Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CYCLOBENZAPRINE TABLETS (FLEXERIL) 10 MG (TAKE HOME) [4080352]

Facility

$15.00

Service Code	NDC 00004080140
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

CYCLOBENZAPRINE TABLETS (FLEXERIL) 10 MG (TAKE HOME) [4080352]

Facility

$15.00

Service Code	NDC 00004080140
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

CYCLOPENTOLATE 1 % EYE DROPS [2025]

Facility

$51.00

Service Code	NDC 61314039601
Hospital Revenue Code	637
Min. Negotiated Rate	$26.01
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
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: University Health Alliance Commercial	$37.17

CYCLOPENTOLATE 1 % EYE DROPS [2025]

Facility

$51.00

Service Code	NDC 61314039601
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

CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION [174600]

Facility

$1,171.00

Service Code	HCPCS J9073
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$1,135.87
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.50
Rate for Payer: AlohaCare Medicare	$0.50
Rate for Payer: AlohaCare Medicare	$0.50
Rate for Payer: AlohaCare Medicare	$0.50
Rate for Payer: Cash Price	$1,266.00
Rate for Payer: Cash Price	$1,266.00
Rate for Payer: Cash Price	$791.40
Rate for Payer: Cash Price	$702.60
Rate for Payer: Cash Price	$791.40
Rate for Payer: Cash Price	$633.00
Rate for Payer: Cash Price	$702.60
Rate for Payer: Cash Price	$633.00
Rate for Payer: Devoted Health Medicare	$0.55
Rate for Payer: Devoted Health Medicare	$0.55
Rate for Payer: Devoted Health Medicare	$0.55
Rate for Payer: Devoted Health Medicare	$0.55
Rate for Payer: Hawaii Medical Service Association ABD	$1.16
Rate for Payer: Hawaii Medical Service Association ABD	$1.16
Rate for Payer: Hawaii Medical Service Association ABD	$1.16
Rate for Payer: Hawaii Medical Service Association ABD	$1.16
Rate for Payer: Hawaii Medical Service Association Commercial	$0.63
Rate for Payer: Hawaii Medical Service Association Commercial	$0.63
Rate for Payer: Hawaii Medical Service Association Commercial	$0.63
Rate for Payer: Hawaii Medical Service Association Commercial	$0.63
Rate for Payer: Hawaii Medical Service Association Medicare	$0.50
Rate for Payer: Hawaii Medical Service Association Medicare	$0.50
Rate for Payer: Hawaii Medical Service Association Medicare	$0.50
Rate for Payer: Hawaii Medical Service Association Medicare	$0.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.16
Rate for Payer: Hawaii Western Management Group Commercial	$1,112.45
Rate for Payer: Hawaii Western Management Group Commercial	$2,004.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,002.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,253.05
Rate for Payer: Health Management Network Commercial	$1,793.50
Rate for Payer: Health Management Network Commercial	$896.75
Rate for Payer: Health Management Network Commercial	$1,121.15
Rate for Payer: Health Management Network Commercial	$995.35
Rate for Payer: Humana Medicare	$0.50
Rate for Payer: Humana Medicare	$0.50
Rate for Payer: Humana Medicare	$0.50
Rate for Payer: Humana Medicare	$0.50
Rate for Payer: Kaiser Permanente Commercial	$737.73
Rate for Payer: Kaiser Permanente Commercial	$1,329.30
Rate for Payer: Kaiser Permanente Commercial	$830.97
Rate for Payer: Kaiser Permanente Commercial	$664.65
Rate for Payer: Kaiser Permanente Medicaid	$672.69
Rate for Payer: Kaiser Permanente Medicaid	$538.05
Rate for Payer: Kaiser Permanente Medicaid	$1,076.10
Rate for Payer: Kaiser Permanente Medicaid	$597.21
Rate for Payer: Kaiser Permanente Medicare	$0.50
Rate for Payer: Kaiser Permanente Medicare	$0.50
Rate for Payer: Kaiser Permanente Medicare	$0.50
Rate for Payer: Kaiser Permanente Medicare	$0.50
Rate for Payer: MDX Hawaii PPO	$1,023.35
Rate for Payer: MDX Hawaii PPO	$2,046.70
Rate for Payer: MDX Hawaii PPO	$1,135.87
Rate for Payer: MDX Hawaii PPO	$1,279.43
Rate for Payer: Ohana Health Plan Medicaid	$0.55
Rate for Payer: Ohana Health Plan Medicaid	$0.55
Rate for Payer: Ohana Health Plan Medicaid	$0.55
Rate for Payer: Ohana Health Plan Medicaid	$0.55
Rate for Payer: Ohana Health Plan Medicare	$0.50
Rate for Payer: Ohana Health Plan Medicare	$0.50
Rate for Payer: Ohana Health Plan Medicare	$0.50
Rate for Payer: Ohana Health Plan Medicare	$0.50
Rate for Payer: UnitedHealthcare Medicaid	$633.00
Rate for Payer: UnitedHealthcare Medicaid	$702.60
Rate for Payer: UnitedHealthcare Medicaid	$1,266.00
Rate for Payer: UnitedHealthcare Medicaid	$791.40
Rate for Payer: UnitedHealthcare Medicare	$0.50
Rate for Payer: UnitedHealthcare Medicare	$0.50
Rate for Payer: UnitedHealthcare Medicare	$0.50
Rate for Payer: UnitedHealthcare Medicare	$0.50
Rate for Payer: University Health Alliance Commercial	$1,537.98
Rate for Payer: University Health Alliance Commercial	$853.54
Rate for Payer: University Health Alliance Commercial	$768.99
Rate for Payer: University Health Alliance Commercial	$961.42

CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION [174600]

Facility

$2,110.00

Service Code	HCPCS J9073
Hospital Revenue Code	250
Min. Negotiated Rate	$1,793.50
Max. Negotiated Rate	$2,046.70
Rate for Payer: Cash Price	$1,266.00
Rate for Payer: Cash Price	$633.00
Rate for Payer: Cash Price	$791.40
Rate for Payer: Cash Price	$702.60
Rate for Payer: Health Management Network Commercial	$1,121.15
Rate for Payer: Health Management Network Commercial	$1,793.50
Rate for Payer: Health Management Network Commercial	$995.35
Rate for Payer: Health Management Network Commercial	$896.75
Rate for Payer: MDX Hawaii PPO	$2,046.70
Rate for Payer: MDX Hawaii PPO	$1,023.35
Rate for Payer: MDX Hawaii PPO	$1,135.87
Rate for Payer: MDX Hawaii PPO	$1,279.43

CYCLOPHOSPHAMIDE 50 MG CAPSULE [126405]

Facility

$45.00

Service Code	HCPCS J8530
Hospital Revenue Code	637
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$10.20
Rate for Payer: Cash Price	$10.20
Rate for Payer: Cash Price	$27.00
Rate for Payer: Hawaii Medical Service Association ABD	$1.98
Rate for Payer: Hawaii Medical Service Association ABD	$1.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.98
Rate for Payer: Hawaii Western Management Group Commercial	$42.75
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$10.71
Rate for Payer: Kaiser Permanente Commercial	$28.35
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: UnitedHealthcare Medicaid	$1.49
Rate for Payer: UnitedHealthcare Medicaid	$1.49
Rate for Payer: University Health Alliance Commercial	$12.39
Rate for Payer: University Health Alliance Commercial	$32.80

CYCLOPHOSPHAMIDE 50 MG CAPSULE [126405]

Facility

$17.00

Service Code	HCPCS J8530
Hospital Revenue Code	250
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Cash Price	$27.00
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: MDX Hawaii PPO	$43.65

CYCLOSPORINE 250 MG/5 ML INTRAVENOUS SOLUTION [9705]

Facility

$141.00

Service Code	HCPCS J7516
Hospital Revenue Code	250
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$136.77
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cash Price	$128.40
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: MDX Hawaii PPO	$136.77
Rate for Payer: MDX Hawaii PPO	$207.58

CYCLOSPORINE 250 MG/5 ML INTRAVENOUS SOLUTION [9705]

Facility

$214.00

Service Code	HCPCS J7516
Hospital Revenue Code	636
Min. Negotiated Rate	$72.69
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$128.40
Rate for Payer: Cash Price	$128.40
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cash Price	$84.60
Rate for Payer: Hawaii Medical Service Association ABD	$72.69
Rate for Payer: Hawaii Medical Service Association ABD	$72.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$72.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$72.69
Rate for Payer: Hawaii Western Management Group Commercial	$133.95
Rate for Payer: Hawaii Western Management Group Commercial	$203.30
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$134.82
Rate for Payer: Kaiser Permanente Commercial	$88.83
Rate for Payer: Kaiser Permanente Medicaid	$109.14
Rate for Payer: Kaiser Permanente Medicaid	$71.91
Rate for Payer: MDX Hawaii PPO	$136.77
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: UnitedHealthcare Medicaid	$128.40
Rate for Payer: UnitedHealthcare Medicaid	$84.60
Rate for Payer: University Health Alliance Commercial	$102.77
Rate for Payer: University Health Alliance Commercial	$155.98

CYCLOSPORINE MODIFIED 100 MG CAPSULE [28843]

Facility

$20.00

Service Code	HCPCS J7502
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

CYCLOSPORINE MODIFIED 100 MG CAPSULE [28843]

Facility

$20.00

Service Code	HCPCS J7502
Hospital Revenue Code	636
Min. Negotiated Rate	$2.07
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Hawaii Medical Service Association ABD	$2.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.07
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: UnitedHealthcare Medicaid	$12.00
Rate for Payer: University Health Alliance Commercial	$14.58

CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLUTION [28844]

Facility

$450.00

Service Code	HCPCS J7502
Hospital Revenue Code	637
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Hawaii Medical Service Association ABD	$2.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.07
Rate for Payer: Hawaii Western Management Group Commercial	$427.50
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Kaiser Permanente Commercial	$283.50
Rate for Payer: Kaiser Permanente Medicaid	$229.50
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: UnitedHealthcare Medicaid	$1.55
Rate for Payer: University Health Alliance Commercial	$328.00

CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLUTION [28844]

Facility

$450.00

Service Code	HCPCS J7502
Hospital Revenue Code	250
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$270.00
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: MDX Hawaii PPO	$436.50

CYCLOSPORINE MODIFIED 25 MG CAPSULE [28842]

Facility

$5.00

Service Code	HCPCS J7515
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

CYCLOSPORINE MODIFIED 25 MG CAPSULE [28842]

Facility

$5.00

Service Code	HCPCS J7515
Hospital Revenue Code	636
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$4.85
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.77
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
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

CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP [2032]

Facility

$127.00

Service Code	NDC 64980050448
Hospital Revenue Code	637
Min. Negotiated Rate	$64.77
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$76.20
Rate for Payer: Hawaii Western Management Group Commercial	$120.65
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$80.01
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: University Health Alliance Commercial	$92.57

CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP [2032]

Facility

$127.00

Service Code	NDC 64980050448
Hospital Revenue Code	250
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$76.20
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: MDX Hawaii PPO	$123.19

CYPROHEPTADINE 4 MG TABLET [2033]

Facility

$4.00

Service Code	NDC 70710111001
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

CYPROHEPTADINE 4 MG TABLET [2033]

Facility

$4.00

Service Code	NDC 70710111001
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
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: University Health Alliance Commercial	$2.92

CYSTIC FIBROSIS - PULMONARY DISEASE

Facility

$6,582.13

Service Code	APR-DRG 1311
Min. Negotiated Rate	$6,582.13
Max. Negotiated Rate	$6,582.13
Rate for Payer: AlohaCare Medicaid	$6,582.13
Rate for Payer: Hawaii Medical Service Association ABD	$6,582.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,582.13
Rate for Payer: Kaiser Permanente Medicaid	$6,582.13
Rate for Payer: Ohana Health Plan Medicaid	$6,582.13
Rate for Payer: UnitedHealthcare Medicaid	$6,582.13

CYSTIC FIBROSIS - PULMONARY DISEASE

Facility

$9,399.31

Service Code	APR-DRG 1312
Min. Negotiated Rate	$9,399.31
Max. Negotiated Rate	$9,399.31
Rate for Payer: AlohaCare Medicaid	$9,399.31
Rate for Payer: Hawaii Medical Service Association ABD	$9,399.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,399.31
Rate for Payer: Kaiser Permanente Medicaid	$9,399.31
Rate for Payer: Ohana Health Plan Medicaid	$9,399.31
Rate for Payer: UnitedHealthcare Medicaid	$9,399.31

CYSTIC FIBROSIS - PULMONARY DISEASE

Facility

$12,958.79

Service Code	APR-DRG 1313
Min. Negotiated Rate	$12,958.79
Max. Negotiated Rate	$12,958.79
Rate for Payer: AlohaCare Medicaid	$12,958.79
Rate for Payer: Hawaii Medical Service Association ABD	$12,958.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12,958.79
Rate for Payer: Kaiser Permanente Medicaid	$12,958.79
Rate for Payer: Ohana Health Plan Medicaid	$12,958.79
Rate for Payer: UnitedHealthcare Medicaid	$12,958.79

CYSTIC FIBROSIS - PULMONARY DISEASE

Facility

$17,504.51

Service Code	APR-DRG 1314
Min. Negotiated Rate	$17,504.51
Max. Negotiated Rate	$17,504.51
Rate for Payer: AlohaCare Medicaid	$17,504.51
Rate for Payer: Hawaii Medical Service Association ABD	$17,504.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17,504.51
Rate for Payer: Kaiser Permanente Medicaid	$17,504.51
Rate for Payer: Ohana Health Plan Medicaid	$17,504.51
Rate for Payer: UnitedHealthcare Medicaid	$17,504.51

CYSTOSTOMY, CYSTOTOMY WITH DRAINAGE

Facility

$10,679.55

Service Code	CPT 51040
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$2,469.46
Rate for Payer: AlohaCare Medicare	$2,469.46
Rate for Payer: Devoted Health Medicare	$2,716.41
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,469.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$2,469.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,469.46
Rate for Payer: Ohana Health Plan Medicaid	$2,716.41
Rate for Payer: Ohana Health Plan Medicare	$2,469.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,469.46
Rate for Payer: University Health Alliance Commercial	$10,679.55

Know your out-of-pocket cost for care.

All Charges