Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

IP

$51.00

Service Code	NDC 66689000802
Hospital Revenue Code	250
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: MDX Hawaii PPO	$49.47

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

IP

$4.00

Service Code	NDC 66689003799
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

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

OP

$4.00

Service Code	NDC 66689003799
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

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

OP

$51.00

Service Code	NDC 00121086802
Hospital Revenue Code	637
Min. Negotiated Rate	$26.01
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$32.13
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: University Health Alliance Commercial	$37.17

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

OP

$60.00

Service Code	NDC 60432053760
Hospital Revenue Code	637
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: University Health Alliance Commercial	$43.73

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

OP

$8.00

Service Code	NDC 60687080017
Hospital Revenue Code	637
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: University Health Alliance Commercial	$5.83

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

OP

$8.00

Service Code	NDC 60687080040
Hospital Revenue Code	637
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: University Health Alliance Commercial	$5.83

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

IP

$51.00

Service Code	NDC 69315050460
Hospital Revenue Code	250
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: MDX Hawaii PPO	$49.47

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

OP

$51.00

Service Code	NDC 69315050460
Hospital Revenue Code	637
Min. Negotiated Rate	$26.01
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$32.13
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: University Health Alliance Commercial	$37.17

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

OP

$51.00

Service Code	NDC 66689000802
Hospital Revenue Code	637
Min. Negotiated Rate	$26.01
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$32.13
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: University Health Alliance Commercial	$37.17

NYSTATIN SUSPENSION (MYCOSTATIN) 100000 UNIT/1 ML (60 ML) (TAKE HOME) [4080382]

Facility

OP

$15.00

Service Code	NDC 00004080170
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

NYSTATIN SUSPENSION (MYCOSTATIN) 100000 UNIT/1 ML (60 ML) (TAKE HOME) [4080382]

Facility

IP

$15.00

Service Code	NDC 00004080170
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

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

IP

$88.00

Service Code	NDC 45802088014
Hospital Revenue Code	250
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$85.36
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: MDX Hawaii PPO	$85.36

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

OP

$88.00

Service Code	NDC 45802088014
Hospital Revenue Code	637
Min. Negotiated Rate	$44.88
Max. Negotiated Rate	$85.36
Rate for Payer: Cash Price	$52.80
Rate for Payer: Hawaii Western Management Group Commercial	$83.60
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Kaiser Permanente Commercial	$55.44
Rate for Payer: Kaiser Permanente Medicaid	$44.88
Rate for Payer: MDX Hawaii PPO	$85.36
Rate for Payer: University Health Alliance Commercial	$64.14

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]

Facility

IP

$66.00

Service Code	NDC 45802024414
Hospital Revenue Code	250
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$39.60
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: MDX Hawaii PPO	$64.02

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]

Facility

IP

$146.00

Service Code	NDC 62332058515
Hospital Revenue Code	250
Min. Negotiated Rate	$124.10
Max. Negotiated Rate	$141.62
Rate for Payer: Cash Price	$87.60
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: MDX Hawaii PPO	$141.62

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]

Facility

OP

$66.00

Service Code	NDC 45802024414
Hospital Revenue Code	637
Min. Negotiated Rate	$33.66
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$39.60
Rate for Payer: Hawaii Western Management Group Commercial	$62.70
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$41.58
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: University Health Alliance Commercial	$48.11

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]

Facility

OP

$146.00

Service Code	NDC 62332058515
Hospital Revenue Code	637
Min. Negotiated Rate	$74.46
Max. Negotiated Rate	$141.62
Rate for Payer: Cash Price	$87.60
Rate for Payer: Hawaii Western Management Group Commercial	$138.70
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: Kaiser Permanente Commercial	$91.98
Rate for Payer: Kaiser Permanente Medicaid	$74.46
Rate for Payer: MDX Hawaii PPO	$141.62
Rate for Payer: University Health Alliance Commercial	$106.42

OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [124767]

Facility

IP

$14,581.00

Service Code	HCPCS J9301
Hospital Revenue Code	250
Min. Negotiated Rate	$12,393.85
Max. Negotiated Rate	$14,143.57
Rate for Payer: Cash Price	$8,748.60
Rate for Payer: Cash Price	$972.60
Rate for Payer: Cash Price	$9,720.60
Rate for Payer: Health Management Network Commercial	$1,377.85
Rate for Payer: Health Management Network Commercial	$13,770.85
Rate for Payer: Health Management Network Commercial	$12,393.85
Rate for Payer: MDX Hawaii PPO	$1,572.37
Rate for Payer: MDX Hawaii PPO	$14,143.57
Rate for Payer: MDX Hawaii PPO	$15,714.97

OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [124767]

