Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

FAMOTIDINE 20 MG TABLET [10011]

Facility

OP

$6.00

Service Code	NDC 50268030315
Hospital Revenue Code	637
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$4.56
Rate for Payer: Cash Price	$3.60
Rate for Payer: Devoted Health Medicare	$5.04
Rate for Payer: Hawaii Medical Service Association Medicare	$4.56
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$4.56
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$4.56
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$4.56
Rate for Payer: Ohana Health Plan Medicare	$4.56
Rate for Payer: UnitedHealthcare Medicare	$4.56
Rate for Payer: University Health Alliance Commercial	$4.37

FAMOTIDINE 20 MG TABLET [10011]

Facility

IP

$1.00

Service Code	NDC 60687059501
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: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

FAMOTIDINE 20 MG TABLET [10011]

Facility

IP

$1.00

Service Code	NDC 00904719306
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: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

FAMOTIDINE 20 MG TABLET [10011]

Facility

OP

$1.00

Service Code	NDC 00904719361
Hospital Revenue Code	637
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.76
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.76
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.76
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.76
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.76
Rate for Payer: Ohana Health Plan Medicare	$0.76
Rate for Payer: UnitedHealthcare Medicare	$0.76
Rate for Payer: University Health Alliance Commercial	$0.73

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

IP

$266.00

Service Code	NDC 68382044405
Hospital Revenue Code	250
Min. Negotiated Rate	$226.10
Max. Negotiated Rate	$258.02
Rate for Payer: Cash Price	$159.60
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: MDX Hawaii PPO	$258.02

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

IP

$266.00

Service Code	NDC 27241024949
Hospital Revenue Code	250
Min. Negotiated Rate	$226.10
Max. Negotiated Rate	$258.02
Rate for Payer: Cash Price	$159.60
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: MDX Hawaii PPO	$258.02

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

IP

$266.00

Service Code	NDC 00832604550
Hospital Revenue Code	250
Min. Negotiated Rate	$226.10
Max. Negotiated Rate	$258.02
Rate for Payer: Cash Price	$159.60
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: MDX Hawaii PPO	$258.02

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

OP

$266.00

Service Code	NDC 27241024949
Hospital Revenue Code	637
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$258.02
Rate for Payer: AlohaCare Medicaid	$133.00
Rate for Payer: AlohaCare Medicare	$202.16
Rate for Payer: Cash Price	$159.60
Rate for Payer: Devoted Health Medicare	$223.44
Rate for Payer: Hawaii Medical Service Association Medicare	$202.16
Rate for Payer: Hawaii Western Management Group Commercial	$252.70
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Humana Medicare	$202.16
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: Kaiser Permanente Medicaid	$135.66
Rate for Payer: Kaiser Permanente Medicare	$202.16
Rate for Payer: MDX Hawaii PPO	$258.02
Rate for Payer: Ohana Health Plan Medicaid	$202.16
Rate for Payer: Ohana Health Plan Medicare	$202.16
Rate for Payer: UnitedHealthcare Medicare	$202.16
Rate for Payer: University Health Alliance Commercial	$193.89

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

OP

$266.00

Service Code	NDC 00832604550
Hospital Revenue Code	637
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$258.02
Rate for Payer: AlohaCare Medicaid	$133.00
Rate for Payer: AlohaCare Medicare	$202.16
Rate for Payer: Cash Price	$159.60
Rate for Payer: Devoted Health Medicare	$223.44
Rate for Payer: Hawaii Medical Service Association Medicare	$202.16
Rate for Payer: Hawaii Western Management Group Commercial	$252.70
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Humana Medicare	$202.16
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: Kaiser Permanente Medicaid	$135.66
Rate for Payer: Kaiser Permanente Medicare	$202.16
Rate for Payer: MDX Hawaii PPO	$258.02
Rate for Payer: Ohana Health Plan Medicaid	$202.16
Rate for Payer: Ohana Health Plan Medicare	$202.16
Rate for Payer: UnitedHealthcare Medicare	$202.16
Rate for Payer: University Health Alliance Commercial	$193.89

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

OP

$266.00

Service Code	NDC 68382044405
Hospital Revenue Code	637
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$258.02
Rate for Payer: AlohaCare Medicaid	$133.00
Rate for Payer: AlohaCare Medicare	$202.16
Rate for Payer: Cash Price	$159.60
Rate for Payer: Devoted Health Medicare	$223.44
Rate for Payer: Hawaii Medical Service Association Medicare	$202.16
Rate for Payer: Hawaii Western Management Group Commercial	$252.70
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Humana Medicare	$202.16
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: Kaiser Permanente Medicaid	$135.66
Rate for Payer: Kaiser Permanente Medicare	$202.16
Rate for Payer: MDX Hawaii PPO	$258.02
Rate for Payer: Ohana Health Plan Medicaid	$202.16
Rate for Payer: Ohana Health Plan Medicare	$202.16
Rate for Payer: UnitedHealthcare Medicare	$202.16
Rate for Payer: University Health Alliance Commercial	$193.89

