Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

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

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 SODIUM 250 MG/2.5ML IJ (WET SOLR VIAL) [4309489]

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 SODIUM 250 MG/2.5ML IJ (WET SOLR VIAL) [4309489]

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 SODIUM 500 MG/5ML IJ (WET SOLR VIAL) [4309490]

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 500 MG/5ML IJ (WET SOLR VIAL) [4309490]

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

CEFUROXIME AXETIL 250 MG TABLET [9495]

Facility

$16.00

Service Code	NDC 65862069920
Hospital Revenue Code	637
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Hawaii Western Management Group Commercial	$15.20
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Kaiser Permanente Commercial	$10.08
Rate for Payer: Kaiser Permanente Medicaid	$8.16
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: University Health Alliance Commercial	$11.66

CEFUROXIME AXETIL 250 MG TABLET [9495]

Facility

$20.00

Service Code	NDC 67877021560
Hospital Revenue Code	637
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Hawaii Western Management Group Commercial	$19.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$10.20
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: University Health Alliance Commercial	$14.58

CEFUROXIME AXETIL 250 MG TABLET [9495]

Facility

$16.00

Service Code	NDC 65862069920
Hospital Revenue Code	250
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: MDX Hawaii PPO	$15.52

CEFUROXIME AXETIL 250 MG TABLET [9495]

Facility

$20.00

Service Code	NDC 67877021560
Hospital Revenue Code	250
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: MDX Hawaii PPO	$19.40

CEFUROXIME AXETIL 500 MG TABLET [9496]

Facility

$25.00

Service Code	NDC 65862070020
Hospital Revenue Code	250
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: MDX Hawaii PPO	$24.25

CEFUROXIME AXETIL 500 MG TABLET [9496]

Facility

$25.00

Service Code	NDC 65862070020
Hospital Revenue Code	637
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Hawaii Western Management Group Commercial	$23.75
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$15.75
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: University Health Alliance Commercial	$18.22

CEFUROXIME SODIUM 750 MG/8.3 ML IJ (WET SOLR VIAL) [4301465]

Facility

$18.00

Service Code	HCPCS J0697
Hospital Revenue Code	636
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Hawaii Medical Service Association ABD	$2.29
Rate for Payer: Hawaii Medical Service Association ABD	$2.29
Rate for Payer: Hawaii Medical Service Association ABD	$2.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.29
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Hawaii Western Management Group Commercial	$23.75
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$8.19
Rate for Payer: Kaiser Permanente Commercial	$11.34
Rate for Payer: Kaiser Permanente Commercial	$15.75
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: UnitedHealthcare Medicaid	$7.80
Rate for Payer: UnitedHealthcare Medicaid	$15.00
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: University Health Alliance Commercial	$18.22
Rate for Payer: University Health Alliance Commercial	$9.48
Rate for Payer: University Health Alliance Commercial	$13.12

CEFUROXIME SODIUM 750 MG/8.3 ML IJ (WET SOLR VIAL) [4301465]

Facility

$18.00

Service Code	HCPCS J0697
Hospital Revenue Code	250
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$15.00
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: MDX Hawaii PPO	$17.46

CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION [1465]

Facility

$13.00

Service Code	HCPCS J0697
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

CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION [1465]

Facility

$13.00

Service Code	HCPCS J0697
Hospital Revenue Code	636
Min. Negotiated Rate	$2.29
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	$2.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.29
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

CELECOXIB 100 MG CAPSULE [24500]

Facility

$17.00

Service Code	NDC 60687043601
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

CELECOXIB 100 MG CAPSULE [24500]

Facility

$17.00

Service Code	NDC 60687043611
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

CELECOXIB 100 MG CAPSULE [24500]

Facility

$17.00

Service Code	NDC 60687043601
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

CELECOXIB 100 MG CAPSULE [24500]

Facility

$17.00

Service Code	NDC 60687043611
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

CELECOXIB 200 MG CAPSULE [24501]

Facility

$9.00

Service Code	NDC 60687044701
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

CELECOXIB 200 MG CAPSULE [24501]

Facility

$9.00

Service Code	NDC 60687044711
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

CELECOXIB 200 MG CAPSULE [24501]

Facility

$9.00

Service Code	NDC 60687044701
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: University Health Alliance Commercial	$6.56

CELECOXIB 200 MG CAPSULE [24501]

Facility

$9.00

Service Code	NDC 60687044711
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: University Health Alliance Commercial	$6.56

CELECT VENA CAVA FILTER SET

Facility

$2,790.00

Service Code	HCPCS C1880
Hospital Revenue Code	272
Min. Negotiated Rate	$1,422.90
Max. Negotiated Rate	$2,706.30
Rate for Payer: Cash Price	$1,674.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,650.50
Rate for Payer: Health Management Network Commercial	$2,371.50
Rate for Payer: Kaiser Permanente Commercial	$1,757.70
Rate for Payer: Kaiser Permanente Medicaid	$1,422.90
Rate for Payer: MDX Hawaii PPO	$2,706.30
Rate for Payer: University Health Alliance Commercial	$2,033.63

CELECT VENA CAVA FILTER SET

Facility

$2,790.00

Service Code	HCPCS C1880
Hospital Revenue Code	272
Min. Negotiated Rate	$2,371.50
Max. Negotiated Rate	$2,706.30
Rate for Payer: Cash Price	$1,674.00
Rate for Payer: Health Management Network Commercial	$2,371.50
Rate for Payer: MDX Hawaii PPO	$2,706.30

Know your out-of-pocket cost for care.

All Charges