Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

COLCHICINE 0.6 MG TABLET [1821]

Facility

$28.00

Service Code	NDC 60687072711
Hospital Revenue Code	637
Min. Negotiated Rate	$14.28
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$17.64
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: University Health Alliance Commercial	$20.41

COLCHICINE TABLETS (COLCRYS) 0.6 MG (TAKE HOME) [4080350]

Facility

$15.00

Service Code	NDC 00004080138
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

COLCHICINE TABLETS (COLCRYS) 0.6 MG (TAKE HOME) [4080350]

Facility

$15.00

Service Code	NDC 00004080138
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

COLESEVELAM 625 MG TABLET [28372]

Facility

$14.00

Service Code	NDC 69452015825
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

COLESEVELAM 625 MG TABLET [28372]

Facility

$14.00

Service Code	NDC 60687038525
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

COLESEVELAM 625 MG TABLET [28372]

Facility

$14.00

Service Code	NDC 69452015825
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

COLESEVELAM 625 MG TABLET [28372]

Facility

$14.00

Service Code	NDC 60687038525
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

COLISTIMETHATE SODIUM (CBA) 150 MG/2ML IJ (WET SOLR VIAL) [430160225]

Facility

$84.00

Service Code	HCPCS J0770
Hospital Revenue Code	636
Min. Negotiated Rate	$11.39
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cash Price	$50.40
Rate for Payer: Hawaii Medical Service Association ABD	$11.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.39
Rate for Payer: Hawaii Western Management Group Commercial	$79.80
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Kaiser Permanente Commercial	$52.92
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: UnitedHealthcare Medicaid	$50.40
Rate for Payer: University Health Alliance Commercial	$61.23

COLISTIMETHATE SODIUM (CBA) 150 MG/2ML IJ (WET SOLR VIAL) [430160225]

Facility

$84.00

Service Code	HCPCS J0770
Hospital Revenue Code	250
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$50.40
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: MDX Hawaii PPO	$81.48

COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION [160225]

Facility

$84.00

Service Code	HCPCS J0770
Hospital Revenue Code	250
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$50.40
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: MDX Hawaii PPO	$81.48

COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION [160225]

Facility

$84.00

Service Code	HCPCS J0770
Hospital Revenue Code	636
Min. Negotiated Rate	$11.39
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cash Price	$50.40
Rate for Payer: Hawaii Medical Service Association ABD	$11.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.39
Rate for Payer: Hawaii Western Management Group Commercial	$79.80
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Kaiser Permanente Commercial	$52.92
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: UnitedHealthcare Medicaid	$50.40
Rate for Payer: University Health Alliance Commercial	$61.23

COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 0.9 MG SOLUTION FOR INJECTION [101010]

Facility

$9,363.00

Service Code	HCPCS J0775
Hospital Revenue Code	636
Min. Negotiated Rate	$73.16
Max. Negotiated Rate	$9,082.11
Rate for Payer: AlohaCare Medicaid	$78.35
Rate for Payer: AlohaCare Medicare	$78.35
Rate for Payer: Cash Price	$5,617.80
Rate for Payer: Cash Price	$5,617.80
Rate for Payer: Devoted Health Medicare	$86.19
Rate for Payer: Hawaii Medical Service Association ABD	$73.16
Rate for Payer: Hawaii Medical Service Association Commercial	$97.94
Rate for Payer: Hawaii Medical Service Association Medicare	$78.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$73.16
Rate for Payer: Hawaii Western Management Group Commercial	$8,894.85
Rate for Payer: Health Management Network Commercial	$7,958.55
Rate for Payer: Humana Medicare	$78.35
Rate for Payer: Kaiser Permanente Commercial	$5,898.69
Rate for Payer: Kaiser Permanente Medicaid	$4,775.13
Rate for Payer: Kaiser Permanente Medicare	$78.35
Rate for Payer: MDX Hawaii PPO	$9,082.11
Rate for Payer: Ohana Health Plan Medicaid	$86.19
Rate for Payer: Ohana Health Plan Medicare	$78.35
Rate for Payer: UnitedHealthcare Medicaid	$5,617.80
Rate for Payer: UnitedHealthcare Medicare	$78.35
Rate for Payer: University Health Alliance Commercial	$6,824.69

COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 0.9 MG SOLUTION FOR INJECTION [101010]

Facility

$9,363.00

Service Code	HCPCS J0775
Hospital Revenue Code	250
Min. Negotiated Rate	$7,958.55
Max. Negotiated Rate	$9,082.11
Rate for Payer: Cash Price	$5,617.80
Rate for Payer: Health Management Network Commercial	$7,958.55
Rate for Payer: MDX Hawaii PPO	$9,082.11

COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]

Facility

$953.00

Service Code	NDC 50484001030
Hospital Revenue Code	250
Min. Negotiated Rate	$810.05
Max. Negotiated Rate	$924.41
Rate for Payer: Cash Price	$571.80
Rate for Payer: Health Management Network Commercial	$810.05
Rate for Payer: MDX Hawaii PPO	$924.41

COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]