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [183771]

Facility

IP

$3.00

Service Code	HCPCS J1308
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: MDX Hawaii PPO	$4.85

FAMOTIDINE TABLETS (PEPCID) 20 MG (TAKE HOME) [4080361]

Facility

OP

$15.00

Service Code	NDC 00004080149
Hospital Revenue Code	253
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$11.40
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Medicare	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$11.40
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$11.40
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$11.40
Rate for Payer: Ohana Health Plan Medicare	$11.40
Rate for Payer: UnitedHealthcare Medicare	$11.40
Rate for Payer: University Health Alliance Commercial	$10.93

FAMOTIDINE TABLETS (PEPCID) 20 MG (TAKE HOME) [4080361]

Facility

IP

$15.00

Service Code	NDC 00004080149
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: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION [170526]

Facility

OP

$4,204.00

Service Code	HCPCS J9358
Hospital Revenue Code	636
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$4,077.88
Rate for Payer: AlohaCare Medicaid	$2,102.00
Rate for Payer: AlohaCare Medicare	$3,195.04
Rate for Payer: Cash Price	$2,522.40
Rate for Payer: Cash Price	$2,522.40
Rate for Payer: Devoted Health Medicare	$3,531.36
Rate for Payer: Hawaii Medical Service Association ABD	$30.00
Rate for Payer: Hawaii Medical Service Association Commercial	$39.08
Rate for Payer: Hawaii Medical Service Association Medicare	$3,195.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,993.80
Rate for Payer: Health Management Network Commercial	$3,573.40
Rate for Payer: Humana Medicare	$3,195.04
Rate for Payer: Kaiser Permanente Commercial	$3,783.60
Rate for Payer: Kaiser Permanente Medicaid	$2,144.04
Rate for Payer: Kaiser Permanente Medicare	$3,195.04
Rate for Payer: MDX Hawaii PPO	$4,077.88
Rate for Payer: Ohana Health Plan Medicaid	$3,195.04
Rate for Payer: Ohana Health Plan Medicare	$3,195.04
Rate for Payer: UnitedHealthcare Medicaid	$2,522.40
Rate for Payer: UnitedHealthcare Medicare	$3,195.04
Rate for Payer: University Health Alliance Commercial	$3,064.30

FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION [170526]

Facility

IP

$4,204.00

Service Code	HCPCS J9358
Hospital Revenue Code	250
Min. Negotiated Rate	$3,573.40
Max. Negotiated Rate	$4,077.88
Rate for Payer: Cash Price	$2,522.40
Rate for Payer: Health Management Network Commercial	$3,573.40
Rate for Payer: Kaiser Permanente Commercial	$3,783.60
Rate for Payer: MDX Hawaii PPO	$4,077.88

FAM-TRASTUZUMAB DERUXTEC-NXKI 100 MG/5ML IV (WET SOLR VIAL) [430170526]

Facility

OP

$4,204.00

Service Code	HCPCS J9358
Hospital Revenue Code	636
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$4,077.88
Rate for Payer: AlohaCare Medicaid	$2,102.00
Rate for Payer: AlohaCare Medicaid	$2,798.50
Rate for Payer: AlohaCare Medicare	$4,253.72
Rate for Payer: AlohaCare Medicare	$3,195.04
Rate for Payer: Cash Price	$2,522.40
Rate for Payer: Cash Price	$2,522.40
Rate for Payer: Cash Price	$3,358.20
Rate for Payer: Cash Price	$3,358.20
Rate for Payer: Devoted Health Medicare	$3,531.36
Rate for Payer: Devoted Health Medicare	$4,701.48
Rate for Payer: Hawaii Medical Service Association ABD	$30.00
Rate for Payer: Hawaii Medical Service Association ABD	$30.00
Rate for Payer: Hawaii Medical Service Association Commercial	$39.08
Rate for Payer: Hawaii Medical Service Association Commercial	$39.08
Rate for Payer: Hawaii Medical Service Association Medicare	$3,195.04
Rate for Payer: Hawaii Medical Service Association Medicare	$4,253.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,993.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,317.15
Rate for Payer: Health Management Network Commercial	$3,573.40
Rate for Payer: Health Management Network Commercial	$4,757.45
Rate for Payer: Humana Medicare	$3,195.04
Rate for Payer: Humana Medicare	$4,253.72
Rate for Payer: Kaiser Permanente Commercial	$3,783.60
Rate for Payer: Kaiser Permanente Commercial	$5,037.30
Rate for Payer: Kaiser Permanente Medicaid	$2,144.04
Rate for Payer: Kaiser Permanente Medicaid	$2,854.47
Rate for Payer: Kaiser Permanente Medicare	$3,195.04
Rate for Payer: Kaiser Permanente Medicare	$4,253.72
Rate for Payer: MDX Hawaii PPO	$4,077.88
Rate for Payer: MDX Hawaii PPO	$5,429.09
Rate for Payer: Ohana Health Plan Medicaid	$4,253.72
Rate for Payer: Ohana Health Plan Medicaid	$3,195.04
Rate for Payer: Ohana Health Plan Medicare	$3,195.04
Rate for Payer: Ohana Health Plan Medicare	$4,253.72
Rate for Payer: UnitedHealthcare Medicaid	$2,522.40
Rate for Payer: UnitedHealthcare Medicaid	$3,358.20
Rate for Payer: UnitedHealthcare Medicare	$4,253.72
Rate for Payer: UnitedHealthcare Medicare	$3,195.04
Rate for Payer: University Health Alliance Commercial	$3,064.30
Rate for Payer: University Health Alliance Commercial	$4,079.65

