Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

AMPICILLIN 250 MG SOLUTION FOR INJECTION [473]

Facility

$15.00

Service Code	HCPCS J0290
Hospital Revenue Code	636
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.49
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: UnitedHealthcare Medicaid	$9.00
Rate for Payer: University Health Alliance Commercial	$10.93

AMPICILLIN 2 G IN 100 ML NS ADD-A-VIAL (SIMPLE) [4080102]

Facility

$4,264.00

Service Code	HCPCS J0290
Hospital Revenue Code	250
Min. Negotiated Rate	$3,624.40
Max. Negotiated Rate	$4,136.08
Rate for Payer: Cash Price	$2,558.40
Rate for Payer: Health Management Network Commercial	$3,624.40
Rate for Payer: MDX Hawaii PPO	$4,136.08

AMPICILLIN 2 G IN 100 ML NS ADD-A-VIAL (SIMPLE) [4080102]

Facility

$4,264.00

Service Code	HCPCS J0290
Hospital Revenue Code	636
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$4,136.08
Rate for Payer: Cash Price	$2,558.40
Rate for Payer: Cash Price	$2,558.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.49
Rate for Payer: Hawaii Western Management Group Commercial	$4,050.80
Rate for Payer: Health Management Network Commercial	$3,624.40
Rate for Payer: Kaiser Permanente Commercial	$2,686.32
Rate for Payer: Kaiser Permanente Medicaid	$2,174.64
Rate for Payer: MDX Hawaii PPO	$4,136.08
Rate for Payer: UnitedHealthcare Medicaid	$2,558.40
Rate for Payer: University Health Alliance Commercial	$3,108.03

AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [472]

Facility

$42.00

Service Code	HCPCS J0290
Hospital Revenue Code	250
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: MDX Hawaii PPO	$40.74

AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [472]

Facility

$42.00

Service Code	HCPCS J0290
Hospital Revenue Code	636
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cash Price	$25.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.49
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$26.46
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: UnitedHealthcare Medicaid	$25.20
Rate for Payer: University Health Alliance Commercial	$30.61

AMPICILLIN 500 MG CAPSULE [466]

Facility

$3.00

Service Code	NDC 00781214501
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

AMPICILLIN 500 MG CAPSULE [466]

Facility

$3.00

Service Code	NDC 00781214501
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: University Health Alliance Commercial	$2.19

AMPICILLIN 500 MG SOLUTION FOR INJECTION [474]

Facility

$16.00

Service Code	HCPCS J0290
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

AMPICILLIN 500 MG SOLUTION FOR INJECTION [474]

Facility

$16.00

Service Code	HCPCS J0290
Hospital Revenue Code	636
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$9.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.49
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: UnitedHealthcare Medicaid	$9.60
Rate for Payer: University Health Alliance Commercial	$11.66

AMPICILLIN SODIUM 1 G/8ML IJ (WET SOLR VIAL) [430469]

Facility

$26.00

Service Code	HCPCS J0290
Hospital Revenue Code	250
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: MDX Hawaii PPO	$25.22

AMPICILLIN SODIUM 1 G/8ML IJ (WET SOLR VIAL) [430469]

Facility

$26.00

Service Code	HCPCS J0290
Hospital Revenue Code	636
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$15.60
Rate for Payer: Cash Price	$15.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.49
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$16.38
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: University Health Alliance Commercial	$18.95

AMPICILLIN SODIUM 2 G/16ML IJ (WET SOLR VIAL) [430472]

Facility

$42.00

Service Code	HCPCS J0290
Hospital Revenue Code	636
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cash Price	$25.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.49
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$26.46
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: UnitedHealthcare Medicaid	$25.20
Rate for Payer: University Health Alliance Commercial	$30.61

AMPICILLIN SODIUM 2 G/16ML IJ (WET SOLR VIAL) [430472]

Facility

$42.00

Service Code	HCPCS J0290
Hospital Revenue Code	250
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: MDX Hawaii PPO	$40.74

AMPICILLIN SODIUM 500 MG/2ML IJ (WET SOLR VIAL) [430474]

Facility

$16.00

Service Code	HCPCS J0290
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

AMPICILLIN SODIUM 500 MG/2ML IJ (WET SOLR VIAL) [430474]

Facility

$16.00

Service Code	HCPCS J0290
Hospital Revenue Code	636
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$9.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.49
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: UnitedHealthcare Medicaid	$9.60
Rate for Payer: University Health Alliance Commercial	$11.66

AMPICILLIN SODIUM 500 MG/5ML IJ (WET SOLR VIAL) [43047401]

Facility

$16.00

Service Code	HCPCS J0290
Hospital Revenue Code	636
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$9.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.49
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: UnitedHealthcare Medicaid	$9.60
Rate for Payer: University Health Alliance Commercial	$11.66

AMPICILLIN SODIUM 500 MG/5ML IJ (WET SOLR VIAL) [43047401]

Facility

$16.00

Service Code	HCPCS J0290
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

AMPICILLIN-SULBACTAM 1.5 G/4ML IJ (WET SOLR VIAL) [4309083]

Facility

$18.00

Service Code	HCPCS J0295
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	$11.40
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: MDX Hawaii PPO	$18.43

AMPICILLIN-SULBACTAM 1.5 G/4ML IJ (WET SOLR VIAL) [4309083]

Facility

$19.00

Service Code	HCPCS J0295
Hospital Revenue Code	636
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$11.40
Rate for Payer: Hawaii Medical Service Association ABD	$1.49
Rate for Payer: Hawaii Medical Service Association ABD	$1.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.49
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$11.97
Rate for Payer: Kaiser Permanente Commercial	$11.34
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: UnitedHealthcare Medicaid	$11.40
Rate for Payer: University Health Alliance Commercial	$13.12
Rate for Payer: University Health Alliance Commercial	$13.85

AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION [9083]

Facility

$18.00

Service Code	HCPCS J0295
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	$11.40
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: MDX Hawaii PPO	$18.43

AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION [9083]

Facility

$19.00

Service Code	HCPCS J0295
Hospital Revenue Code	636
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Cash Price	$11.40
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$10.80
Rate for Payer: Hawaii Medical Service Association ABD	$1.49
Rate for Payer: Hawaii Medical Service Association ABD	$1.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.49
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$11.97
Rate for Payer: Kaiser Permanente Commercial	$11.34
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: UnitedHealthcare Medicaid	$11.40
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: University Health Alliance Commercial	$13.12
Rate for Payer: University Health Alliance Commercial	$13.85

AMPICILLIN-SULBACTAM 3 G/8ML IJ (WET SOLR VIAL) [4309084]

Facility

$20.00

Service Code	HCPCS J0295
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

AMPICILLIN-SULBACTAM 3 G/8ML IJ (WET SOLR VIAL) [4309084]

Facility

$20.00

Service Code	HCPCS J0295
Hospital Revenue Code	636
Min. Negotiated Rate	$1.49
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	$1.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.49
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

AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]

Facility

$20.00

Service Code	HCPCS J0295
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

AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]

Facility

$20.00

Service Code	HCPCS J0295
Hospital Revenue Code	636
Min. Negotiated Rate	$1.49
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	$1.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.49
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

Know your out-of-pocket cost for care.

All Charges