Facility

OP

$1,621.00

Service Code	HCPCS J9301
Hospital Revenue Code	636
Min. Negotiated Rate	$78.46
Max. Negotiated Rate	$1,572.37
Rate for Payer: AlohaCare Medicaid	$81.81
Rate for Payer: AlohaCare Medicaid	$81.81
Rate for Payer: AlohaCare Medicaid	$81.81
Rate for Payer: AlohaCare Medicare	$81.81
Rate for Payer: AlohaCare Medicare	$81.81
Rate for Payer: AlohaCare Medicare	$81.81
Rate for Payer: Cash Price	$9,720.60
Rate for Payer: Cash Price	$8,748.60
Rate for Payer: Cash Price	$9,720.60
Rate for Payer: Cash Price	$972.60
Rate for Payer: Cash Price	$8,748.60
Rate for Payer: Cash Price	$972.60
Rate for Payer: Devoted Health Medicare	$89.99
Rate for Payer: Devoted Health Medicare	$89.99
Rate for Payer: Devoted Health Medicare	$89.99
Rate for Payer: Hawaii Medical Service Association ABD	$78.46
Rate for Payer: Hawaii Medical Service Association ABD	$78.46
Rate for Payer: Hawaii Medical Service Association ABD	$78.46
Rate for Payer: Hawaii Medical Service Association Commercial	$102.26
Rate for Payer: Hawaii Medical Service Association Commercial	$102.26
Rate for Payer: Hawaii Medical Service Association Commercial	$102.26
Rate for Payer: Hawaii Medical Service Association Medicare	$81.81
Rate for Payer: Hawaii Medical Service Association Medicare	$81.81
Rate for Payer: Hawaii Medical Service Association Medicare	$81.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$78.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$78.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$78.46
Rate for Payer: Hawaii Western Management Group Commercial	$15,390.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,539.95
Rate for Payer: Hawaii Western Management Group Commercial	$13,851.95
Rate for Payer: Health Management Network Commercial	$1,377.85
Rate for Payer: Health Management Network Commercial	$12,393.85
Rate for Payer: Health Management Network Commercial	$13,770.85
Rate for Payer: Humana Medicare	$81.81
Rate for Payer: Humana Medicare	$81.81
Rate for Payer: Humana Medicare	$81.81
Rate for Payer: Kaiser Permanente Commercial	$9,186.03
Rate for Payer: Kaiser Permanente Commercial	$10,206.63
Rate for Payer: Kaiser Permanente Commercial	$1,021.23
Rate for Payer: Kaiser Permanente Medicaid	$7,436.31
Rate for Payer: Kaiser Permanente Medicaid	$8,262.51
Rate for Payer: Kaiser Permanente Medicaid	$826.71
Rate for Payer: Kaiser Permanente Medicare	$81.81
Rate for Payer: Kaiser Permanente Medicare	$81.81
Rate for Payer: Kaiser Permanente Medicare	$81.81
Rate for Payer: MDX Hawaii PPO	$1,572.37
Rate for Payer: MDX Hawaii PPO	$15,714.97
Rate for Payer: MDX Hawaii PPO	$14,143.57
Rate for Payer: Ohana Health Plan Medicaid	$89.99
Rate for Payer: Ohana Health Plan Medicaid	$89.99
Rate for Payer: Ohana Health Plan Medicaid	$89.99
Rate for Payer: Ohana Health Plan Medicare	$81.81
Rate for Payer: Ohana Health Plan Medicare	$81.81
Rate for Payer: Ohana Health Plan Medicare	$81.81
Rate for Payer: UnitedHealthcare Medicaid	$9,720.60
Rate for Payer: UnitedHealthcare Medicaid	$8,748.60
Rate for Payer: UnitedHealthcare Medicaid	$972.60
Rate for Payer: UnitedHealthcare Medicare	$81.81
Rate for Payer: UnitedHealthcare Medicare	$81.81
Rate for Payer: UnitedHealthcare Medicare	$81.81
Rate for Payer: University Health Alliance Commercial	$1,181.55
Rate for Payer: University Health Alliance Commercial	$10,628.09
Rate for Payer: University Health Alliance Commercial	$11,808.91

OBT BLADELESS-LONG 8MM 470360

Facility

OP

$158.00

Hospital Revenue Code	272
Min. Negotiated Rate	$80.58
Max. Negotiated Rate	$153.26
Rate for Payer: Cash Price	$94.80
Rate for Payer: Hawaii Western Management Group Commercial	$150.10
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: Kaiser Permanente Commercial	$99.54
Rate for Payer: Kaiser Permanente Medicaid	$80.58
Rate for Payer: MDX Hawaii PPO	$153.26
Rate for Payer: University Health Alliance Commercial	$115.17

OBT BLADELESS-LONG 8MM 470360

Facility

IP

$158.00

Hospital Revenue Code	272
Min. Negotiated Rate	$134.30
Max. Negotiated Rate	$153.26
Rate for Payer: Cash Price	$94.80
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: MDX Hawaii PPO	$153.26

OBTURATOR BLADELESS 8MM 470359

Facility

IP

$150.00

Hospital Revenue Code	272
Min. Negotiated Rate	$127.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$90.00
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: MDX Hawaii PPO	$145.50

OBTURATOR BLADELESS 8MM 470359

Facility

OP

$150.00

Hospital Revenue Code	272
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$90.00
Rate for Payer: Hawaii Western Management Group Commercial	$142.50
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Kaiser Permanente Commercial	$94.50
Rate for Payer: Kaiser Permanente Medicaid	$76.50
Rate for Payer: MDX Hawaii PPO	$145.50
Rate for Payer: University Health Alliance Commercial	$109.33

OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]

Facility

IP

$30.00

Service Code	HCPCS J2354
Hospital Revenue Code	250
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: MDX Hawaii PPO	$29.10

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