Facility

$953.00

Service Code	NDC 50484001030
Hospital Revenue Code	637
Min. Negotiated Rate	$486.03
Max. Negotiated Rate	$924.41
Rate for Payer: Cash Price	$571.80
Rate for Payer: Hawaii Western Management Group Commercial	$905.35
Rate for Payer: Health Management Network Commercial	$810.05
Rate for Payer: Kaiser Permanente Commercial	$600.39
Rate for Payer: Kaiser Permanente Medicaid	$486.03
Rate for Payer: MDX Hawaii PPO	$924.41
Rate for Payer: University Health Alliance Commercial	$694.64

COLLAR CERVICAL CHILD REG PED5

Facility

$136.00

Service Code	HCPCS L0172
Hospital Revenue Code	274
Min. Negotiated Rate	$76.16
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$81.60
Rate for Payer: Hawaii Western Management Group Commercial	$95.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: University Health Alliance Commercial	$76.16

COLLAR CERVICAL CHILD REG PED5

Facility

$136.00

Service Code	HCPCS L0172
Hospital Revenue Code	274
Min. Negotiated Rate	$69.36
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$81.60
Rate for Payer: Hawaii Western Management Group Commercial	$95.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Kaiser Permanente Commercial	$85.68
Rate for Payer: Kaiser Permanente Medicaid	$69.36
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: UnitedHealthcare Medicaid	$78.38
Rate for Payer: University Health Alliance Commercial	$76.16

COLLAR CERVICAL CHILD SHT PED4

Facility

$136.00

Service Code	HCPCS L0172
Hospital Revenue Code	274
Min. Negotiated Rate	$76.16
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$81.60
Rate for Payer: Hawaii Western Management Group Commercial	$95.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: University Health Alliance Commercial	$76.16

COLLAR CERVICAL CHILD SHT PED4

Facility

$136.00

Service Code	HCPCS L0172
Hospital Revenue Code	274
Min. Negotiated Rate	$69.36
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$81.60
Rate for Payer: Hawaii Western Management Group Commercial	$95.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Kaiser Permanente Commercial	$85.68
Rate for Payer: Kaiser Permanente Medicaid	$69.36
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: UnitedHealthcare Medicaid	$78.38
Rate for Payer: University Health Alliance Commercial	$76.16

COLLAR CERVICAL CHILD SM

Facility

$137.00

Service Code	HCPCS L0172
Hospital Revenue Code	274
Min. Negotiated Rate	$76.72
Max. Negotiated Rate	$132.89
Rate for Payer: Cash Price	$82.20
Rate for Payer: Hawaii Western Management Group Commercial	$95.90
Rate for Payer: Health Management Network Commercial	$116.45
Rate for Payer: MDX Hawaii PPO	$132.89
Rate for Payer: University Health Alliance Commercial	$76.72

COLLAR CERVICAL CHILD SM

Facility

$137.00

Service Code	HCPCS L0172
Hospital Revenue Code	274
Min. Negotiated Rate	$69.87
Max. Negotiated Rate	$132.89
Rate for Payer: Cash Price	$82.20
Rate for Payer: Cash Price	$82.20
Rate for Payer: Hawaii Western Management Group Commercial	$95.90
Rate for Payer: Health Management Network Commercial	$116.45
Rate for Payer: Kaiser Permanente Commercial	$86.31
Rate for Payer: Kaiser Permanente Medicaid	$69.87
Rate for Payer: MDX Hawaii PPO	$132.89
Rate for Payer: UnitedHealthcare Medicaid	$78.38
Rate for Payer: University Health Alliance Commercial	$76.72

COLLAR CERVICAL INF PED1

Facility

$134.00

Service Code	HCPCS L0172
Hospital Revenue Code	274
Min. Negotiated Rate	$75.04
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$80.40
Rate for Payer: Hawaii Western Management Group Commercial	$93.80
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: MDX Hawaii PPO	$129.98
Rate for Payer: University Health Alliance Commercial	$75.04

COLLAR CERVICAL INF PED1

Facility

$134.00

Service Code	HCPCS L0172
Hospital Revenue Code	274
Min. Negotiated Rate	$68.34
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$80.40
Rate for Payer: Cash Price	$80.40
Rate for Payer: Hawaii Western Management Group Commercial	$93.80
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Kaiser Permanente Commercial	$84.42
Rate for Payer: Kaiser Permanente Medicaid	$68.34
Rate for Payer: MDX Hawaii PPO	$129.98
Rate for Payer: UnitedHealthcare Medicaid	$78.38
Rate for Payer: University Health Alliance Commercial	$75.04

COLLAR CERVICAL INF REG PED2

Facility

$136.00

Service Code	HCPCS L0172
Hospital Revenue Code	274
Min. Negotiated Rate	$69.36
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$81.60
Rate for Payer: Hawaii Western Management Group Commercial	$95.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Kaiser Permanente Commercial	$85.68
Rate for Payer: Kaiser Permanente Medicaid	$69.36
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: UnitedHealthcare Medicaid	$78.38
Rate for Payer: University Health Alliance Commercial	$76.16

COLLAR CERVICAL INF REG PED2

Facility

$136.00

Service Code	HCPCS L0172
Hospital Revenue Code	274
Min. Negotiated Rate	$76.16
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$81.60
Rate for Payer: Hawaii Western Management Group Commercial	$95.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: University Health Alliance Commercial	$76.16

Know your out-of-pocket cost for care.

All Charges