Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [9009]

Facility

OP

$14.00

Service Code	NDC 57237031603
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

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [9009]

Facility

IP

$14.00

Service Code	NDC 00121176130
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

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [9009]

Facility

IP

$15.00

Service Code	NDC 00536129383
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

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9014]

Facility

OP

$17.00

Service Code	NDC 00536001583
Hospital Revenue Code	637
Min. Negotiated Rate	$8.67
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$10.71
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: University Health Alliance Commercial	$12.39

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9014]

Facility

IP

$16.00

Service Code	NDC 00121176230
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

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9014]

Facility

IP

$17.00

Service Code	NDC 00536001583
Hospital Revenue Code	250
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: MDX Hawaii PPO	$16.49

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9014]

Facility

OP

$16.00

Service Code	NDC 00121176230
Hospital Revenue Code	637
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
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: University Health Alliance Commercial	$11.66

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

IP

$8.00

Service Code	NDC 60687042201
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

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

IP

$13.00

Service Code	NDC 50268006915
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: MDX Hawaii PPO	$12.61

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

IP

$8.00

Service Code	NDC 60687042211
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

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

OP

$13.00

Service Code	NDC 50268006915
Hospital Revenue Code	637
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$8.19
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: University Health Alliance Commercial	$9.48

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

OP

$8.00

Service Code	NDC 60687042201
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

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

OP

$8.00

Service Code	NDC 60687042211
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

AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [180668]

Facility

OP

$144.00

Service Code	NDC 00121064616
Hospital Revenue Code	637
Min. Negotiated Rate	$73.44
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$86.40
Rate for Payer: Hawaii Western Management Group Commercial	$136.80
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Kaiser Permanente Commercial	$90.72
Rate for Payer: Kaiser Permanente Medicaid	$73.44
Rate for Payer: MDX Hawaii PPO	$139.68
Rate for Payer: University Health Alliance Commercial	$104.96

AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [180668]

Facility

IP

$144.00

Service Code	NDC 00121064616
Hospital Revenue Code	250
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: MDX Hawaii PPO	$139.68

AMBIENT HIPVAC 50 IFS

Facility

OP

$1,500.00

Hospital Revenue Code	272
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,425.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: Kaiser Permanente Commercial	$945.00
Rate for Payer: Kaiser Permanente Medicaid	$765.00
Rate for Payer: MDX Hawaii PPO	$1,455.00
Rate for Payer: University Health Alliance Commercial	$1,093.35

AMBIENT HIPVAC 50 IFS

Facility

IP

$1,500.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,275.00
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Health Management Network Commercial	$1,275.00
Rate for Payer: MDX Hawaii PPO	$1,455.00

AMIKACIN 500 MG/2 ML INJECTION SOLUTION [108131]

Facility

IP

$32.00

Service Code	HCPCS J0278
Hospital Revenue Code	250
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cash Price	$24.60
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: MDX Hawaii PPO	$39.77
Rate for Payer: MDX Hawaii PPO	$13.58

AMIKACIN 500 MG/2 ML INJECTION SOLUTION [108131]

Facility

OP

$14.00

Service Code	HCPCS J0278
Hospital Revenue Code	636
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$24.60
Rate for Payer: Cash Price	$24.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.62
Rate for Payer: Hawaii Medical Service Association ABD	$0.62
Rate for Payer: Hawaii Medical Service Association ABD	$0.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Hawaii Western Management Group Commercial	$38.95
Rate for Payer: Hawaii Western Management Group Commercial	$30.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Kaiser Permanente Commercial	$8.82
Rate for Payer: Kaiser Permanente Commercial	$20.16
Rate for Payer: Kaiser Permanente Commercial	$25.83
Rate for Payer: Kaiser Permanente Medicaid	$20.91
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: MDX Hawaii PPO	$39.77
Rate for Payer: UnitedHealthcare Medicaid	$19.20
Rate for Payer: UnitedHealthcare Medicaid	$24.60
Rate for Payer: UnitedHealthcare Medicaid	$8.40
Rate for Payer: University Health Alliance Commercial	$23.32
Rate for Payer: University Health Alliance Commercial	$29.88
Rate for Payer: University Health Alliance Commercial	$10.20

AMILORIDE 5 MG TABLET [391]

Facility

IP

$1.00

Service Code	NDC 00574029201
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

AMILORIDE 5 MG TABLET [391]

Facility

OP

$1.00

Service Code	NDC 00574029201
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

AMINO ACID 4.25 % NO.1-DEXTROSE 5 %-ELECTROLYTES NO.39 IV SOLUTION [23162]

Facility

IP

$182.00

Service Code	NDC 00338702201
Hospital Revenue Code	250
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$176.54
Rate for Payer: Cash Price	$109.20
Rate for Payer: Health Management Network Commercial	$154.70
Rate for Payer: MDX Hawaii PPO	$176.54

AMINO ACID 4.25 % NO.1-DEXTROSE 5 %-ELECTROLYTES NO.39 IV SOLUTION [23162]

Facility

IP

$182.00

Service Code	NDC 00338702206
Hospital Revenue Code	250
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$176.54
Rate for Payer: Cash Price	$109.20
Rate for Payer: Health Management Network Commercial	$154.70
Rate for Payer: MDX Hawaii PPO	$176.54

AMINO ACID 4.25 % NO.1-DEXTROSE 5 %-ELECTROLYTES NO.39 IV SOLUTION [23162]

Facility

IP

$182.00

Service Code	NDC 00338114403
Hospital Revenue Code	250
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$176.54
Rate for Payer: Cash Price	$109.20
Rate for Payer: Cash Price	$218.40
Rate for Payer: Health Management Network Commercial	$154.70
Rate for Payer: Health Management Network Commercial	$309.40
Rate for Payer: MDX Hawaii PPO	$176.54
Rate for Payer: MDX Hawaii PPO	$353.08

AMINO ACID 4.25 % NO.1 IN DEXTROSE 5 % INTRAVENOUS SOLUTION [25749]

Facility

IP

$161.00

Service Code	NDC 00338113303
Hospital Revenue Code	250
Min. Negotiated Rate	$136.85
Max. Negotiated Rate	$156.17
Rate for Payer: Cash Price	$96.60
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: MDX Hawaii PPO	$156.17

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