FAM-TRASTUZUMAB DERUXTEC-NXKI 100 MG/5ML IV (WET SOLR VIAL) [430170526]

Facility

IP

$4,204.00

Service Code	HCPCS J9358
Hospital Revenue Code	250
Min. Negotiated Rate	$3,573.40
Max. Negotiated Rate	$4,077.88
Rate for Payer: Cash Price	$2,522.40
Rate for Payer: Cash Price	$3,358.20
Rate for Payer: Health Management Network Commercial	$4,757.45
Rate for Payer: Health Management Network Commercial	$3,573.40
Rate for Payer: Kaiser Permanente Commercial	$3,783.60
Rate for Payer: Kaiser Permanente Commercial	$5,037.30
Rate for Payer: MDX Hawaii PPO	$4,077.88
Rate for Payer: MDX Hawaii PPO	$5,429.09

FAT EMULSION 20 % INTRAVENOUS [10014]

Facility

IP

$119.00

Service Code	NDC 00264446030
Hospital Revenue Code	250
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: MDX Hawaii PPO	$115.43

FAT EMULSION 20 % INTRAVENOUS [10014]

Facility

IP

$132.00

Service Code	NDC 00338051958
Hospital Revenue Code	250
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$79.20
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: MDX Hawaii PPO	$128.04

FAT EMULSION 20 % INTRAVENOUS [10014]

Facility

IP

$212.00

Service Code	NDC 65219053301
Hospital Revenue Code	250
Min. Negotiated Rate	$180.20
Max. Negotiated Rate	$205.64
Rate for Payer: Cash Price	$127.20
Rate for Payer: Health Management Network Commercial	$180.20
Rate for Payer: Kaiser Permanente Commercial	$190.80
Rate for Payer: MDX Hawaii PPO	$205.64

FAT EMULSION 20 % INTRAVENOUS [10014]

Facility

IP

$207.00

Service Code	NDC 00338051909
Hospital Revenue Code	250
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$124.20
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79

FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS [166807]

Facility

IP

$126.00

Service Code	NDC 63323082004
Hospital Revenue Code	258
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22

FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS [166807]

Facility

OP

$126.00

Service Code	NDC 63323082004
Hospital Revenue Code	258
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$95.76
Rate for Payer: Cash Price	$75.60
Rate for Payer: Devoted Health Medicare	$105.84
Rate for Payer: Hawaii Medical Service Association Medicare	$95.76
Rate for Payer: Hawaii Western Management Group Commercial	$119.70
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$95.76
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$95.76
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$95.76
Rate for Payer: Ohana Health Plan Medicare	$95.76
Rate for Payer: UnitedHealthcare Medicare	$95.76
Rate for Payer: University Health Alliance Commercial	$91.84

FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS [166807]

Facility

IP

$126.00

Service Code	NDC 63323082074
Hospital Revenue Code	258
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$75.60
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22

FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS [166807]

Facility

OP

$126.00

Service Code	NDC 63323082074
Hospital Revenue Code	258
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$95.76
Rate for Payer: Cash Price	$75.60
Rate for Payer: Devoted Health Medicare	$105.84
Rate for Payer: Hawaii Medical Service Association Medicare	$95.76
Rate for Payer: Hawaii Western Management Group Commercial	$119.70
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$95.76
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$95.76
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$95.76
Rate for Payer: Ohana Health Plan Medicare	$95.76
Rate for Payer: UnitedHealthcare Medicare	$95.76
Rate for Payer: University Health Alliance Commercial	$91.84

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