Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [127964]

Facility

$14,938.00

Service Code	HCPCS J9271
Hospital Revenue Code	636
Min. Negotiated Rate	$58.56
Max. Negotiated Rate	$14,489.86
Rate for Payer: AlohaCare Medicaid	$61.25
Rate for Payer: AlohaCare Medicaid	$61.25
Rate for Payer: AlohaCare Medicare	$61.25
Rate for Payer: AlohaCare Medicare	$61.25
Rate for Payer: Cash Price	$8,962.80
Rate for Payer: Cash Price	$4,631.40
Rate for Payer: Cash Price	$8,962.80
Rate for Payer: Cash Price	$4,631.40
Rate for Payer: Devoted Health Medicare	$67.38
Rate for Payer: Devoted Health Medicare	$67.38
Rate for Payer: Hawaii Medical Service Association ABD	$58.56
Rate for Payer: Hawaii Medical Service Association ABD	$58.56
Rate for Payer: Hawaii Medical Service Association Commercial	$76.56
Rate for Payer: Hawaii Medical Service Association Commercial	$76.56
Rate for Payer: Hawaii Medical Service Association Medicare	$61.25
Rate for Payer: Hawaii Medical Service Association Medicare	$61.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$58.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$58.56
Rate for Payer: Hawaii Western Management Group Commercial	$14,191.10
Rate for Payer: Hawaii Western Management Group Commercial	$7,333.05
Rate for Payer: Health Management Network Commercial	$12,697.30
Rate for Payer: Health Management Network Commercial	$6,561.15
Rate for Payer: Humana Medicare	$61.25
Rate for Payer: Humana Medicare	$61.25
Rate for Payer: Kaiser Permanente Commercial	$4,862.97
Rate for Payer: Kaiser Permanente Commercial	$9,410.94
Rate for Payer: Kaiser Permanente Medicaid	$3,936.69
Rate for Payer: Kaiser Permanente Medicaid	$7,618.38
Rate for Payer: Kaiser Permanente Medicare	$61.25
Rate for Payer: Kaiser Permanente Medicare	$61.25
Rate for Payer: MDX Hawaii PPO	$7,487.43
Rate for Payer: MDX Hawaii PPO	$14,489.86
Rate for Payer: Ohana Health Plan Medicaid	$67.38
Rate for Payer: Ohana Health Plan Medicaid	$67.38
Rate for Payer: Ohana Health Plan Medicare	$61.25
Rate for Payer: Ohana Health Plan Medicare	$61.25
Rate for Payer: UnitedHealthcare Medicaid	$8,962.80
Rate for Payer: UnitedHealthcare Medicaid	$4,631.40
Rate for Payer: UnitedHealthcare Medicare	$61.25
Rate for Payer: UnitedHealthcare Medicare	$61.25
Rate for Payer: University Health Alliance Commercial	$10,888.31
Rate for Payer: University Health Alliance Commercial	$5,626.38

PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [127964]

Facility

$7,719.00

Service Code	HCPCS J9271
Hospital Revenue Code	250
Min. Negotiated Rate	$6,561.15
Max. Negotiated Rate	$7,487.43
Rate for Payer: Cash Price	$4,631.40
Rate for Payer: Cash Price	$8,962.80
Rate for Payer: Health Management Network Commercial	$12,697.30
Rate for Payer: Health Management Network Commercial	$6,561.15
Rate for Payer: MDX Hawaii PPO	$7,487.43
Rate for Payer: MDX Hawaii PPO	$14,489.86

PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]

Facility

$90.00

Service Code	HCPCS J9305
Hospital Revenue Code	250
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$54.00
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: MDX Hawaii PPO	$87.30

PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]

Facility

$90.00

Service Code	HCPCS J9305
Hospital Revenue Code	636
Min. Negotiated Rate	$3.73
Max. Negotiated Rate	$87.30
Rate for Payer: AlohaCare Medicaid	$4.04
Rate for Payer: AlohaCare Medicare	$4.04
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Devoted Health Medicare	$4.44
Rate for Payer: Hawaii Medical Service Association ABD	$3.73
Rate for Payer: Hawaii Medical Service Association Commercial	$5.05
Rate for Payer: Hawaii Medical Service Association Medicare	$4.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.73
Rate for Payer: Hawaii Western Management Group Commercial	$85.50
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Humana Medicare	$4.04
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$45.90
Rate for Payer: Kaiser Permanente Medicare	$4.04
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: Ohana Health Plan Medicaid	$4.44
Rate for Payer: Ohana Health Plan Medicare	$4.04
Rate for Payer: UnitedHealthcare Medicaid	$54.00
Rate for Payer: UnitedHealthcare Medicare	$4.04
Rate for Payer: University Health Alliance Commercial	$65.60

