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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

OXYTOCIN 10 UNIT/ML INJECTION SOLUTION [5944]

Facility

IP

$59.00

Service Code	NDC 42023011602
Hospital Revenue Code	250
Min. Negotiated Rate	$50.15
Max. Negotiated Rate	$57.23
Rate for Payer: Cash Price	$35.40
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Kaiser Permanente Commercial	$53.10
Rate for Payer: MDX Hawaii PPO	$57.23

OXYTOCIN 10 UNIT/ML INJECTION SOLUTION [5944]

Facility

IP

$7.00

Service Code	NDC 63323001207
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: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

OXYTOCIN 10 UNIT/ML INJECTION SOLUTION [5944]

Facility

IP

$43.00

Service Code	NDC 63323001210
Hospital Revenue Code	250
Min. Negotiated Rate	$36.55
Max. Negotiated Rate	$41.71
Rate for Payer: Cash Price	$25.80
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Kaiser Permanente Commercial	$38.70
Rate for Payer: MDX Hawaii PPO	$41.71

OXYTOCIN 10 UNIT/ML INJECTION SOLUTION [5944]

Facility

IP

$15.00

Service Code	NDC 63323001203
Hospital Revenue Code	250
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

OXYTOCIN 10 UNIT/ML INJECTION SOLUTION [5944]

Facility

IP

$15.00

Service Code	NDC 63323001211
Hospital Revenue Code	250
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$26.40
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Commercial	$39.60
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: MDX Hawaii PPO	$42.68

OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [136947]

Facility

IP

$81.00

Service Code	NDC 70092106807
Hospital Revenue Code	250
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$78.57
Rate for Payer: Cash Price	$48.60
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Kaiser Permanente Commercial	$72.90
Rate for Payer: MDX Hawaii PPO	$78.57

OXYTOCIN 30 UNIT/500 ML IN NS BOLUS [4080179]

Facility

IP

$81.00

Service Code	NDC 70092106807
Hospital Revenue Code	250
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$78.57
Rate for Payer: Cash Price	$48.60
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Kaiser Permanente Commercial	$72.90
Rate for Payer: MDX Hawaii PPO	$78.57

OXYTOCIN 30 UNITS IN 500 ML NS (SIMPLE) [4080272]

Facility

IP

$58.00

Service Code	NDC 00004080196
Hospital Revenue Code	250
Min. Negotiated Rate	$49.30
Max. Negotiated Rate	$56.26
Rate for Payer: Cash Price	$34.80
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: Kaiser Permanente Commercial	$52.20
Rate for Payer: MDX Hawaii PPO	$56.26

PACEL BIPOLAR PACING CATH 5FR

Facility

IP

$536.00

Hospital Revenue Code	272
Min. Negotiated Rate	$455.60
Max. Negotiated Rate	$519.92
Rate for Payer: Cash Price	$321.60
Rate for Payer: Health Management Network Commercial	$455.60
Rate for Payer: Kaiser Permanente Commercial	$482.40
Rate for Payer: MDX Hawaii PPO	$519.92

PACEL BIPOLAR PACING CATH 5FR

Facility

OP

$536.00

Hospital Revenue Code	272
Min. Negotiated Rate	$268.00
Max. Negotiated Rate	$519.92
Rate for Payer: AlohaCare Medicaid	$268.00
Rate for Payer: AlohaCare Medicare	$407.36
Rate for Payer: Cash Price	$321.60
Rate for Payer: Devoted Health Medicare	$450.24
Rate for Payer: Hawaii Medical Service Association Medicare	$407.36
Rate for Payer: Hawaii Western Management Group Commercial	$509.20
Rate for Payer: Health Management Network Commercial	$455.60
Rate for Payer: Humana Medicare	$407.36
Rate for Payer: Kaiser Permanente Commercial	$482.40
Rate for Payer: Kaiser Permanente Medicaid	$273.36
Rate for Payer: Kaiser Permanente Medicare	$407.36
Rate for Payer: MDX Hawaii PPO	$519.92
Rate for Payer: Ohana Health Plan Medicaid	$407.36
Rate for Payer: Ohana Health Plan Medicare	$407.36
Rate for Payer: UnitedHealthcare Medicare	$407.36
Rate for Payer: University Health Alliance Commercial	$390.69

