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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [2357]

Facility

IP

$28.00

Service Code	NDC 00338002302
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: MDX Hawaii PPO	$27.16

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [2357]

Facility

IP

$20.00

Service Code	NDC 00264752020
Hospital Revenue Code	250
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: MDX Hawaii PPO	$19.40

DEXTROSE 10 % IV BOLUS [400302]

Facility

IP

$28.00

Service Code	NDC 00338002302
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: MDX Hawaii PPO	$27.16

DEXTROSE 10 % IV BOLUS [400302]

Facility

IP

$20.00

Service Code	NDC 00264752020
Hospital Revenue Code	250
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: MDX Hawaii PPO	$19.40

DEXTROSE 10 % IV BOLUS [400302]

Facility

IP

$25.00

Service Code	NDC 00264752000
Hospital Revenue Code	250
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: MDX Hawaii PPO	$24.25

DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE [2361]

Facility

IP

$87.00

Service Code	NDC 00409177540
Hospital Revenue Code	250
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: MDX Hawaii PPO	$84.39

DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE [2361]

Facility

IP

$87.00

Service Code	NDC 00409177510
Hospital Revenue Code	250
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: MDX Hawaii PPO	$84.39

DEXTROSE 40 % ORAL GEL [81823]

Facility

IP

$14.00

Service Code	NDC 06930000000
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: MDX Hawaii PPO	$13.58

DEXTROSE 40 % ORAL GEL [81823]

Facility

IP

$14.00

Service Code	NDC 07030000000
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: MDX Hawaii PPO	$13.58

DEXTROSE 40 % ORAL GEL [81823]

Facility

IP

$10.00

Service Code	NDC 06905000000
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

DEXTROSE 40 % ORAL GEL [81823]

Facility

IP

$10.00

Service Code	NDC 06924000000
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

DEXTROSE 40 % ORAL GEL [81823]

Facility

IP

$14.00

Service Code	NDC 06915000000
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: MDX Hawaii PPO	$13.58

DEXTROSE 40 % ORAL GEL [81823]

Facility

OP

$14.00

Service Code	NDC 06930000000
Hospital Revenue Code	637
Min. Negotiated Rate	$4.34
Max. Negotiated Rate	$13.58
Rate for Payer: AlohaCare Medicaid	$7.00
Rate for Payer: AlohaCare Medicare	$4.34
Rate for Payer: Cash Price	$8.40
Rate for Payer: Devoted Health Medicare	$4.76
Rate for Payer: Hawaii Medical Service Association Medicare	$4.34
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Humana Medicare	$4.34
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicare	$4.34
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: Ohana Health Plan Medicaid	$4.34
Rate for Payer: Ohana Health Plan Medicare	$4.34
Rate for Payer: UnitedHealthcare Medicare	$4.34
Rate for Payer: University Health Alliance Commercial	$10.20

DEXTROSE 40 % ORAL GEL [81823]

Facility

OP

$10.00

Service Code	NDC 06905000000
Hospital Revenue Code	637
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$3.10
Rate for Payer: Cash Price	$6.00
Rate for Payer: Devoted Health Medicare	$3.40
Rate for Payer: Hawaii Medical Service Association Medicare	$3.10
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$3.10
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$3.10
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$3.10
Rate for Payer: Ohana Health Plan Medicare	$3.10
Rate for Payer: UnitedHealthcare Medicare	$3.10
Rate for Payer: University Health Alliance Commercial	$7.29

DEXTROSE 40 % ORAL GEL [81823]

Facility

OP

$14.00

Service Code	NDC 07030000000
Hospital Revenue Code	637
Min. Negotiated Rate	$4.34
Max. Negotiated Rate	$13.58
Rate for Payer: AlohaCare Medicaid	$7.00
Rate for Payer: AlohaCare Medicare	$4.34
Rate for Payer: Cash Price	$8.40
Rate for Payer: Devoted Health Medicare	$4.76
Rate for Payer: Hawaii Medical Service Association Medicare	$4.34
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Humana Medicare	$4.34
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicare	$4.34
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: Ohana Health Plan Medicaid	$4.34
Rate for Payer: Ohana Health Plan Medicare	$4.34
Rate for Payer: UnitedHealthcare Medicare	$4.34
Rate for Payer: University Health Alliance Commercial	$10.20

DEXTROSE 40 % ORAL GEL [81823]

Facility

OP

$10.00

Service Code	NDC 06924000000
Hospital Revenue Code	637
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$3.10
Rate for Payer: Cash Price	$6.00
Rate for Payer: Devoted Health Medicare	$3.40
Rate for Payer: Hawaii Medical Service Association Medicare	$3.10
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$3.10
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$3.10
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$3.10
Rate for Payer: Ohana Health Plan Medicare	$3.10
Rate for Payer: UnitedHealthcare Medicare	$3.10
Rate for Payer: University Health Alliance Commercial	$7.29

DEXTROSE 40 % ORAL GEL [81823]

