Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

OP

$7.00

Service Code	NDC 60687080311
Hospital Revenue Code	637
Min. Negotiated Rate	$3.57
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$4.41
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: University Health Alliance Commercial	$5.10

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

OP

$7.00

Service Code	NDC 60687080301
Hospital Revenue Code	637
Min. Negotiated Rate	$3.57
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$4.41
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: University Health Alliance Commercial	$5.10

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

OP

$18.00

Service Code	NDC 65862050320
Hospital Revenue Code	637
Min. Negotiated Rate	$9.18
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$11.34
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: University Health Alliance Commercial	$13.12

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

IP

$7.00

Service Code	NDC 60687080311
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: MDX Hawaii PPO	$6.79

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

IP

$7.00

Service Code	NDC 60687080301
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: MDX Hawaii PPO	$6.79

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

IP

$18.00

Service Code	NDC 65862050320
Hospital Revenue Code	250
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$17.46

AMOXICILLIN CAPSULES (AMOXIL) 500 MG (TAKE HOME) [4080335]

Facility

IP

$15.00

Service Code	NDC 00004080123
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

AMOXICILLIN CAPSULES (AMOXIL) 500 MG (TAKE HOME) [4080335]

Facility

OP

$15.00

Service Code	NDC 00004080123
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

AMOXICILLIN/CLAVULANATE 875/125 MG TABLETS (AUGMENTIN) (TAKE HOME) [4080336]

Facility

IP

$15.00

Service Code	NDC 00004080124
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

AMOXICILLIN/CLAVULANATE 875/125 MG TABLETS (AUGMENTIN) (TAKE HOME) [4080336]

Facility

OP

$15.00

Service Code	NDC 00004080124
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

AMOXICILLIN/CLAVULANATE SUSPENSION (AUGMENTIN) 400 MG/5 ML (100 ML) (TAKE HOME) [4080337]

Facility

OP

$15.00

Service Code	NDC 00004080125
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

AMOXICILLIN/CLAVULANATE SUSPENSION (AUGMENTIN) 400 MG/5 ML (100 ML) (TAKE HOME) [4080337]

Facility

IP

$15.00

Service Code	NDC 00004080125
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

AMOXICILLIN SUSPENSION 125 MG/5 ML (150 ML) (TAKE HOME) [4080333]

Facility

IP

$15.00

Service Code	NDC 00004080121
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

AMOXICILLIN SUSPENSION 125 MG/5 ML (150 ML) (TAKE HOME) [4080333]

Facility

OP

$15.00

Service Code	NDC 00004080121
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

AMOXICILLIN SUSPENSION 400 MG/5 ML (100 ML) (TAKE HOME) [4080334]

Facility

OP

$15.00

Service Code	NDC 00004080122
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

AMOXICILLIN SUSPENSION 400 MG/5 ML (100 ML) (TAKE HOME) [4080334]

Facility

IP

$15.00

Service Code	NDC 00004080122
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

AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION [166800]

Facility

OP

$120.00

Service Code	HCPCS J0285
Hospital Revenue Code	636
Min. Negotiated Rate	$34.12
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Hawaii Medical Service Association ABD	$34.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$34.12
Rate for Payer: Hawaii Western Management Group Commercial	$114.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: UnitedHealthcare Medicaid	$72.00
Rate for Payer: University Health Alliance Commercial	$87.47

AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION [166800]

Facility

IP

$120.00

Service Code	HCPCS J0285
Hospital Revenue Code	250
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: MDX Hawaii PPO	$116.40

AMPHOTERICIN B LIPOSOME 50 MG/12.5ML IV (WET SUSR VIAL) [43021900]

Facility

IP

$1,479.00

Service Code	HCPCS J0289
Hospital Revenue Code	250
Min. Negotiated Rate	$1,257.15
Max. Negotiated Rate	$1,434.63
Rate for Payer: Cash Price	$887.40
Rate for Payer: Cash Price	$343.80
Rate for Payer: Health Management Network Commercial	$1,257.15
Rate for Payer: Health Management Network Commercial	$487.05
Rate for Payer: MDX Hawaii PPO	$1,434.63
Rate for Payer: MDX Hawaii PPO	$555.81

AMPHOTERICIN B LIPOSOME 50 MG/12.5ML IV (WET SUSR VIAL) [43021900]

