Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

GLIDEWIRE .25ANGL M0066802021

Facility

OP

$183.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$93.33
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$109.80
Rate for Payer: Hawaii Western Management Group Commercial	$173.85
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Kaiser Permanente Commercial	$115.29
Rate for Payer: Kaiser Permanente Medicaid	$93.33
Rate for Payer: MDX Hawaii PPO	$177.51
Rate for Payer: University Health Alliance Commercial	$133.39

GLIDEWIRE STIFF ANG 35X260

Facility

IP

$277.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$235.45
Max. Negotiated Rate	$268.69
Rate for Payer: Cash Price	$166.20
Rate for Payer: Health Management Network Commercial	$235.45
Rate for Payer: MDX Hawaii PPO	$268.69

GLIDEWIRE STIFF ANG 35X260

Facility

OP

$277.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$141.27
Max. Negotiated Rate	$268.69
Rate for Payer: Cash Price	$166.20
Rate for Payer: Hawaii Western Management Group Commercial	$263.15
Rate for Payer: Health Management Network Commercial	$235.45
Rate for Payer: Kaiser Permanente Commercial	$174.51
Rate for Payer: Kaiser Permanente Medicaid	$141.27
Rate for Payer: MDX Hawaii PPO	$268.69
Rate for Payer: University Health Alliance Commercial	$201.91

GLIDEWIRE STRAIGHT 0.25

Facility

IP

$183.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$155.55
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$109.80
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: MDX Hawaii PPO	$177.51

GLIDEWIRE STRAIGHT 0.25

Facility

OP

$183.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$93.33
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$109.80
Rate for Payer: Hawaii Western Management Group Commercial	$173.85
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Kaiser Permanente Commercial	$115.29
Rate for Payer: Kaiser Permanente Medicaid	$93.33
Rate for Payer: MDX Hawaii PPO	$177.51
Rate for Payer: University Health Alliance Commercial	$133.39

GLIDEWIRE STRAIGHT .035

Facility

IP

$189.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$160.65
Max. Negotiated Rate	$183.33
Rate for Payer: Cash Price	$113.40
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: MDX Hawaii PPO	$183.33

GLIDEWIRE STRAIGHT .035

Facility

OP

$189.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$96.39
Max. Negotiated Rate	$183.33
Rate for Payer: Cash Price	$113.40
Rate for Payer: Hawaii Western Management Group Commercial	$179.55
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Kaiser Permanente Commercial	$119.07
Rate for Payer: Kaiser Permanente Medicaid	$96.39
Rate for Payer: MDX Hawaii PPO	$183.33
Rate for Payer: University Health Alliance Commercial	$137.76

GLIPIZIDE 10 MG TABLET [10116]

Facility

OP

$3.00

Service Code	NDC 60687070111
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

GLIPIZIDE 10 MG TABLET [10116]

Facility

IP

$3.00

Service Code	NDC 60687070111
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

GLIPIZIDE 10 MG TABLET [10116]

Facility

IP

$3.00

Service Code	NDC 60505014200
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

GLIPIZIDE 10 MG TABLET [10116]

Facility

IP

$3.00

Service Code	NDC 60687070101
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

GLIPIZIDE 10 MG TABLET [10116]

Facility

OP

$3.00

Service Code	NDC 60505014200
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

GLIPIZIDE 10 MG TABLET [10116]

Facility

OP

$3.00

Service Code	NDC 60687070101
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

GLIPIZIDE 5 MG TABLET [10117]

Facility

IP

$2.00

Service Code	NDC 50268036115
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

GLIPIZIDE 5 MG TABLET [10117]

Facility

OP

$2.00

Service Code	NDC 60687069001
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

GLIPIZIDE 5 MG TABLET [10117]

Facility

OP

$2.00

Service Code	NDC 60687069011
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

GLIPIZIDE 5 MG TABLET [10117]

Facility

IP

$2.00

Service Code	NDC 60687069011
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

GLIPIZIDE 5 MG TABLET [10117]

Facility

OP

$2.00

Service Code	NDC 60505014100
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

GLIPIZIDE 5 MG TABLET [10117]

Facility

OP

$2.00

Service Code	NDC 50268036115
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

GLIPIZIDE 5 MG TABLET [10117]

Facility

IP

$2.00

Service Code	NDC 60687069001
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

GLIPIZIDE 5 MG TABLET [10117]

Facility

IP

$2.00

Service Code	NDC 60505014100
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

GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR [37650]

Facility

OP

$3.00

Service Code	NDC 64980028101
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

GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR [37650]

Facility

IP

$3.00

Service Code	NDC 64980028101
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

GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR [37650]

Facility

OP

$3.00

Service Code	NDC 59651078201
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

GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR [37650]

Facility

IP

$3.00

Service Code	NDC 59651078201
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

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