PACEMAKER ASSURITY MRI PM2272

Facility

OP

$10,000.00

Service Code	HCPCS C1785
Hospital Revenue Code	275
Min. Negotiated Rate	$5,000.00
Max. Negotiated Rate	$9,700.00
Rate for Payer: AlohaCare Medicaid	$5,000.00
Rate for Payer: AlohaCare Medicare	$7,600.00
Rate for Payer: Cash Price	$6,000.00
Rate for Payer: Devoted Health Medicare	$8,400.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,600.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,000.00
Rate for Payer: Health Management Network Commercial	$8,500.00
Rate for Payer: Humana Medicare	$7,600.00
Rate for Payer: Kaiser Permanente Commercial	$9,000.00
Rate for Payer: Kaiser Permanente Medicaid	$5,100.00
Rate for Payer: Kaiser Permanente Medicare	$7,600.00
Rate for Payer: MDX Hawaii PPO	$9,700.00
Rate for Payer: Ohana Health Plan Medicaid	$7,600.00
Rate for Payer: Ohana Health Plan Medicare	$7,600.00
Rate for Payer: UnitedHealthcare Medicare	$7,600.00
Rate for Payer: University Health Alliance Commercial	$5,600.00

PACEMAKER ASSURITY MRI PM2272

Facility

IP

$10,000.00

Service Code	HCPCS C1785
Hospital Revenue Code	275
Min. Negotiated Rate	$5,600.00
Max. Negotiated Rate	$9,700.00
Rate for Payer: Cash Price	$6,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,000.00
Rate for Payer: Health Management Network Commercial	$8,500.00
Rate for Payer: Kaiser Permanente Commercial	$9,000.00
Rate for Payer: MDX Hawaii PPO	$9,700.00
Rate for Payer: University Health Alliance Commercial	$5,600.00

PACEMAKER DUAL ASSURITY PM2240

Facility

OP

$9,200.00

Service Code	HCPCS C1785
Hospital Revenue Code	275
Min. Negotiated Rate	$4,600.00
Max. Negotiated Rate	$8,924.00
Rate for Payer: AlohaCare Medicaid	$4,600.00
Rate for Payer: AlohaCare Medicare	$6,992.00
Rate for Payer: Cash Price	$5,520.00
Rate for Payer: Devoted Health Medicare	$7,728.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,992.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,440.00
Rate for Payer: Health Management Network Commercial	$7,820.00
Rate for Payer: Humana Medicare	$6,992.00
Rate for Payer: Kaiser Permanente Commercial	$8,280.00
Rate for Payer: Kaiser Permanente Medicaid	$4,692.00
Rate for Payer: Kaiser Permanente Medicare	$6,992.00
Rate for Payer: MDX Hawaii PPO	$8,924.00
Rate for Payer: Ohana Health Plan Medicaid	$6,992.00
Rate for Payer: Ohana Health Plan Medicare	$6,992.00
Rate for Payer: UnitedHealthcare Medicare	$6,992.00
Rate for Payer: University Health Alliance Commercial	$5,152.00

PACEMAKER DUAL ASSURITY PM2240

Facility

IP

$9,200.00

Service Code	HCPCS C1785
Hospital Revenue Code	275
Min. Negotiated Rate	$5,152.00
Max. Negotiated Rate	$8,924.00
Rate for Payer: Cash Price	$5,520.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,440.00
Rate for Payer: Health Management Network Commercial	$7,820.00
Rate for Payer: Kaiser Permanente Commercial	$8,280.00
Rate for Payer: MDX Hawaii PPO	$8,924.00
Rate for Payer: University Health Alliance Commercial	$5,152.00

PACEMAKER PM1272SYSCELL

Facility

IP

$10,850.00

Service Code	HCPCS C1786
Hospital Revenue Code	275
Min. Negotiated Rate	$6,076.00
Max. Negotiated Rate	$10,524.50
Rate for Payer: Cash Price	$6,510.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,595.00
Rate for Payer: Health Management Network Commercial	$9,222.50
Rate for Payer: Kaiser Permanente Commercial	$9,765.00
Rate for Payer: MDX Hawaii PPO	$10,524.50
Rate for Payer: University Health Alliance Commercial	$6,076.00