Facility

OP

$573.00

Service Code	HCPCS J0289
Hospital Revenue Code	636
Min. Negotiated Rate	$22.62
Max. Negotiated Rate	$555.81
Rate for Payer: AlohaCare Medicaid	$22.81
Rate for Payer: AlohaCare Medicaid	$22.81
Rate for Payer: AlohaCare Medicare	$22.81
Rate for Payer: AlohaCare Medicare	$22.81
Rate for Payer: Cash Price	$343.80
Rate for Payer: Cash Price	$343.80
Rate for Payer: Cash Price	$887.40
Rate for Payer: Cash Price	$887.40
Rate for Payer: Devoted Health Medicare	$25.09
Rate for Payer: Devoted Health Medicare	$25.09
Rate for Payer: Hawaii Medical Service Association ABD	$22.62
Rate for Payer: Hawaii Medical Service Association ABD	$22.62
Rate for Payer: Hawaii Medical Service Association Commercial	$28.51
Rate for Payer: Hawaii Medical Service Association Commercial	$28.51
Rate for Payer: Hawaii Medical Service Association Medicare	$22.81
Rate for Payer: Hawaii Medical Service Association Medicare	$22.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.62
Rate for Payer: Hawaii Western Management Group Commercial	$1,405.05
Rate for Payer: Hawaii Western Management Group Commercial	$544.35
Rate for Payer: Health Management Network Commercial	$1,257.15
Rate for Payer: Health Management Network Commercial	$487.05
Rate for Payer: Humana Medicare	$22.81
Rate for Payer: Humana Medicare	$22.81
Rate for Payer: Kaiser Permanente Commercial	$931.77
Rate for Payer: Kaiser Permanente Commercial	$360.99
Rate for Payer: Kaiser Permanente Medicaid	$292.23
Rate for Payer: Kaiser Permanente Medicaid	$754.29
Rate for Payer: Kaiser Permanente Medicare	$22.81
Rate for Payer: Kaiser Permanente Medicare	$22.81
Rate for Payer: MDX Hawaii PPO	$555.81
Rate for Payer: MDX Hawaii PPO	$1,434.63
Rate for Payer: Ohana Health Plan Medicaid	$25.09
Rate for Payer: Ohana Health Plan Medicaid	$25.09
Rate for Payer: Ohana Health Plan Medicare	$22.81
Rate for Payer: Ohana Health Plan Medicare	$22.81
Rate for Payer: UnitedHealthcare Medicaid	$343.80
Rate for Payer: UnitedHealthcare Medicaid	$887.40
Rate for Payer: UnitedHealthcare Medicare	$22.81
Rate for Payer: UnitedHealthcare Medicare	$22.81
Rate for Payer: University Health Alliance Commercial	$417.66
Rate for Payer: University Health Alliance Commercial	$1,078.04

AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION [21900]

Facility

IP

$573.00

Service Code	HCPCS J0289
Hospital Revenue Code	250
Min. Negotiated Rate	$487.05
Max. Negotiated Rate	$555.81
Rate for Payer: Cash Price	$343.80
Rate for Payer: Health Management Network Commercial	$487.05
Rate for Payer: MDX Hawaii PPO	$555.81

AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION [21900]

Facility

OP

$573.00

Service Code	HCPCS J0289
Hospital Revenue Code	636
Min. Negotiated Rate	$22.62
Max. Negotiated Rate	$555.81
Rate for Payer: AlohaCare Medicaid	$22.81
Rate for Payer: AlohaCare Medicare	$22.81
Rate for Payer: Cash Price	$343.80
Rate for Payer: Cash Price	$343.80
Rate for Payer: Devoted Health Medicare	$25.09
Rate for Payer: Hawaii Medical Service Association ABD	$22.62
Rate for Payer: Hawaii Medical Service Association Commercial	$28.51
Rate for Payer: Hawaii Medical Service Association Medicare	$22.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.62
Rate for Payer: Hawaii Western Management Group Commercial	$544.35
Rate for Payer: Health Management Network Commercial	$487.05
Rate for Payer: Humana Medicare	$22.81
Rate for Payer: Kaiser Permanente Commercial	$360.99
Rate for Payer: Kaiser Permanente Medicaid	$292.23
Rate for Payer: Kaiser Permanente Medicare	$22.81
Rate for Payer: MDX Hawaii PPO	$555.81
Rate for Payer: Ohana Health Plan Medicaid	$25.09
Rate for Payer: Ohana Health Plan Medicare	$22.81
Rate for Payer: UnitedHealthcare Medicaid	$343.80
Rate for Payer: UnitedHealthcare Medicare	$22.81
Rate for Payer: University Health Alliance Commercial	$417.66

AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [469]

Facility

IP

$28.00

Service Code	HCPCS J0290
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: MDX Hawaii PPO	$27.16

AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [469]

Facility

OP

$26.00

Service Code	HCPCS J0290
Hospital Revenue Code	636
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$15.60
Rate for Payer: Cash Price	$15.60
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Hawaii Medical Service Association ABD	$0.49
Rate for Payer: Hawaii Medical Service Association ABD	$0.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.49
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$17.64
Rate for Payer: Kaiser Permanente Commercial	$16.38
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: UnitedHealthcare Medicaid	$16.80
Rate for Payer: University Health Alliance Commercial	$20.41
Rate for Payer: University Health Alliance Commercial	$18.95

AMPICILLIN 250 MG SOLUTION FOR INJECTION [473]

Facility

IP

$15.00

Service Code	HCPCS J0290
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

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