Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

FUSION CUP 14MM RMRUFC-14

Facility

IP

$1,211.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,029.35
Max. Negotiated Rate	$1,174.67
Rate for Payer: Cash Price	$726.60
Rate for Payer: Health Management Network Commercial	$1,029.35
Rate for Payer: MDX Hawaii PPO	$1,174.67

FUSION CUP 14MM RMRUFC-14

Facility

OP

$1,211.00

Hospital Revenue Code	272
Min. Negotiated Rate	$617.61
Max. Negotiated Rate	$1,174.67
Rate for Payer: Cash Price	$726.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,150.45
Rate for Payer: Health Management Network Commercial	$1,029.35
Rate for Payer: Kaiser Permanente Commercial	$762.93
Rate for Payer: Kaiser Permanente Medicaid	$617.61
Rate for Payer: MDX Hawaii PPO	$1,174.67
Rate for Payer: University Health Alliance Commercial	$882.70

GABAPENTIN 100 MG CAPSULE [18309]

Facility

IP

$2.00

Service Code	NDC 65162010110
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

GABAPENTIN 100 MG CAPSULE [18309]

Facility

OP

$3.00

Service Code	NDC 60687058001
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

GABAPENTIN 100 MG CAPSULE [18309]

Facility

OP

$2.00

Service Code	NDC 65162010110
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

GABAPENTIN 100 MG CAPSULE [18309]

Facility

IP

$3.00

Service Code	NDC 60687058001
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

GABAPENTIN 100 MG CAPSULE [18309]

Facility

IP

$3.00

Service Code	NDC 60687058011
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

GABAPENTIN 100 MG CAPSULE [18309]

Facility

OP

$3.00

Service Code	NDC 60687058011
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

GABAPENTIN 250 MG/5 ML ORAL SOLUTION [29169]

Facility

OP

$575.00

Service Code	NDC 42192060816
Hospital Revenue Code	637
Min. Negotiated Rate	$293.25
Max. Negotiated Rate	$557.75
Rate for Payer: Cash Price	$345.00
Rate for Payer: Hawaii Western Management Group Commercial	$546.25
Rate for Payer: Health Management Network Commercial	$488.75
Rate for Payer: Kaiser Permanente Commercial	$362.25
Rate for Payer: Kaiser Permanente Medicaid	$293.25
Rate for Payer: MDX Hawaii PPO	$557.75
Rate for Payer: University Health Alliance Commercial	$419.12

GABAPENTIN 250 MG/5 ML ORAL SOLUTION [29169]

Facility

IP

$575.00

Service Code	NDC 42192060816
Hospital Revenue Code	250
Min. Negotiated Rate	$488.75
Max. Negotiated Rate	$557.75
Rate for Payer: Cash Price	$345.00
Rate for Payer: Health Management Network Commercial	$488.75
Rate for Payer: MDX Hawaii PPO	$557.75

GABAPENTIN 300 MG CAPSULE [18308]

Facility

OP

$5.00

Service Code	NDC 60687059101
Hospital Revenue Code	637
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: University Health Alliance Commercial	$3.64

GABAPENTIN 300 MG CAPSULE [18308]

Facility

IP

$5.00

Service Code	NDC 60687059101
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$4.85

GABAPENTIN 300 MG CAPSULE [18308]

Facility

IP

$5.00

Service Code	NDC 60687059111
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$4.85

GABAPENTIN 300 MG CAPSULE [18308]

Facility

OP

$5.00

Service Code	NDC 60687059111
Hospital Revenue Code	637
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: University Health Alliance Commercial	$3.64

GABAPENTIN 400 MG CAPSULE [18307]

Facility

IP

$5.00

Service Code	NDC 60687060211
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$4.85

GABAPENTIN 400 MG CAPSULE [18307]

Facility

OP

$1.00

Service Code	NDC 00904666761
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

GABAPENTIN 400 MG CAPSULE [18307]

Facility

OP

$5.00

Service Code	NDC 60687060201
Hospital Revenue Code	637
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: University Health Alliance Commercial	$3.64

GABAPENTIN 400 MG CAPSULE [18307]

Facility

IP

$5.00

Service Code	NDC 60687060201
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$4.85

GABAPENTIN 400 MG CAPSULE [18307]

Facility

IP

$1.00

Service Code	NDC 00904666761
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

GABAPENTIN 400 MG CAPSULE [18307]

Facility

OP

$5.00

Service Code	NDC 60687060211
Hospital Revenue Code	637
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: University Health Alliance Commercial	$3.64

GABAPENTIN 600 MG TABLET [25855]

Facility

OP

$9.00

Service Code	NDC 60687050711
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: University Health Alliance Commercial	$6.56

GABAPENTIN 600 MG TABLET [25855]

Facility

OP

$9.00

Service Code	NDC 60687050701
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: University Health Alliance Commercial	$6.56

GABAPENTIN 600 MG TABLET [25855]

Facility

IP

$9.00

Service Code	NDC 60687050711
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

GABAPENTIN 600 MG TABLET [25855]

Facility

OP

$2.00

Service Code	NDC 00904682361
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

GABAPENTIN 600 MG TABLET [25855]

Facility

IP

$2.00

Service Code	NDC 00904682361
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

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