Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

FAMOTIDINE 20 MG TABLET [10011]

Facility

OP

$6.00

Service Code	NDC 50268030315
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

FAMOTIDINE 20 MG TABLET [10011]

Facility

IP

$1.00

Service Code	NDC 00904719306
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

FAMOTIDINE 20 MG TABLET [10011]

Facility

IP

$1.00

Service Code	NDC 00904719361
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

FAMOTIDINE 20 MG TABLET [10011]

Facility

IP

$6.00

Service Code	NDC 50268030315
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

FAMOTIDINE 20 MG TABLET [10011]

Facility

IP

$1.00

Service Code	NDC 60687059501
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

FAMOTIDINE 20 MG TABLET [10011]

Facility

OP

$1.00

Service Code	NDC 00904719306
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

FAMOTIDINE 20 MG TABLET [10011]

Facility

OP

$1.00

Service Code	NDC 00904719361
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

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

OP

$266.00

Service Code	NDC 27241024949
Hospital Revenue Code	637
Min. Negotiated Rate	$135.66
Max. Negotiated Rate	$258.02
Rate for Payer: Cash Price	$159.60
Rate for Payer: Hawaii Western Management Group Commercial	$252.70
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Kaiser Permanente Commercial	$167.58
Rate for Payer: Kaiser Permanente Medicaid	$135.66
Rate for Payer: MDX Hawaii PPO	$258.02
Rate for Payer: University Health Alliance Commercial	$193.89

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

IP

$266.00

Service Code	NDC 00832604550
Hospital Revenue Code	250
Min. Negotiated Rate	$226.10
Max. Negotiated Rate	$258.02
Rate for Payer: Cash Price	$159.60
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: MDX Hawaii PPO	$258.02

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

OP

$266.00

Service Code	NDC 00832604550
Hospital Revenue Code	637
Min. Negotiated Rate	$135.66
Max. Negotiated Rate	$258.02
Rate for Payer: Cash Price	$159.60
Rate for Payer: Hawaii Western Management Group Commercial	$252.70
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Kaiser Permanente Commercial	$167.58
Rate for Payer: Kaiser Permanente Medicaid	$135.66
Rate for Payer: MDX Hawaii PPO	$258.02
Rate for Payer: University Health Alliance Commercial	$193.89

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

IP

$266.00

Service Code	NDC 68382044405
Hospital Revenue Code	250
Min. Negotiated Rate	$226.10
Max. Negotiated Rate	$258.02
Rate for Payer: Cash Price	$159.60
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: MDX Hawaii PPO	$258.02

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

OP

$266.00

Service Code	NDC 68382044405
Hospital Revenue Code	637
Min. Negotiated Rate	$135.66
Max. Negotiated Rate	$258.02
Rate for Payer: Cash Price	$159.60
Rate for Payer: Hawaii Western Management Group Commercial	$252.70
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Kaiser Permanente Commercial	$167.58
Rate for Payer: Kaiser Permanente Medicaid	$135.66
Rate for Payer: MDX Hawaii PPO	$258.02
Rate for Payer: University Health Alliance Commercial	$193.89

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

IP

$266.00

Service Code	NDC 27241024949
Hospital Revenue Code	250
Min. Negotiated Rate	$226.10
Max. Negotiated Rate	$258.02
Rate for Payer: Cash Price	$159.60
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: MDX Hawaii PPO	$258.02

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [183771]

Facility

IP

$5.00

Service Code	HCPCS J1308
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: MDX Hawaii PPO	$3.88

FAMOTIDINE TABLETS (PEPCID) 20 MG (TAKE HOME) [4080361]

Facility

OP

$15.00

Service Code	NDC 00004080149
Hospital Revenue Code	253
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
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: University Health Alliance Commercial	$10.93

FAMOTIDINE TABLETS (PEPCID) 20 MG (TAKE HOME) [4080361]

Facility

IP

$15.00

Service Code	NDC 00004080149
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

FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION [170526]

Facility

OP

$4,204.00

Service Code	HCPCS J9358
Hospital Revenue Code	636
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$4,077.88
Rate for Payer: AlohaCare Medicaid	$31.26
Rate for Payer: AlohaCare Medicare	$31.26
Rate for Payer: Cash Price	$2,522.40
Rate for Payer: Cash Price	$2,522.40
Rate for Payer: Devoted Health Medicare	$34.39
Rate for Payer: Hawaii Medical Service Association ABD	$30.00
Rate for Payer: Hawaii Medical Service Association Commercial	$39.08
Rate for Payer: Hawaii Medical Service Association Medicare	$31.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,993.80
Rate for Payer: Health Management Network Commercial	$3,573.40
Rate for Payer: Humana Medicare	$31.26
Rate for Payer: Kaiser Permanente Commercial	$2,648.52
Rate for Payer: Kaiser Permanente Medicaid	$2,144.04
Rate for Payer: Kaiser Permanente Medicare	$31.26
Rate for Payer: MDX Hawaii PPO	$4,077.88
Rate for Payer: Ohana Health Plan Medicaid	$34.39
Rate for Payer: Ohana Health Plan Medicare	$31.26
Rate for Payer: UnitedHealthcare Medicaid	$2,522.40
Rate for Payer: UnitedHealthcare Medicare	$31.26
Rate for Payer: University Health Alliance Commercial	$3,064.30

FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION [170526]

Facility

IP

$4,204.00

Service Code	HCPCS J9358
Hospital Revenue Code	250
Min. Negotiated Rate	$3,573.40
Max. Negotiated Rate	$4,077.88
Rate for Payer: Cash Price	$2,522.40
Rate for Payer: Health Management Network Commercial	$3,573.40
Rate for Payer: MDX Hawaii PPO	$4,077.88

FAM-TRASTUZUMAB DERUXTEC-NXKI 100 MG/5ML IV (WET SOLR VIAL) [430170526]

Facility

IP

$4,204.00

Service Code	HCPCS J9358
Hospital Revenue Code	250
Min. Negotiated Rate	$3,573.40
Max. Negotiated Rate	$4,077.88
Rate for Payer: Cash Price	$2,522.40
Rate for Payer: Cash Price	$3,358.20
Rate for Payer: Health Management Network Commercial	$3,573.40
Rate for Payer: Health Management Network Commercial	$4,757.45
Rate for Payer: MDX Hawaii PPO	$4,077.88
Rate for Payer: MDX Hawaii PPO	$5,429.09

FAM-TRASTUZUMAB DERUXTEC-NXKI 100 MG/5ML IV (WET SOLR VIAL) [430170526]

Facility

OP

$5,597.00

Service Code	HCPCS J9358
Hospital Revenue Code	636
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$5,429.09
Rate for Payer: AlohaCare Medicaid	$31.26
Rate for Payer: AlohaCare Medicaid	$31.26
Rate for Payer: AlohaCare Medicare	$31.26
Rate for Payer: AlohaCare Medicare	$31.26
Rate for Payer: Cash Price	$3,358.20
Rate for Payer: Cash Price	$3,358.20
Rate for Payer: Cash Price	$2,522.40
Rate for Payer: Cash Price	$2,522.40
Rate for Payer: Devoted Health Medicare	$34.39
Rate for Payer: Devoted Health Medicare	$34.39
Rate for Payer: Hawaii Medical Service Association ABD	$30.00
Rate for Payer: Hawaii Medical Service Association ABD	$30.00
Rate for Payer: Hawaii Medical Service Association Commercial	$39.08
Rate for Payer: Hawaii Medical Service Association Commercial	$39.08
Rate for Payer: Hawaii Medical Service Association Medicare	$31.26
Rate for Payer: Hawaii Medical Service Association Medicare	$31.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,993.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,317.15
Rate for Payer: Health Management Network Commercial	$3,573.40
Rate for Payer: Health Management Network Commercial	$4,757.45
Rate for Payer: Humana Medicare	$31.26
Rate for Payer: Humana Medicare	$31.26
Rate for Payer: Kaiser Permanente Commercial	$2,648.52
Rate for Payer: Kaiser Permanente Commercial	$3,526.11
Rate for Payer: Kaiser Permanente Medicaid	$2,854.47
Rate for Payer: Kaiser Permanente Medicaid	$2,144.04
Rate for Payer: Kaiser Permanente Medicare	$31.26
Rate for Payer: Kaiser Permanente Medicare	$31.26
Rate for Payer: MDX Hawaii PPO	$5,429.09
Rate for Payer: MDX Hawaii PPO	$4,077.88
Rate for Payer: Ohana Health Plan Medicaid	$34.39
Rate for Payer: Ohana Health Plan Medicaid	$34.39
Rate for Payer: Ohana Health Plan Medicare	$31.26
Rate for Payer: Ohana Health Plan Medicare	$31.26
Rate for Payer: UnitedHealthcare Medicaid	$3,358.20
Rate for Payer: UnitedHealthcare Medicaid	$2,522.40
Rate for Payer: UnitedHealthcare Medicare	$31.26
Rate for Payer: UnitedHealthcare Medicare	$31.26
Rate for Payer: University Health Alliance Commercial	$4,079.65
Rate for Payer: University Health Alliance Commercial	$3,064.30

FASCIECTOMY, PALM ONLY, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT)

Facility

OP

$10,679.55

Service Code	CPT 26121
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$10,679.55

FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);

Facility

OP

$10,679.55

Service Code	CPT 26123
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$10,679.55

FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT); EACH ADDITIONAL DIGIT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

OP

$2,837.00

Service Code	CPT 26125
Hospital Revenue Code	360
Min. Negotiated Rate	$216.88
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$216.88

FAT EMULSION 20 % INTRAVENOUS [10014]

Facility

IP

$119.00

Service Code	NDC 00264446030
Hospital Revenue Code	250
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: MDX Hawaii PPO	$115.43

FAT EMULSION 20 % INTRAVENOUS [10014]

Facility

IP

$212.00

Service Code	NDC 65219053301
Hospital Revenue Code	250
Min. Negotiated Rate	$180.20
Max. Negotiated Rate	$205.64
Rate for Payer: Cash Price	$127.20
Rate for Payer: Health Management Network Commercial	$180.20
Rate for Payer: MDX Hawaii PPO	$205.64

<<
<
232
233
234
235
236
237
238
239
240
241
>
>>