PEMETREXED DISODIUM 500 MG/20ML IV (WET SOLR VIAL) [43037894]

Facility

$270.00

Service Code	HCPCS J9305
Hospital Revenue Code	636
Min. Negotiated Rate	$3.73
Max. Negotiated Rate	$261.90
Rate for Payer: AlohaCare Medicaid	$4.04
Rate for Payer: AlohaCare Medicare	$4.04
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Devoted Health Medicare	$4.44
Rate for Payer: Hawaii Medical Service Association ABD	$3.73
Rate for Payer: Hawaii Medical Service Association Commercial	$5.05
Rate for Payer: Hawaii Medical Service Association Medicare	$4.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.73
Rate for Payer: Hawaii Western Management Group Commercial	$256.50
Rate for Payer: Health Management Network Commercial	$229.50
Rate for Payer: Humana Medicare	$4.04
Rate for Payer: Kaiser Permanente Commercial	$170.10
Rate for Payer: Kaiser Permanente Medicaid	$137.70
Rate for Payer: Kaiser Permanente Medicare	$4.04
Rate for Payer: MDX Hawaii PPO	$261.90
Rate for Payer: Ohana Health Plan Medicaid	$4.44
Rate for Payer: Ohana Health Plan Medicare	$4.04
Rate for Payer: UnitedHealthcare Medicaid	$162.00
Rate for Payer: UnitedHealthcare Medicare	$4.04
Rate for Payer: University Health Alliance Commercial	$196.80

PEMETREXED DISODIUM 500 MG/20ML IV (WET SOLR VIAL) [43037894]

Facility

$270.00

Service Code	HCPCS J9305
Hospital Revenue Code	250
Min. Negotiated Rate	$229.50
Max. Negotiated Rate	$261.90
Rate for Payer: Cash Price	$162.00
Rate for Payer: Health Management Network Commercial	$229.50
Rate for Payer: MDX Hawaii PPO	$261.90

PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]

Facility

$270.00

Service Code	HCPCS J9305
Hospital Revenue Code	250
Min. Negotiated Rate	$229.50
Max. Negotiated Rate	$261.90
Rate for Payer: Cash Price	$162.00
Rate for Payer: Health Management Network Commercial	$229.50
Rate for Payer: MDX Hawaii PPO	$261.90

PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]

Facility

$270.00

Service Code	HCPCS J9305
Hospital Revenue Code	636
Min. Negotiated Rate	$3.73
Max. Negotiated Rate	$261.90
Rate for Payer: AlohaCare Medicaid	$4.04
Rate for Payer: AlohaCare Medicare	$4.04
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Devoted Health Medicare	$4.44
Rate for Payer: Hawaii Medical Service Association ABD	$3.73
Rate for Payer: Hawaii Medical Service Association Commercial	$5.05
Rate for Payer: Hawaii Medical Service Association Medicare	$4.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.73
Rate for Payer: Hawaii Western Management Group Commercial	$256.50
Rate for Payer: Health Management Network Commercial	$229.50
Rate for Payer: Humana Medicare	$4.04
Rate for Payer: Kaiser Permanente Commercial	$170.10
Rate for Payer: Kaiser Permanente Medicaid	$137.70
Rate for Payer: Kaiser Permanente Medicare	$4.04
Rate for Payer: MDX Hawaii PPO	$261.90
Rate for Payer: Ohana Health Plan Medicaid	$4.44
Rate for Payer: Ohana Health Plan Medicare	$4.04
Rate for Payer: UnitedHealthcare Medicaid	$162.00
Rate for Payer: UnitedHealthcare Medicare	$4.04
Rate for Payer: University Health Alliance Commercial	$196.80

PENCIL SMOKE EVACUATION ROCKER

Facility

$207.00

Hospital Revenue Code	272
Min. Negotiated Rate	$105.57
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$124.20
Rate for Payer: Hawaii Western Management Group Commercial	$196.65
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$130.41
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: University Health Alliance Commercial	$150.88

