate	$635.80
Max. Negotiated Rate	$725.56
Rate for Payer: Cash Price	$448.80
Rate for Payer: Health Management Network Commercial	$635.80
Rate for Payer: MDX Hawaii PPO	$725.56

CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION [128163]

Facility

$748.00

Service Code	HCPCS J0714
Hospital Revenue Code	636
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$725.56
Rate for Payer: AlohaCare Medicaid	$104.75
Rate for Payer: AlohaCare Medicare	$104.75
Rate for Payer: Cash Price	$448.80
Rate for Payer: Cash Price	$448.80
Rate for Payer: Devoted Health Medicare	$115.22
Rate for Payer: Hawaii Medical Service Association ABD	$104.95
Rate for Payer: Hawaii Medical Service Association Commercial	$130.94
Rate for Payer: Hawaii Medical Service Association Medicare	$104.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$104.95
Rate for Payer: Hawaii Western Management Group Commercial	$710.60
Rate for Payer: Health Management Network Commercial	$635.80
Rate for Payer: Humana Medicare	$104.75
Rate for Payer: Kaiser Permanente Commercial	$471.24
Rate for Payer: Kaiser Permanente Medicaid	$381.48
Rate for Payer: Kaiser Permanente Medicare	$104.75
Rate for Payer: MDX Hawaii PPO	$725.56
Rate for Payer: Ohana Health Plan Medicaid	$115.22
Rate for Payer: Ohana Health Plan Medicare	$104.75
Rate for Payer: UnitedHealthcare Medicaid	$448.80
Rate for Payer: UnitedHealthcare Medicare	$104.75
Rate for Payer: University Health Alliance Commercial	$545.22

CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK [9492]

Facility

$60.00

Service Code	HCPCS J0696
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

CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK [9492]

Facility

$60.00

Service Code	HCPCS J0696
Hospital Revenue Code	636
Min. Negotiated Rate	$9.70
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	$9.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.70
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

CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]

Facility

$7.00

Service Code	HCPCS J0696
Hospital Revenue Code	636
Min. Negotiated Rate	$3.57
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$4.20
Rate for Payer: Hawaii Medical Service Association ABD	$9.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.70
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$4.41
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: University Health Alliance Commercial	$5.10

CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]

Facility

$7.00

Service Code	HCPCS J0696
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: MDX Hawaii PPO	$6.79

CEFTRIAXONE 250 MG SOLUTION FOR INJECTION [9489]

Facility

$4.00

Service Code	HCPCS J0696
Hospital Revenue Code	636
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Medical Service Association ABD	$9.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.70
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: UnitedHealthcare Medicaid	$2.40
Rate for Payer: University Health Alliance Commercial	$2.92

CEFTRIAXONE 250 MG SOLUTION FOR INJECTION [9489]

Facility

$4.00

Service Code	HCPCS J0696
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

CEFTRIAXONE 2 GM IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080093]

Facility

$13.00

Service Code	NDC 00004080032
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

CEFTRIAXONE 2 GM IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080093]

Facility

$13.00

Service Code	NDC 00004080032
Hospital Revenue Code	636
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
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

CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK [9493]

Facility

$79.00

Service Code	HCPCS J0696
Hospital Revenue Code	250
Min. Negotiated Rate	$67.15
Max. Negotiated Rate	$76.63
Rate for Payer: Cash Price	$47.40
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: MDX Hawaii PPO	$76.63

CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK [9493]

Facility

$79.00

Service Code	HCPCS J0696
Hospital Revenue Code	636
Min. Negotiated Rate	$9.70
Max. Negotiated Rate	$76.63
Rate for Payer: Cash Price	$47.40
Rate for Payer: Cash Price	$47.40
Rate for Payer: Hawaii Medical Service Association ABD	$9.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.70
Rate for Payer: Hawaii Western Management Group Commercial	$75.05
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: Kaiser Permanente Commercial	$49.77
Rate for Payer: Kaiser Permanente Medicaid	$40.29
Rate for Payer: MDX Hawaii PPO	$76.63
Rate for Payer: UnitedHealthcare Medicaid	$47.40
Rate for Payer: University Health Alliance Commercial	$57.58

CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION [9488]

Facility

$13.00

Service Code	HCPCS J0696
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

CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION [9488]

Facility

$13.00

Service Code	HCPCS J0696
Hospital Revenue Code	636
Min. Negotiated Rate	$6.63
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	$9.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.70
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

CEFTRIAXONE 500 MG SOLUTION FOR INJECTION [9490]

Facility

$5.00

Service Code	HCPCS J0696
Hospital Revenue Code	636
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Medical Service Association ABD	$9.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.70
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: UnitedHealthcare Medicaid	$3.00
Rate for Payer: University Health Alliance Commercial	$3.64

CEFTRIAXONE 500 MG SOLUTION FOR INJECTION [9490]

Facility

$5.00

Service Code	HCPCS J0696
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

CEFTRIAXONE SODIUM 1 G/10ML IJ (WET SOLR VIAL) [4309487]

Facility

$7.00

Service Code	HCPCS J0696
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: MDX Hawaii PPO	$6.79

Know your out-of-pocket cost for care.

All Charges