PACEMAKER PM1272SYSCELL

Facility

OP

$10,850.00

Service Code	HCPCS C1786
Hospital Revenue Code	275
Min. Negotiated Rate	$5,425.00
Max. Negotiated Rate	$10,524.50
Rate for Payer: AlohaCare Medicaid	$5,425.00
Rate for Payer: AlohaCare Medicare	$8,246.00
Rate for Payer: Cash Price	$6,510.00
Rate for Payer: Devoted Health Medicare	$9,114.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,246.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,595.00
Rate for Payer: Health Management Network Commercial	$9,222.50
Rate for Payer: Humana Medicare	$8,246.00
Rate for Payer: Kaiser Permanente Commercial	$9,765.00
Rate for Payer: Kaiser Permanente Medicaid	$5,533.50
Rate for Payer: Kaiser Permanente Medicare	$8,246.00
Rate for Payer: MDX Hawaii PPO	$10,524.50
Rate for Payer: Ohana Health Plan Medicaid	$8,246.00
Rate for Payer: Ohana Health Plan Medicare	$8,246.00
Rate for Payer: UnitedHealthcare Medicare	$8,246.00
Rate for Payer: University Health Alliance Commercial	$6,076.00

PACEMAKER SINGLE CHAMBER

Facility

IP

$12,004.00

Service Code	HCPCS C1786
Hospital Revenue Code	275
Min. Negotiated Rate	$6,722.24
Max. Negotiated Rate	$11,643.88
Rate for Payer: Cash Price	$7,202.40
Rate for Payer: Hawaii Western Management Group Commercial	$8,402.80
Rate for Payer: Health Management Network Commercial	$10,203.40
Rate for Payer: Kaiser Permanente Commercial	$10,803.60
Rate for Payer: MDX Hawaii PPO	$11,643.88
Rate for Payer: University Health Alliance Commercial	$6,722.24

PACEMAKER SINGLE CHAMBER

Facility

OP

$12,004.00

Service Code	HCPCS C1786
Hospital Revenue Code	275
Min. Negotiated Rate	$6,002.00
Max. Negotiated Rate	$11,643.88
Rate for Payer: AlohaCare Medicaid	$6,002.00
Rate for Payer: AlohaCare Medicare	$9,123.04
Rate for Payer: Cash Price	$7,202.40
Rate for Payer: Devoted Health Medicare	$10,083.36
Rate for Payer: Hawaii Medical Service Association Medicare	$9,123.04
Rate for Payer: Hawaii Western Management Group Commercial	$8,402.80
Rate for Payer: Health Management Network Commercial	$10,203.40
Rate for Payer: Humana Medicare	$9,123.04
Rate for Payer: Kaiser Permanente Commercial	$10,803.60
Rate for Payer: Kaiser Permanente Medicaid	$6,122.04
Rate for Payer: Kaiser Permanente Medicare	$9,123.04
Rate for Payer: MDX Hawaii PPO	$11,643.88
Rate for Payer: Ohana Health Plan Medicaid	$9,123.04
Rate for Payer: Ohana Health Plan Medicare	$9,123.04
Rate for Payer: UnitedHealthcare Medicare	$9,123.04
Rate for Payer: University Health Alliance Commercial	$6,722.24

PACEMAKER SNGL CD135-740C

Facility

IP

$27,900.00

Service Code	HCPCS C1722
Hospital Revenue Code	275
Min. Negotiated Rate	$15,624.00
Max. Negotiated Rate	$27,063.00
Rate for Payer: Cash Price	$16,740.00
Rate for Payer: Hawaii Western Management Group Commercial	$19,530.00
Rate for Payer: Health Management Network Commercial	$23,715.00
Rate for Payer: Kaiser Permanente Commercial	$25,110.00
Rate for Payer: MDX Hawaii PPO	$27,063.00
Rate for Payer: University Health Alliance Commercial	$15,624.00

