Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT [168883]

Facility

OP

$176.00

Service Code	HCPCS 90710
Hospital Revenue Code	636
Min. Negotiated Rate	$88.00
Max. Negotiated Rate	$299.87
Rate for Payer: AlohaCare Medicaid	$88.00
Rate for Payer: AlohaCare Medicare	$133.76
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
Rate for Payer: Devoted Health Medicare	$147.84
Rate for Payer: Hawaii Medical Service Association ABD	$299.87
Rate for Payer: Hawaii Medical Service Association Medicare	$133.76
Rate for Payer: Hawaii Medical Service Association Non-ABD	$299.87
Rate for Payer: Hawaii Western Management Group Commercial	$167.20
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: Humana Medicare	$133.76
Rate for Payer: Kaiser Permanente Commercial	$158.40
Rate for Payer: Kaiser Permanente Medicaid	$89.76
Rate for Payer: Kaiser Permanente Medicare	$133.76
Rate for Payer: MDX Hawaii PPO	$170.72
Rate for Payer: Ohana Health Plan Medicaid	$133.76
Rate for Payer: Ohana Health Plan Medicare	$133.76
Rate for Payer: UnitedHealthcare Medicaid	$105.60
Rate for Payer: UnitedHealthcare Medicare	$133.76
Rate for Payer: University Health Alliance Commercial	$128.29

MECLIZINE 12.5 MG TABLET [12024]

Facility

IP

$3.00

Service Code	NDC 50268052215
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: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

MECLIZINE 12.5 MG TABLET [12024]

Facility

OP

$3.00

Service Code	NDC 60687077565
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

MECLIZINE 12.5 MG TABLET [12024]

Facility

OP

$3.00

Service Code	NDC 60687077511
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

MECLIZINE 12.5 MG TABLET [12024]

Facility

OP

$3.00

Service Code	NDC 50268052215
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

MECLIZINE 12.5 MG TABLET [12024]

Facility

IP

$3.00

Service Code	NDC 50268052211
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: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

MECLIZINE 12.5 MG TABLET [12024]

Facility

IP

$3.00

Service Code	NDC 60687077511
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: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

MECLIZINE 12.5 MG TABLET [12024]

Facility

IP

$3.00

Service Code	NDC 60687077565
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: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

MECLIZINE 12.5 MG TABLET [12024]

Facility

OP

$3.00

Service Code	NDC 50268052211
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

MECLIZINE 25 MG CHEWABLE TABLET [4822]

Facility

OP

$1.00

Service Code	NDC 00536129901
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

MECLIZINE 25 MG CHEWABLE TABLET [4822]

Facility

IP

$1.00

Service Code	NDC 00536129901
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

MECLIZINE 25 MG CHEWABLE TABLET [4822]

Facility

OP

$1.00

Service Code	NDC 68001052900
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

MECLIZINE 25 MG CHEWABLE TABLET [4822]

Facility

IP

$1.00

Service Code	NDC 68001052900
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

MECLIZINE CHEWABLE TABLETS (ANTIVERT) 25 MG (TAKE HOME) [4080373]

Facility

OP

$15.00

Service Code	NDC 00004080161
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

MECLIZINE CHEWABLE TABLETS (ANTIVERT) 25 MG (TAKE HOME) [4080373]

Facility

IP

$15.00

Service Code	NDC 00004080161
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

MEDIALIZED DOME 1518-20-038

Facility

IP

$1,650.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$924.00
Max. Negotiated Rate	$1,600.50
Rate for Payer: Cash Price	$990.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: Kaiser Permanente Commercial	$1,485.00
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: University Health Alliance Commercial	$924.00

MEDIALIZED DOME 1518-20-038

Facility

OP

$1,650.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$825.00
Max. Negotiated Rate	$1,600.50
Rate for Payer: AlohaCare Medicaid	$825.00
Rate for Payer: AlohaCare Medicare	$1,254.00
Rate for Payer: Cash Price	$990.00
Rate for Payer: Devoted Health Medicare	$1,386.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,254.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: Humana Medicare	$1,254.00
Rate for Payer: Kaiser Permanente Commercial	$1,485.00
Rate for Payer: Kaiser Permanente Medicaid	$841.50
Rate for Payer: Kaiser Permanente Medicare	$1,254.00
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: Ohana Health Plan Medicaid	$1,254.00
Rate for Payer: Ohana Health Plan Medicare	$1,254.00
Rate for Payer: UnitedHealthcare Medicare	$1,254.00
Rate for Payer: University Health Alliance Commercial	$924.00

