Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

GRISEOFULVIN MICROSIZE 125 MG/5 ML ORAL SUSPENSION [10138]

Facility

IP

$156.00

Service Code	NDC 69097036108
Hospital Revenue Code	250
Min. Negotiated Rate	$132.60
Max. Negotiated Rate	$151.32
Rate for Payer: Cash Price	$93.60
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: MDX Hawaii PPO	$151.32

GRISEOFULVIN MICROSIZE 125 MG/5 ML ORAL SUSPENSION [10138]

Facility

IP

$160.00

Service Code	NDC 00713085004
Hospital Revenue Code	250
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: MDX Hawaii PPO	$155.20

GRISEOFULVIN MICROSIZE 125 MG/5 ML ORAL SUSPENSION [10138]

Facility

OP

$160.00

Service Code	NDC 00713085004
Hospital Revenue Code	637
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Hawaii Western Management Group Commercial	$152.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Medicaid	$81.60
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: University Health Alliance Commercial	$116.62

GRISEOFULVIN MICROSIZE 125 MG/5 ML ORAL SUSPENSION [10138]

Facility

OP

$156.00

Service Code	NDC 69097036108
Hospital Revenue Code	637
Min. Negotiated Rate	$79.56
Max. Negotiated Rate	$151.32
Rate for Payer: Cash Price	$93.60
Rate for Payer: Hawaii Western Management Group Commercial	$148.20
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: Kaiser Permanente Commercial	$98.28
Rate for Payer: Kaiser Permanente Medicaid	$79.56
Rate for Payer: MDX Hawaii PPO	$151.32
Rate for Payer: University Health Alliance Commercial	$113.71

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]

Facility

IP

$7.00

Service Code	NDC 00121148800
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

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]

Facility

IP

$9.00

Service Code	NDC 69618006854
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

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]

Facility

OP

$7.00

Service Code	NDC 00121148800
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

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]

Facility

IP

$7.00

Service Code	NDC 00121148810
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

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]

Facility

OP

$9.00

Service Code	NDC 69618006854
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

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]

Facility

OP

$7.00

Service Code	NDC 00121148810
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

GUAIFENESIN/CODEINE 100-10 MG/5 ML SOLUTION UDC (ROBITUSSIN AC) (TAKE HOME) [4080363]

Facility

IP

$15.00

Service Code	NDC 00004080151
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

GUAIFENESIN/CODEINE 100-10 MG/5 ML SOLUTION UDC (ROBITUSSIN AC) (TAKE HOME) [4080363]

Facility

OP

$15.00

Service Code	NDC 00004080151
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

GUAIFENESIN/DM 100-10 MG/10 ML SYRUP (ROBITUSSIN DM) (118 ML) (TAKE HOME) [4080394]

Facility

IP

$15.00

Service Code	NDC 00004080182
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

GUAIFENESIN/DM 100-10 MG/10 ML SYRUP (ROBITUSSIN DM) (118 ML) (TAKE HOME) [4080394]

Facility

OP

$15.00

Service Code	NDC 00004080182
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

GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR [37651]

Facility

OP

$4.00

Service Code	NDC 68084057211
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.92

GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR [37651]

Facility

OP

$4.00

Service Code	NDC 68084057201
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.92

GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR [37651]

Facility

IP

$4.00

Service Code	NDC 68084057211
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR [37651]

Facility

IP

$4.00

Service Code	NDC 68084057201
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

GUIDE BP DRILL 47-4309-061-15

Facility

IP

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$669.80
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: MDX Hawaii PPO	$764.36

GUIDE BP DRILL 47-4309-061-15

Facility

OP

$788.00

Hospital Revenue Code	272
Min. Negotiated Rate	$401.88
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$472.80
Rate for Payer: Hawaii Western Management Group Commercial	$748.60
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Kaiser Permanente Commercial	$496.44
Rate for Payer: Kaiser Permanente Medicaid	$401.88
Rate for Payer: MDX Hawaii PPO	$764.36
Rate for Payer: University Health Alliance Commercial	$574.37

GUIDE MINI 1.8MM GUIDEMINI-1.8

Facility

IP

$200.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: MDX Hawaii PPO	$194.00

GUIDE MINI 1.8MM GUIDEMINI-1.8

Facility

OP

$200.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: University Health Alliance Commercial	$145.78

GUIDE PEG 1.8MM GUIDEPEG-1.8

Facility

IP

$563.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$337.80
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: MDX Hawaii PPO	$546.11

GUIDE PEG 1.8MM GUIDEPEG-1.8

Facility

OP

$563.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$287.13
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$337.80
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$354.69
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: University Health Alliance Commercial	$410.37

GUIDE PIN 1.3MMX140CM 128047

Facility

IP

$262.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$222.70
Max. Negotiated Rate	$254.14
Rate for Payer: Cash Price	$157.20
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: MDX Hawaii PPO	$254.14

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