Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

GABAPENTIN 600 MG TABLET [25855]

Facility

IP

$9.00

Service Code	NDC 60687050701
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 800 MG TABLET [25856]

Facility

OP

$11.00

Service Code	NDC 68001041200
Hospital Revenue Code	637
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: University Health Alliance Commercial	$8.02

GABAPENTIN 800 MG TABLET [25856]

Facility

IP

$11.00

Service Code	NDC 60687051801
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: MDX Hawaii PPO	$10.67

GABAPENTIN 800 MG TABLET [25856]

Facility

IP

$3.00

Service Code	NDC 00904710861
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 800 MG TABLET [25856]

Facility

IP

$11.00

Service Code	NDC 68001041200
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: MDX Hawaii PPO	$10.67

GABAPENTIN 800 MG TABLET [25856]

Facility

OP

$11.00

Service Code	NDC 60687051801
Hospital Revenue Code	637
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: University Health Alliance Commercial	$8.02

GABAPENTIN 800 MG TABLET [25856]

Facility

OP

$3.00

Service Code	NDC 00904710861
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

GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [188640]

Facility

OP

$165.00

Service Code	HCPCS A9573
Hospital Revenue Code	255
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$160.05
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cash Price	$39.60
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Hawaii Western Management Group Commercial	$156.75
Rate for Payer: Hawaii Western Management Group Commercial	$62.70
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$41.58
Rate for Payer: Kaiser Permanente Commercial	$138.60
Rate for Payer: Kaiser Permanente Commercial	$103.95
Rate for Payer: Kaiser Permanente Medicaid	$84.15
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: MDX Hawaii PPO	$160.05
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: UnitedHealthcare Medicaid	$2.56
Rate for Payer: UnitedHealthcare Medicaid	$2.56
Rate for Payer: UnitedHealthcare Medicaid	$2.56
Rate for Payer: University Health Alliance Commercial	$160.36
Rate for Payer: University Health Alliance Commercial	$120.27
Rate for Payer: University Health Alliance Commercial	$48.11

GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [188640]

Facility

IP

$220.00

Service Code	HCPCS A9573
Hospital Revenue Code	255
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cash Price	$39.60
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: MDX Hawaii PPO	$160.05

GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [124929]

Facility

OP

$177.00

Service Code	HCPCS A9575
Hospital Revenue Code	255
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$171.69
Rate for Payer: Cash Price	$106.20
Rate for Payer: Cash Price	$83.40
Rate for Payer: Cash Price	$83.40
Rate for Payer: Cash Price	$106.20
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Hawaii Western Management Group Commercial	$168.15
Rate for Payer: Hawaii Western Management Group Commercial	$132.05
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$111.51
Rate for Payer: Kaiser Permanente Commercial	$148.68
Rate for Payer: Kaiser Permanente Commercial	$87.57
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: Kaiser Permanente Medicaid	$90.27
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: MDX Hawaii PPO	$171.69
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: UnitedHealthcare Medicaid	$0.09
Rate for Payer: UnitedHealthcare Medicaid	$0.09
Rate for Payer: UnitedHealthcare Medicaid	$0.09
Rate for Payer: University Health Alliance Commercial	$129.02
Rate for Payer: University Health Alliance Commercial	$101.32
Rate for Payer: University Health Alliance Commercial	$172.02

GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [124929]

Facility

IP

$177.00

Service Code	HCPCS A9575
Hospital Revenue Code	255
Min. Negotiated Rate	$150.45
Max. Negotiated Rate	$171.69
Rate for Payer: Cash Price	$106.20
Rate for Payer: Cash Price	$83.40
Rate for Payer: Cash Price	$141.60
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: MDX Hawaii PPO	$171.69

GAMMA 3 SYSTEM 3425-1340S

Facility

IP

$6,402.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,585.12
Max. Negotiated Rate	$6,209.94
Rate for Payer: Cash Price	$3,841.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,481.40
Rate for Payer: Health Management Network Commercial	$5,441.70
Rate for Payer: MDX Hawaii PPO	$6,209.94
Rate for Payer: University Health Alliance Commercial	$3,585.12

