Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

AMLODIPINE TABLETS (NORVASC) 5 MG (TAKE HOME) [4080332]

Facility

$15.00

Service Code	NDC 00004080120
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

AMMONIUM LACTATE 12 % LOTION [10380]

Facility

$134.00

Service Code	NDC 98426000000
Hospital Revenue Code	637
Min. Negotiated Rate	$68.34
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$80.40
Rate for Payer: Hawaii Western Management Group Commercial	$127.30
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: University Health Alliance Commercial	$97.67

AMMONIUM LACTATE 12 % LOTION [10380]

Facility

$134.00

Service Code	NDC 98426000000
Hospital Revenue Code	250
Min. Negotiated Rate	$113.90
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$80.40
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: MDX Hawaii PPO	$129.98

AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION [453]

Facility

$15.00

Service Code	NDC 00143988815
Hospital Revenue Code	250
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

AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION [453]

Facility

$15.00

Service Code	NDC 00143988815
Hospital Revenue Code	637
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

AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [454]

Facility

$22.00

Service Code	NDC 00143988915
Hospital Revenue Code	250
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: MDX Hawaii PPO	$21.34

AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [454]

Facility

$22.00

Service Code	NDC 00143988915
Hospital Revenue Code	637
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Kaiser Permanente Commercial	$13.86
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: University Health Alliance Commercial	$16.04

AMOXICILLIN 250 MG CAPSULE [450]

Facility

$1.00

Service Code	NDC 00781202001
Hospital Revenue Code	637
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: University Health Alliance Commercial	$0.73

AMOXICILLIN 250 MG CAPSULE [450]

Facility

$1.00

Service Code	NDC 00781202001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: MDX Hawaii PPO	$0.97

AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [25246]

Facility

$30.00

Service Code	NDC 00093416173
Hospital Revenue Code	637
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
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: University Health Alliance Commercial	$21.87

AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [25246]

Facility

$30.00

Service Code	NDC 00143988701
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

AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [25246]

Facility

$30.00

Service Code	NDC 00093416173
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

AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [25246]

Facility

$30.00

Service Code	NDC 00143988701
Hospital Revenue Code	637
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
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: University Health Alliance Commercial	$21.87

AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [33230]

Facility

$138.00

Service Code	NDC 65862053401
Hospital Revenue Code	250
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$133.86
Rate for Payer: Cash Price	$82.80
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: MDX Hawaii PPO	$133.86

AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [33230]

Facility

$138.00

Service Code	NDC 65862053401
Hospital Revenue Code	637
Min. Negotiated Rate	$70.38
Max. Negotiated Rate	$133.86
Rate for Payer: Cash Price	$82.80
Rate for Payer: Hawaii Western Management Group Commercial	$131.10
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Kaiser Permanente Commercial	$86.94
Rate for Payer: Kaiser Permanente Medicaid	$70.38
Rate for Payer: MDX Hawaii PPO	$133.86
Rate for Payer: University Health Alliance Commercial	$100.59

AMOXICILLIN 500 MG CAPSULE [451]

Facility

$2.00

Service Code	NDC 00781261301
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

AMOXICILLIN 500 MG CAPSULE [451]

Facility

$2.00

Service Code	NDC 65862001701
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

AMOXICILLIN 500 MG CAPSULE [451]

Facility

$2.00

Service Code	NDC 65862001701
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

AMOXICILLIN 500 MG CAPSULE [451]

Facility

$2.00

Service Code	NDC 00781261301
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]

Facility

$7.00

Service Code	NDC 60687079211
Hospital Revenue Code	637
Min. Negotiated Rate	$3.57
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
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: University Health Alliance Commercial	$5.10

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]

Facility

$7.00

Service Code	NDC 60687079211
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

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]

Facility

$14.00

Service Code	NDC 65862050220
Hospital Revenue Code	637
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$13.58
Rate for Payer: Kaiser Permanente Medicaid	$7.14
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: MDX Hawaii PPO	$13.58
Rate for Payer: University Health Alliance Commercial	$10.20

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]

Facility

$14.00

Service Code	NDC 65862050220
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

AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION [31177]

Facility

$104.00

Service Code	NDC 00781613957
Hospital Revenue Code	637
Min. Negotiated Rate	$53.04
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$62.40
Rate for Payer: Hawaii Western Management Group Commercial	$98.80
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$65.52
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: University Health Alliance Commercial	$75.81

AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION [31177]

Facility

$104.00

Service Code	NDC 00781613957
Hospital Revenue Code	250
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: MDX Hawaii PPO	$100.88

Know your out-of-pocket cost for care.

All Charges