MEDIAL MALLEOLAR PIN PLATE

Facility

IP

$2,895.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,621.20
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: Kaiser Permanente Commercial	$2,605.50
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

MEDIAL MALLEOLAR PIN PLATE

Facility

OP

$2,895.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,447.50
Max. Negotiated Rate	$2,808.15
Rate for Payer: AlohaCare Medicaid	$1,447.50
Rate for Payer: AlohaCare Medicare	$2,200.20
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Devoted Health Medicare	$2,431.80
Rate for Payer: Hawaii Medical Service Association Medicare	$2,200.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: Humana Medicare	$2,200.20
Rate for Payer: Kaiser Permanente Commercial	$2,605.50
Rate for Payer: Kaiser Permanente Medicaid	$1,476.45
Rate for Payer: Kaiser Permanente Medicare	$2,200.20
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: Ohana Health Plan Medicaid	$2,200.20
Rate for Payer: Ohana Health Plan Medicare	$2,200.20
Rate for Payer: UnitedHealthcare Medicare	$2,200.20
Rate for Payer: University Health Alliance Commercial	$1,621.20

MEDIAL MALLEOLAR PIN WIRE

Facility

IP

$653.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$555.05
Max. Negotiated Rate	$633.41
Rate for Payer: Cash Price	$391.80
Rate for Payer: Health Management Network Commercial	$555.05
Rate for Payer: Kaiser Permanente Commercial	$587.70
Rate for Payer: MDX Hawaii PPO	$633.41

MEDIAL MALLEOLAR PIN WIRE

Facility

OP

$653.00

Service Code	HCPCS C1713
Hospital Revenue Code	272
Min. Negotiated Rate	$326.50
Max. Negotiated Rate	$633.41
Rate for Payer: AlohaCare Medicaid	$326.50
Rate for Payer: AlohaCare Medicare	$496.28
Rate for Payer: Cash Price	$391.80
Rate for Payer: Devoted Health Medicare	$548.52
Rate for Payer: Hawaii Medical Service Association Medicare	$496.28
Rate for Payer: Hawaii Western Management Group Commercial	$620.35
Rate for Payer: Health Management Network Commercial	$555.05
Rate for Payer: Humana Medicare	$496.28
Rate for Payer: Kaiser Permanente Commercial	$587.70
Rate for Payer: Kaiser Permanente Medicaid	$333.03
Rate for Payer: Kaiser Permanente Medicare	$496.28
Rate for Payer: MDX Hawaii PPO	$633.41
Rate for Payer: Ohana Health Plan Medicaid	$496.28
Rate for Payer: Ohana Health Plan Medicare	$496.28
Rate for Payer: UnitedHealthcare Medicare	$496.28
Rate for Payer: University Health Alliance Commercial	$475.97

MEDIAL MALLEOLAR SLED

Facility

OP

$2,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$1,100.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: AlohaCare Medicaid	$1,100.00
Rate for Payer: AlohaCare Medicare	$1,672.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Devoted Health Medicare	$1,848.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,672.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,090.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Humana Medicare	$1,672.00
Rate for Payer: Kaiser Permanente Commercial	$1,980.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: Kaiser Permanente Medicare	$1,672.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: Ohana Health Plan Medicaid	$1,672.00
Rate for Payer: Ohana Health Plan Medicare	$1,672.00
Rate for Payer: UnitedHealthcare Medicare	$1,672.00
Rate for Payer: University Health Alliance Commercial	$1,603.58

MEDIAL MALLEOLAR SLED

Facility

IP

$2,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$1,870.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$1,980.00
Rate for Payer: MDX Hawaii PPO	$2,134.00

MEDICAL BACK PROBLEMS WITH MCC

Facility

IP

$14,647.84

Service Code	MSDRG 551
Min. Negotiated Rate	$14,647.84
Max. Negotiated Rate	$14,647.84
Rate for Payer: Hawaii Medical Service Association Commercial	$14,647.84

MEDICAL BACK PROBLEMS WITHOUT MCC

Facility

IP

$14,647.84

Service Code	MSDRG 552
Min. Negotiated Rate	$14,647.84
Max. Negotiated Rate	$14,647.84
Rate for Payer: Hawaii Medical Service Association Commercial	$14,647.84

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