Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]

Facility

IP

$33.00

Service Code	NDC 00006022101
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: MDX Hawaii PPO	$32.01

SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]

Facility

OP

$33.00

Service Code	NDC 00006022131
Hospital Revenue Code	637
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$25.08
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$27.72
Rate for Payer: Hawaii Medical Service Association Medicare	$25.08
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$25.08
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$25.08
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$25.08
Rate for Payer: Ohana Health Plan Medicare	$25.08
Rate for Payer: UnitedHealthcare Medicare	$25.08
Rate for Payer: University Health Alliance Commercial	$24.05

SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]

Facility

IP

$33.00

Service Code	NDC 00006022128
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: MDX Hawaii PPO	$32.01

SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]

Facility

OP

$33.00

Service Code	NDC 00006011254
Hospital Revenue Code	637
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$25.08
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$27.72
Rate for Payer: Hawaii Medical Service Association Medicare	$25.08
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$25.08
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$25.08
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$25.08
Rate for Payer: Ohana Health Plan Medicare	$25.08
Rate for Payer: UnitedHealthcare Medicare	$25.08
Rate for Payer: University Health Alliance Commercial	$24.05

SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]

Facility

IP

$33.00

Service Code	NDC 00006011201
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: MDX Hawaii PPO	$32.01

SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]

Facility

IP

$33.00

Service Code	NDC 00006011254
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: MDX Hawaii PPO	$32.01

SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]

Facility

IP

$33.00

Service Code	NDC 00006011228
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: MDX Hawaii PPO	$32.01

SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]

Facility

IP

$33.00

Service Code	NDC 00006011231
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: MDX Hawaii PPO	$32.01

SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]

Facility

OP

$33.00

Service Code	NDC 00006011201
Hospital Revenue Code	637
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$25.08
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$27.72
Rate for Payer: Hawaii Medical Service Association Medicare	$25.08
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$25.08
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$25.08
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$25.08
Rate for Payer: Ohana Health Plan Medicare	$25.08
Rate for Payer: UnitedHealthcare Medicare	$25.08
Rate for Payer: University Health Alliance Commercial	$24.05

SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]

Facility

OP

$33.00

Service Code	NDC 00006011228
Hospital Revenue Code	637
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$25.08
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$27.72
Rate for Payer: Hawaii Medical Service Association Medicare	$25.08
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$25.08
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$25.08
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$25.08
Rate for Payer: Ohana Health Plan Medicare	$25.08
Rate for Payer: UnitedHealthcare Medicare	$25.08
Rate for Payer: University Health Alliance Commercial	$24.05

SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]

Facility

OP

$33.00

Service Code	NDC 00006011231
Hospital Revenue Code	637
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$25.08
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$27.72
Rate for Payer: Hawaii Medical Service Association Medicare	$25.08
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$25.08
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$25.08
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$25.08
Rate for Payer: Ohana Health Plan Medicare	$25.08
Rate for Payer: UnitedHealthcare Medicare	$25.08
Rate for Payer: University Health Alliance Commercial	$24.05

SIZER GEL 325CC GS10621-325MP

Facility

IP

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 325CC GS10621-325MP

Facility

OP

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$422.00
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$641.44
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$708.96
Rate for Payer: Hawaii Medical Service Association Medicare	$641.44
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$641.44
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$641.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$641.44
Rate for Payer: Ohana Health Plan Medicare	$641.44
Rate for Payer: UnitedHealthcare Medicare	$641.44
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 355CC GS10621-355MP

Facility

OP

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$422.00
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$641.44
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$708.96
Rate for Payer: Hawaii Medical Service Association Medicare	$641.44
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$641.44
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$641.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$641.44
Rate for Payer: Ohana Health Plan Medicare	$641.44
Rate for Payer: UnitedHealthcare Medicare	$641.44
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 355CC GS10621-355MP

Facility

IP

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 385CC GS10621-385MP

Facility

OP

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$422.00
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$641.44
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$708.96
Rate for Payer: Hawaii Medical Service Association Medicare	$641.44
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$641.44
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$641.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$641.44
Rate for Payer: Ohana Health Plan Medicare	$641.44
Rate for Payer: UnitedHealthcare Medicare	$641.44
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 385CC GS10621-385MP

Facility

IP

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 415CC GS10621-415MP

Facility

OP

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$422.00
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$641.44
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$708.96
Rate for Payer: Hawaii Medical Service Association Medicare	$641.44
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$641.44
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$641.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$641.44
Rate for Payer: Ohana Health Plan Medicare	$641.44
Rate for Payer: UnitedHealthcare Medicare	$641.44
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 415CC GS10621-415MP

Facility

IP

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 445CC GS10621-455MP

Facility

OP

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$422.00
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$641.44
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$708.96
Rate for Payer: Hawaii Medical Service Association Medicare	$641.44
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$641.44
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$641.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$641.44
Rate for Payer: Ohana Health Plan Medicare	$641.44
Rate for Payer: UnitedHealthcare Medicare	$641.44
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 445CC GS10621-455MP

Facility

IP

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 535CC GS10621-535HP

Facility

OP

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$422.00
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$641.44
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$708.96
Rate for Payer: Hawaii Medical Service Association Medicare	$641.44
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$641.44
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$641.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$641.44
Rate for Payer: Ohana Health Plan Medicare	$641.44
Rate for Payer: UnitedHealthcare Medicare	$641.44
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 535CC GS10621-535HP

Facility

IP

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 650CC GS10621-650HP

Facility

IP

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

SIZER GEL 650CC GS10621-650HP

Facility

OP

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$422.00
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$641.44
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$708.96
Rate for Payer: Hawaii Medical Service Association Medicare	$641.44
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$641.44
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$641.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$641.44
Rate for Payer: Ohana Health Plan Medicare	$641.44
Rate for Payer: UnitedHealthcare Medicare	$641.44
Rate for Payer: University Health Alliance Commercial	$472.64

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