Facility

OP

$14.00

Service Code	NDC 06915000000
Hospital Revenue Code	637
Min. Negotiated Rate	$4.34
Max. Negotiated Rate	$13.58
Rate for Payer: AlohaCare Medicaid	$7.00
Rate for Payer: AlohaCare Medicare	$4.34
Rate for Payer: Cash Price	$8.40
Rate for Payer: Devoted Health Medicare	$4.76
Rate for Payer: Hawaii Medical Service Association Medicare	$4.34
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Humana Medicare	$4.34
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicare	$4.34
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: Ohana Health Plan Medicaid	$4.34
Rate for Payer: Ohana Health Plan Medicare	$4.34
Rate for Payer: UnitedHealthcare Medicare	$4.34
Rate for Payer: University Health Alliance Commercial	$10.20

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION [2365]

Facility

IP

$44.00

Service Code	NDC 00409664816
Hospital Revenue Code	250
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$42.68
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cash Price	$13.20
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: Kaiser Permanente Commercial	$39.60
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: MDX Hawaii PPO	$42.68
Rate for Payer: MDX Hawaii PPO	$21.34

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION [2365]

Facility

IP

$22.00

Service Code	NDC 00409664802
Hospital Revenue Code	250
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: MDX Hawaii PPO	$21.34

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [201423]

Facility

IP

$61.00

Service Code	NDC 76329330201
Hospital Revenue Code	258
Min. Negotiated Rate	$51.85
Max. Negotiated Rate	$59.17
Rate for Payer: Cash Price	$36.60
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: Kaiser Permanente Commercial	$54.90
Rate for Payer: MDX Hawaii PPO	$59.17

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [201423]

Facility

IP

$60.00

Service Code	NDC 00409751716
Hospital Revenue Code	258
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$54.00
Rate for Payer: MDX Hawaii PPO	$58.20

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [201423]

Facility

IP

$60.00

Service Code	NDC 00409751766
Hospital Revenue Code	258
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$54.00
Rate for Payer: MDX Hawaii PPO	$58.20

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [201423]

Facility

OP

$60.00

Service Code	NDC 00409751716
Hospital Revenue Code	258
Min. Negotiated Rate	$18.60
Max. Negotiated Rate	$58.20
Rate for Payer: AlohaCare Medicaid	$30.00
Rate for Payer: AlohaCare Medicare	$18.60
Rate for Payer: Cash Price	$36.00
Rate for Payer: Devoted Health Medicare	$20.40
Rate for Payer: Hawaii Medical Service Association Medicare	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Humana Medicare	$18.60
Rate for Payer: Kaiser Permanente Commercial	$54.00
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: Kaiser Permanente Medicare	$18.60
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: Ohana Health Plan Medicaid	$18.60
Rate for Payer: Ohana Health Plan Medicare	$18.60
Rate for Payer: UnitedHealthcare Medicare	$18.60
Rate for Payer: University Health Alliance Commercial	$43.73

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [201423]

Facility

OP

$61.00

Service Code	NDC 76329330201
Hospital Revenue Code	258
Min. Negotiated Rate	$18.91
Max. Negotiated Rate	$59.17
Rate for Payer: AlohaCare Medicaid	$30.50
Rate for Payer: AlohaCare Medicare	$18.91
Rate for Payer: Cash Price	$36.60
Rate for Payer: Devoted Health Medicare	$20.74
Rate for Payer: Hawaii Medical Service Association Medicare	$18.91
Rate for Payer: Hawaii Western Management Group Commercial	$57.95
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: Humana Medicare	$18.91
Rate for Payer: Kaiser Permanente Commercial	$54.90
Rate for Payer: Kaiser Permanente Medicaid	$31.11
Rate for Payer: Kaiser Permanente Medicare	$18.91
Rate for Payer: MDX Hawaii PPO	$59.17
Rate for Payer: Ohana Health Plan Medicaid	$18.91
Rate for Payer: Ohana Health Plan Medicare	$18.91
Rate for Payer: UnitedHealthcare Medicare	$18.91
Rate for Payer: University Health Alliance Commercial	$44.46

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [201423]

Facility

OP

$60.00

Service Code	NDC 00409751766
Hospital Revenue Code	258
Min. Negotiated Rate	$18.60
Max. Negotiated Rate	$58.20
Rate for Payer: AlohaCare Medicaid	$30.00
Rate for Payer: AlohaCare Medicare	$18.60
Rate for Payer: Cash Price	$36.00
Rate for Payer: Devoted Health Medicare	$20.40
Rate for Payer: Hawaii Medical Service Association Medicare	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Humana Medicare	$18.60
Rate for Payer: Kaiser Permanente Commercial	$54.00
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: Kaiser Permanente Medicare	$18.60
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: Ohana Health Plan Medicaid	$18.60
Rate for Payer: Ohana Health Plan Medicare	$18.60
Rate for Payer: UnitedHealthcare Medicare	$18.60
Rate for Payer: University Health Alliance Commercial	$43.73

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