PENCIL SMOKE EVACUATION ROCKER

Facility

$207.00

Hospital Revenue Code	272
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$124.20
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: MDX Hawaii PPO	$200.79

PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [183757]

Facility

$665.00

Service Code	HCPCS J0561
Hospital Revenue Code	250
Min. Negotiated Rate	$565.25
Max. Negotiated Rate	$645.05
Rate for Payer: Cash Price	$399.00
Rate for Payer: Health Management Network Commercial	$565.25
Rate for Payer: MDX Hawaii PPO	$645.05

PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [183757]

Facility

$665.00

Service Code	HCPCS J0561
Hospital Revenue Code	636
Min. Negotiated Rate	$29.30
Max. Negotiated Rate	$645.05
Rate for Payer: AlohaCare Medicaid	$31.47
Rate for Payer: AlohaCare Medicare	$31.47
Rate for Payer: Cash Price	$399.00
Rate for Payer: Cash Price	$399.00
Rate for Payer: Devoted Health Medicare	$34.62
Rate for Payer: Hawaii Medical Service Association ABD	$29.30
Rate for Payer: Hawaii Medical Service Association Commercial	$39.34
Rate for Payer: Hawaii Medical Service Association Medicare	$31.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29.30
Rate for Payer: Hawaii Western Management Group Commercial	$631.75
Rate for Payer: Health Management Network Commercial	$565.25
Rate for Payer: Humana Medicare	$31.47
Rate for Payer: Kaiser Permanente Commercial	$418.95
Rate for Payer: Kaiser Permanente Medicaid	$339.15
Rate for Payer: Kaiser Permanente Medicare	$31.47
Rate for Payer: MDX Hawaii PPO	$645.05
Rate for Payer: Ohana Health Plan Medicaid	$34.62
Rate for Payer: Ohana Health Plan Medicare	$31.47
Rate for Payer: UnitedHealthcare Medicaid	$399.00
Rate for Payer: UnitedHealthcare Medicare	$31.47
Rate for Payer: University Health Alliance Commercial	$484.72

PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK [10900]

Facility

$45.00

Service Code	HCPCS J2540
Hospital Revenue Code	250
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$27.00
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: MDX Hawaii PPO	$43.65

PENICILLIN G POTASSIUM 20,000,000 UNITS/40ML IJ (WET SOLR VIAL) [430608501]

Facility

$147.00

Service Code	HCPCS J2540
Hospital Revenue Code	636
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cash Price	$73.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.88
Rate for Payer: Hawaii Medical Service Association ABD	$0.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.88
Rate for Payer: Hawaii Western Management Group Commercial	$116.85
Rate for Payer: Hawaii Western Management Group Commercial	$139.65
Rate for Payer: Health Management Network Commercial	$104.55
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Kaiser Permanente Commercial	$92.61
Rate for Payer: Kaiser Permanente Commercial	$77.49
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: Kaiser Permanente Medicaid	$62.73
Rate for Payer: MDX Hawaii PPO	$119.31
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: UnitedHealthcare Medicaid	$88.20
Rate for Payer: UnitedHealthcare Medicaid	$73.80
Rate for Payer: University Health Alliance Commercial	$89.65
Rate for Payer: University Health Alliance Commercial	$107.15

PENICILLIN G POTASSIUM 20,000,000 UNITS/40ML IJ (WET SOLR VIAL) [430608501]

Facility

$123.00

Service Code	HCPCS J2540
Hospital Revenue Code	250
Min. Negotiated Rate	$104.55
Max. Negotiated Rate	$119.31
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cash Price	$88.20
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Health Management Network Commercial	$104.55
Rate for Payer: MDX Hawaii PPO	$119.31
Rate for Payer: MDX Hawaii PPO	$142.59

PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]

Facility

$123.00

Service Code	HCPCS J2540
Hospital Revenue Code	250
Min. Negotiated Rate	$104.55
Max. Negotiated Rate	$119.31
Rate for Payer: Cash Price	$73.80
Rate for Payer: Health Management Network Commercial	$104.55
Rate for Payer: MDX Hawaii PPO	$119.31

PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]