PACEMAKER SNGL CD135-740C

Facility

OP

$27,900.00

Service Code	HCPCS C1722
Hospital Revenue Code	275
Min. Negotiated Rate	$13,950.00
Max. Negotiated Rate	$27,063.00
Rate for Payer: AlohaCare Medicaid	$13,950.00
Rate for Payer: AlohaCare Medicare	$21,204.00
Rate for Payer: Cash Price	$16,740.00
Rate for Payer: Devoted Health Medicare	$23,436.00
Rate for Payer: Hawaii Medical Service Association Medicare	$21,204.00
Rate for Payer: Hawaii Western Management Group Commercial	$19,530.00
Rate for Payer: Health Management Network Commercial	$23,715.00
Rate for Payer: Humana Medicare	$21,204.00
Rate for Payer: Kaiser Permanente Commercial	$25,110.00
Rate for Payer: Kaiser Permanente Medicaid	$14,229.00
Rate for Payer: Kaiser Permanente Medicare	$21,204.00
Rate for Payer: MDX Hawaii PPO	$27,063.00
Rate for Payer: Ohana Health Plan Medicaid	$21,204.00
Rate for Payer: Ohana Health Plan Medicare	$21,204.00
Rate for Payer: UnitedHealthcare Medicare	$21,204.00
Rate for Payer: University Health Alliance Commercial	$15,624.00

PACK ARTHRO SHOULDER/KNEE

Facility

OP

$496.00

Hospital Revenue Code	272
Min. Negotiated Rate	$248.00
Max. Negotiated Rate	$481.12
Rate for Payer: AlohaCare Medicaid	$248.00
Rate for Payer: AlohaCare Medicare	$376.96
Rate for Payer: Cash Price	$297.60
Rate for Payer: Devoted Health Medicare	$416.64
Rate for Payer: Hawaii Medical Service Association Medicare	$376.96
Rate for Payer: Hawaii Western Management Group Commercial	$471.20
Rate for Payer: Health Management Network Commercial	$421.60
Rate for Payer: Humana Medicare	$376.96
Rate for Payer: Kaiser Permanente Commercial	$446.40
Rate for Payer: Kaiser Permanente Medicaid	$252.96
Rate for Payer: Kaiser Permanente Medicare	$376.96
Rate for Payer: MDX Hawaii PPO	$481.12
Rate for Payer: Ohana Health Plan Medicaid	$376.96
Rate for Payer: Ohana Health Plan Medicare	$376.96
Rate for Payer: UnitedHealthcare Medicare	$376.96
Rate for Payer: University Health Alliance Commercial	$361.53

PACK ARTHRO SHOULDER/KNEE

Facility

IP

$496.00

Hospital Revenue Code	272
Min. Negotiated Rate	$421.60
Max. Negotiated Rate	$481.12
Rate for Payer: Cash Price	$297.60
Rate for Payer: Health Management Network Commercial	$421.60
Rate for Payer: Kaiser Permanente Commercial	$446.40
Rate for Payer: MDX Hawaii PPO	$481.12

PACK AV FISTULA

Facility

IP

$641.00

Hospital Revenue Code	272
Min. Negotiated Rate	$544.85
Max. Negotiated Rate	$621.77
Rate for Payer: Cash Price	$384.60
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: Kaiser Permanente Commercial	$576.90
Rate for Payer: MDX Hawaii PPO	$621.77

PACK AV FISTULA

Facility

OP

$641.00

Hospital Revenue Code	272
Min. Negotiated Rate	$320.50
Max. Negotiated Rate	$621.77
Rate for Payer: AlohaCare Medicaid	$320.50
Rate for Payer: AlohaCare Medicare	$487.16
Rate for Payer: Cash Price	$384.60
Rate for Payer: Devoted Health Medicare	$538.44
Rate for Payer: Hawaii Medical Service Association Medicare	$487.16
Rate for Payer: Hawaii Western Management Group Commercial	$608.95
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: Humana Medicare	$487.16
Rate for Payer: Kaiser Permanente Commercial	$576.90
Rate for Payer: Kaiser Permanente Medicaid	$326.91
Rate for Payer: Kaiser Permanente Medicare	$487.16
Rate for Payer: MDX Hawaii PPO	$621.77
Rate for Payer: Ohana Health Plan Medicaid	$487.16
Rate for Payer: Ohana Health Plan Medicare	$487.16
Rate for Payer: UnitedHealthcare Medicare	$487.16
Rate for Payer: University Health Alliance Commercial	$467.22

PACK BASIC CATARACT

Facility

IP

$80.00

Hospital Revenue Code	272
Min. Negotiated Rate	$68.00
Max. Negotiated Rate	$77.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Health Management Network Commercial	$68.00
Rate for Payer: Kaiser Permanente Commercial	$72.00
Rate for Payer: MDX Hawaii PPO	$77.60

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