GAMMA 3 SYSTEM 3425-1340S

Facility

OP

$6,402.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,265.02
Max. Negotiated Rate	$6,209.94
Rate for Payer: Cash Price	$3,841.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,481.40
Rate for Payer: Health Management Network Commercial	$5,441.70
Rate for Payer: Kaiser Permanente Commercial	$4,033.26
Rate for Payer: Kaiser Permanente Medicaid	$3,265.02
Rate for Payer: MDX Hawaii PPO	$6,209.94
Rate for Payer: University Health Alliance Commercial	$3,585.12

GAMMA4 LNG NAIL RT 8425-2400S

Facility

IP

$7,092.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,971.52
Max. Negotiated Rate	$6,879.24
Rate for Payer: Cash Price	$4,255.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,964.40
Rate for Payer: Health Management Network Commercial	$6,028.20
Rate for Payer: MDX Hawaii PPO	$6,879.24
Rate for Payer: University Health Alliance Commercial	$3,971.52

GAMMA4 LNG NAIL RT 8425-2400S

Facility

OP

$7,092.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,616.92
Max. Negotiated Rate	$6,879.24
Rate for Payer: Cash Price	$4,255.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,964.40
Rate for Payer: Health Management Network Commercial	$6,028.20
Rate for Payer: Kaiser Permanente Commercial	$4,467.96
Rate for Payer: Kaiser Permanente Medicaid	$3,616.92
Rate for Payer: MDX Hawaii PPO	$6,879.24
Rate for Payer: University Health Alliance Commercial	$3,971.52

GAMMAGARD LIQUID 10% INJECTION SOLUTION 10 G/100 ML [4080049]

Facility

IP

$5,239.00

Service Code	HCPCS J1569
Hospital Revenue Code	250
Min. Negotiated Rate	$4,453.15
Max. Negotiated Rate	$5,081.83
Rate for Payer: Cash Price	$3,143.40
Rate for Payer: Health Management Network Commercial	$4,453.15
Rate for Payer: MDX Hawaii PPO	$5,081.83

GAMMAGARD LIQUID 10% INJECTION SOLUTION 10 G/100 ML [4080049]

Facility

OP

$5,239.00

Service Code	HCPCS J1569
Hospital Revenue Code	636
Min. Negotiated Rate	$47.80
Max. Negotiated Rate	$5,081.83
Rate for Payer: AlohaCare Medicaid	$49.08
Rate for Payer: AlohaCare Medicare	$49.08
Rate for Payer: Cash Price	$3,143.40
Rate for Payer: Cash Price	$3,143.40
Rate for Payer: Devoted Health Medicare	$53.99
Rate for Payer: Hawaii Medical Service Association ABD	$47.80
Rate for Payer: Hawaii Medical Service Association Commercial	$61.35
Rate for Payer: Hawaii Medical Service Association Medicare	$49.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$47.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,977.05
Rate for Payer: Health Management Network Commercial	$4,453.15
Rate for Payer: Humana Medicare	$49.08
Rate for Payer: Kaiser Permanente Commercial	$3,300.57
Rate for Payer: Kaiser Permanente Medicaid	$2,671.89
Rate for Payer: Kaiser Permanente Medicare	$49.08
Rate for Payer: MDX Hawaii PPO	$5,081.83
Rate for Payer: Ohana Health Plan Medicaid	$53.99
Rate for Payer: Ohana Health Plan Medicare	$49.08
Rate for Payer: UnitedHealthcare Medicaid	$3,143.40
Rate for Payer: UnitedHealthcare Medicare	$49.08
Rate for Payer: University Health Alliance Commercial	$3,818.71

GAMMAGARD LIQUID 10% INJECTION SOLUTION 5 G/50 ML [4080050]

