Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

OP

$3.00

Service Code	NDC 51079014120
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

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

OP

$3.00

Service Code	NDC 60687080701
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

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

OP

$3.00

Service Code	NDC 60687080711
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

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

OP

$2.00

Service Code	NDC 00555015902
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

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

IP

$3.00

Service Code	NDC 51079014120
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

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

IP

$3.00

Service Code	NDC 60687080711
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

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

IP

$2.00

Service Code	NDC 00555015902
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

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

OP

$8.00

Service Code	NDC 69339013817
Hospital Revenue Code	637
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: University Health Alliance Commercial	$5.83

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

OP

$497.00

Service Code	NDC 00116200116
Hospital Revenue Code	637
Min. Negotiated Rate	$253.47
Max. Negotiated Rate	$482.09
Rate for Payer: Cash Price	$298.20
Rate for Payer: Hawaii Western Management Group Commercial	$472.15
Rate for Payer: Health Management Network Commercial	$422.45
Rate for Payer: Kaiser Permanente Commercial	$313.11
Rate for Payer: Kaiser Permanente Medicaid	$253.47
Rate for Payer: MDX Hawaii PPO	$482.09
Rate for Payer: University Health Alliance Commercial	$362.26

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

IP

$42.00

Service Code	NDC 16571012848
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

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

IP

$8.00

Service Code	NDC 69339013815
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$7.76

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

OP

$8.00

Service Code	NDC 69339013815
Hospital Revenue Code	637
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: University Health Alliance Commercial	$5.83

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

OP

$32.00

Service Code	NDC 00126027216
Hospital Revenue Code	637
Min. Negotiated Rate	$16.32
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Hawaii Western Management Group Commercial	$30.40
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Kaiser Permanente Commercial	$20.16
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: University Health Alliance Commercial	$23.32

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

OP

$42.00

Service Code	NDC 16571012848
Hospital Revenue Code	637
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
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: University Health Alliance Commercial	$30.61

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

OP

$8.00

Service Code	NDC 63739005274
Hospital Revenue Code	637
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: University Health Alliance Commercial	$5.83

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

IP

$8.00

Service Code	NDC 63739005274
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$7.76

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

IP

$32.00

Service Code	NDC 00126027216
Hospital Revenue Code	250
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: MDX Hawaii PPO	$31.04

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

IP

$497.00

Service Code	NDC 00116200116
Hospital Revenue Code	250
Min. Negotiated Rate	$422.45
Max. Negotiated Rate	$482.09
Rate for Payer: Cash Price	$298.20
Rate for Payer: Health Management Network Commercial	$422.45
Rate for Payer: MDX Hawaii PPO	$482.09

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]

Facility

IP

$8.00

Service Code	NDC 69339013817
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: MDX Hawaii PPO	$7.76

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]

Facility

OP

$73.00

Service Code	NDC 67618020030
Hospital Revenue Code	637
Min. Negotiated Rate	$37.23
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$43.80
Rate for Payer: Hawaii Western Management Group Commercial	$69.35
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Kaiser Permanente Commercial	$45.99
Rate for Payer: Kaiser Permanente Medicaid	$37.23
Rate for Payer: MDX Hawaii PPO	$70.81
Rate for Payer: University Health Alliance Commercial	$53.21

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]

Facility

OP

$28.00

Service Code	NDC 67618020004
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

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]

Facility

IP

$40.00

Service Code	NDC 16571011148
Hospital Revenue Code	250
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: MDX Hawaii PPO	$38.80

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]

Facility

IP

$28.00

Service Code	NDC 67618020004
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: MDX Hawaii PPO	$27.16

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]

Facility

OP

$40.00

Service Code	NDC 16571011148
Hospital Revenue Code	637
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Hawaii Western Management Group Commercial	$38.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$20.40
Rate for Payer: MDX Hawaii PPO	$38.80
Rate for Payer: University Health Alliance Commercial	$29.16

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]

Facility

IP

$73.00

Service Code	NDC 67618020030
Hospital Revenue Code	250
Min. Negotiated Rate	$62.05
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$43.80
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: MDX Hawaii PPO	$70.81

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