Facility

$123.00

Service Code	HCPCS J2540
Hospital Revenue Code	636
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$119.31
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cash Price	$73.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.88
Rate for Payer: Hawaii Western Management Group Commercial	$116.85
Rate for Payer: Health Management Network Commercial	$104.55
Rate for Payer: Kaiser Permanente Commercial	$77.49
Rate for Payer: Kaiser Permanente Medicaid	$62.73
Rate for Payer: MDX Hawaii PPO	$119.31
Rate for Payer: UnitedHealthcare Medicaid	$73.80
Rate for Payer: University Health Alliance Commercial	$89.65

PENICILLIN G POTASSIUM 5,000,000 UNITS/5ML IJ (WET SOLR VIAL) [4306086]

Facility

$23.00

Service Code	HCPCS J2540
Hospital Revenue Code	636
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Cash Price	$13.80
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.88
Rate for Payer: Hawaii Medical Service Association ABD	$0.88
Rate for Payer: Hawaii Medical Service Association ABD	$0.88
Rate for Payer: Hawaii Medical Service Association ABD	$0.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.88
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Hawaii Western Management Group Commercial	$37.05
Rate for Payer: Hawaii Western Management Group Commercial	$19.00
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Kaiser Permanente Commercial	$14.49
Rate for Payer: Kaiser Permanente Commercial	$24.57
Rate for Payer: Kaiser Permanente Commercial	$19.53
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$19.89
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicaid	$10.20
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: UnitedHealthcare Medicaid	$13.80
Rate for Payer: UnitedHealthcare Medicaid	$23.40
Rate for Payer: UnitedHealthcare Medicaid	$18.60
Rate for Payer: UnitedHealthcare Medicaid	$12.00
Rate for Payer: University Health Alliance Commercial	$28.43
Rate for Payer: University Health Alliance Commercial	$14.58
Rate for Payer: University Health Alliance Commercial	$16.76
Rate for Payer: University Health Alliance Commercial	$22.60

PENICILLIN G POTASSIUM 5,000,000 UNITS/5ML IJ (WET SOLR VIAL) [4306086]

Facility

$23.00

Service Code	HCPCS J2540
Hospital Revenue Code	250
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$23.40
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: MDX Hawaii PPO	$37.83

PENICILLIN G POTASSIUM 5 MILLION UNIT/100 ML NS ADD-A-VIAL (SIMPLE) [4080099]

Facility

$55.00

Service Code	HCPCS J2540
Hospital Revenue Code	250
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$33.00
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: MDX Hawaii PPO	$53.35

PENICILLIN G POTASSIUM 5 MILLION UNIT/100 ML NS ADD-A-VIAL (SIMPLE) [4080099]

Facility

$55.00

Service Code	HCPCS J2540
Hospital Revenue Code	636
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$33.00
Rate for Payer: Cash Price	$33.00
Rate for Payer: Hawaii Medical Service Association ABD	$0.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.88
Rate for Payer: Hawaii Western Management Group Commercial	$52.25
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Kaiser Permanente Commercial	$34.65
Rate for Payer: Kaiser Permanente Medicaid	$28.05
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: UnitedHealthcare Medicaid	$33.00
Rate for Payer: University Health Alliance Commercial	$40.09

PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]

Facility

$23.00

Service Code	HCPCS J2540
Hospital Revenue Code	636
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Cash Price	$13.80
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.88
Rate for Payer: Hawaii Medical Service Association ABD	$0.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.88
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Hawaii Western Management Group Commercial	$37.05
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Kaiser Permanente Commercial	$14.49
Rate for Payer: Kaiser Permanente Commercial	$24.57
Rate for Payer: Kaiser Permanente Medicaid	$19.89
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: UnitedHealthcare Medicaid	$13.80
Rate for Payer: UnitedHealthcare Medicaid	$23.40
Rate for Payer: University Health Alliance Commercial	$16.76
Rate for Payer: University Health Alliance Commercial	$28.43

PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]

Facility

$39.00

Service Code	HCPCS J2540
Hospital Revenue Code	250
Min. Negotiated Rate	$33.15
Max. Negotiated Rate	$37.83
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$13.80
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: MDX Hawaii PPO	$22.31

PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6087]

Facility

$116.00

Service Code	NDC 00781615395
Hospital Revenue Code	250
Min. Negotiated Rate	$98.60
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: MDX Hawaii PPO	$112.52

PENICILLIN VK TABLETS (VEETIDS) 500 MG (TAKE HOME) [4080387]

Facility

$15.00

Service Code	NDC 00004080175
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

Know your out-of-pocket cost for care.

All Charges