Facility

OP

$2,620.00

Service Code	HCPCS J1569
Hospital Revenue Code	636
Min. Negotiated Rate	$47.80
Max. Negotiated Rate	$2,541.40
Rate for Payer: AlohaCare Medicaid	$49.08
Rate for Payer: AlohaCare Medicare	$49.08
Rate for Payer: Cash Price	$1,572.00
Rate for Payer: Cash Price	$1,572.00
Rate for Payer: Devoted Health Medicare	$53.99
Rate for Payer: Hawaii Medical Service Association ABD	$47.80
Rate for Payer: Hawaii Medical Service Association Commercial	$61.35
Rate for Payer: Hawaii Medical Service Association Medicare	$49.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$47.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,489.00
Rate for Payer: Health Management Network Commercial	$2,227.00
Rate for Payer: Humana Medicare	$49.08
Rate for Payer: Kaiser Permanente Commercial	$1,650.60
Rate for Payer: Kaiser Permanente Medicaid	$1,336.20
Rate for Payer: Kaiser Permanente Medicare	$49.08
Rate for Payer: MDX Hawaii PPO	$2,541.40
Rate for Payer: Ohana Health Plan Medicaid	$53.99
Rate for Payer: Ohana Health Plan Medicare	$49.08
Rate for Payer: UnitedHealthcare Medicaid	$1,572.00
Rate for Payer: UnitedHealthcare Medicare	$49.08
Rate for Payer: University Health Alliance Commercial	$1,909.72

GAMMAGARD LIQUID 10% INJECTION SOLUTION 5 G/50 ML [4080050]

Facility

IP

$2,620.00

Service Code	HCPCS J1569
Hospital Revenue Code	250
Min. Negotiated Rate	$2,227.00
Max. Negotiated Rate	$2,541.40
Rate for Payer: Cash Price	$1,572.00
Rate for Payer: Health Management Network Commercial	$2,227.00
Rate for Payer: MDX Hawaii PPO	$2,541.40

GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]

Facility

IP

$176.00

Service Code	HCPCS J1570
Hospital Revenue Code	250
Min. Negotiated Rate	$149.60
Max. Negotiated Rate	$170.72
Rate for Payer: Cash Price	$105.60
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: MDX Hawaii PPO	$170.72

GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]

Facility

OP

$176.00

Service Code	HCPCS J1570
Hospital Revenue Code	636
Min. Negotiated Rate	$39.62
Max. Negotiated Rate	$170.72
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
Rate for Payer: Hawaii Medical Service Association ABD	$39.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$39.62
Rate for Payer: Hawaii Western Management Group Commercial	$167.20
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: Kaiser Permanente Commercial	$110.88
Rate for Payer: Kaiser Permanente Medicaid	$89.76
Rate for Payer: MDX Hawaii PPO	$170.72
Rate for Payer: UnitedHealthcare Medicaid	$105.60
Rate for Payer: University Health Alliance Commercial	$128.29

GARDENT TEETH GUARDS

Facility

IP

$58.00

Hospital Revenue Code	272
Min. Negotiated Rate	$49.30
Max. Negotiated Rate	$56.26
Rate for Payer: Cash Price	$34.80
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: MDX Hawaii PPO	$56.26

GARDENT TEETH GUARDS

Facility

OP

$58.00

Hospital Revenue Code	272
Min. Negotiated Rate	$29.58
Max. Negotiated Rate	$56.26
Rate for Payer: Cash Price	$34.80
Rate for Payer: Hawaii Western Management Group Commercial	$55.10
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: Kaiser Permanente Commercial	$36.54
Rate for Payer: Kaiser Permanente Medicaid	$29.58
Rate for Payer: MDX Hawaii PPO	$56.26
Rate for Payer: University Health Alliance Commercial	$42.28

GASTRIC FUNDOPLICATION

Facility

IP

$10,330.11

Service Code	APR-DRG 2323
Min. Negotiated Rate	$10,330.11
Max. Negotiated Rate	$10,330.11
Rate for Payer: AlohaCare Medicaid	$10,330.11
Rate for Payer: Hawaii Medical Service Association ABD	$10,330.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,330.11
Rate for Payer: Kaiser Permanente Medicaid	$10,330.11
Rate for Payer: Ohana Health Plan Medicaid	$10,330.11
Rate for Payer: UnitedHealthcare Medicaid	$10,330.11

GASTRIC FUNDOPLICATION

Facility

IP

$23,720.05

Service Code	APR-DRG 2324
Min. Negotiated Rate	$23,720.05
Max. Negotiated Rate	$23,720.05
Rate for Payer: AlohaCare Medicaid	$23,720.05
Rate for Payer: Hawaii Medical Service Association ABD	$23,720.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23,720.05
Rate for Payer: Kaiser Permanente Medicaid	$23,720.05
Rate for Payer: Ohana Health Plan Medicaid	$23,720.05
Rate for Payer: UnitedHealthcare Medicaid	$23,720.05

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