Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE [2361]

Facility

IP

$87.00

Service Code	NDC 00409177510
Hospital Revenue Code	250
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: MDX Hawaii PPO	$84.39

DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE [2361]

Facility

IP

$87.00

Service Code	NDC 00409177540
Hospital Revenue Code	250
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: MDX Hawaii PPO	$84.39

DEXTROSE 40 % ORAL GEL [81823]

Facility

OP

$14.00

Service Code	NDC 07030000000
Hospital Revenue Code	637
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$13.58
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: Kaiser Permanente Medicaid	$7.14
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: University Health Alliance Commercial	$10.20

DEXTROSE 40 % ORAL GEL [81823]

Facility

IP

$14.00

Service Code	NDC 07030000000
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

DEXTROSE 40 % ORAL GEL [81823]

Facility

OP

$10.00

Service Code	NDC 06924000000
Hospital Revenue Code	637
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: University Health Alliance Commercial	$7.29

DEXTROSE 40 % ORAL GEL [81823]

Facility

IP

$14.00

Service Code	NDC 06915000000
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

DEXTROSE 40 % ORAL GEL [81823]

Facility

IP

$10.00

Service Code	NDC 06924000000
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: MDX Hawaii PPO	$9.70

DEXTROSE 40 % ORAL GEL [81823]

Facility

IP

$14.00

Service Code	NDC 06930000000
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

DEXTROSE 40 % ORAL GEL [81823]

Facility

OP

$14.00

Service Code	NDC 06930000000
Hospital Revenue Code	637
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$13.58
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: Kaiser Permanente Medicaid	$7.14
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: University Health Alliance Commercial	$10.20

DEXTROSE 40 % ORAL GEL [81823]

Facility

OP

$10.00

Service Code	NDC 06905000000
Hospital Revenue Code	637
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: University Health Alliance Commercial	$7.29

DEXTROSE 40 % ORAL GEL [81823]

Facility

OP

$14.00

Service Code	NDC 06915000000
Hospital Revenue Code	637
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$13.58
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: Kaiser Permanente Medicaid	$7.14
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: University Health Alliance Commercial	$10.20

DEXTROSE 40 % ORAL GEL [81823]

Facility

IP

$10.00

Service Code	NDC 06905000000
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: MDX Hawaii PPO	$9.70

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION [2365]

Facility

IP

$22.00

Service Code	NDC 00409664802
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

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION [2365]

Facility

IP

$22.00

Service Code	NDC 00409664816
Hospital Revenue Code	250
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Cash Price	$26.40
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: MDX Hawaii PPO	$42.68
Rate for Payer: MDX Hawaii PPO	$21.34

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [201423]

Facility

OP

$60.00

Service Code	NDC 00409751716
Hospital Revenue Code	258
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: University Health Alliance Commercial	$43.73

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [201423]

Facility

IP

$60.00

Service Code	NDC 00409751766
Hospital Revenue Code	258
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: MDX Hawaii PPO	$58.20

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [201423]

Facility

IP

$60.00

Service Code	NDC 00409751716
Hospital Revenue Code	258
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: MDX Hawaii PPO	$58.20

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [201423]

Facility

IP

$61.00

Service Code	NDC 76329330201
Hospital Revenue Code	258
Min. Negotiated Rate	$51.85
Max. Negotiated Rate	$59.17
Rate for Payer: Cash Price	$36.60
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: MDX Hawaii PPO	$59.17

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [201423]

Facility

OP

$61.00

Service Code	NDC 76329330201
Hospital Revenue Code	258
Min. Negotiated Rate	$31.11
Max. Negotiated Rate	$59.17
Rate for Payer: Cash Price	$36.60
Rate for Payer: Hawaii Western Management Group Commercial	$57.95
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: Kaiser Permanente Commercial	$38.43
Rate for Payer: Kaiser Permanente Medicaid	$31.11
Rate for Payer: MDX Hawaii PPO	$59.17
Rate for Payer: University Health Alliance Commercial	$44.46

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [201423]

Facility

OP

$60.00

Service Code	NDC 00409751766
Hospital Revenue Code	258
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: University Health Alliance Commercial	$43.73

DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9812]

Facility

OP

$25.00

Service Code	NDC 00264761600
Hospital Revenue Code	258
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Hawaii Western Management Group Commercial	$23.75
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$15.75
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: University Health Alliance Commercial	$18.22

DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9812]

Facility

IP

$25.00

Service Code	NDC 00264761600
Hospital Revenue Code	258
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: MDX Hawaii PPO	$24.25

DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9814]

Facility

IP

$14.00

Service Code	NDC 00264761200
Hospital Revenue Code	258
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

DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9814]

Facility

IP

$16.00

Service Code	NDC 00264761210
Hospital Revenue Code	258
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

DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9814]

Facility

OP

$14.00

Service Code	NDC 00264761200
Hospital Revenue Code	258
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$13.58
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: Kaiser Permanente Medicaid	$7.14
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: University Health Alliance Commercial	$10.20

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