Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]

Facility

IP

$991.00

Service Code	NDC 55566280001
Hospital Revenue Code	250
Min. Negotiated Rate	$842.35
Max. Negotiated Rate	$961.27
Rate for Payer: Cash Price	$594.60
Rate for Payer: Health Management Network Commercial	$842.35
Rate for Payer: Kaiser Permanente Commercial	$891.90
Rate for Payer: MDX Hawaii PPO	$961.27

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]

Facility

OP

$19.00

Service Code	NDC 00121048905
Hospital Revenue Code	637
Min. Negotiated Rate	$5.89
Max. Negotiated Rate	$18.43
Rate for Payer: AlohaCare Medicaid	$9.50
Rate for Payer: AlohaCare Medicare	$5.89
Rate for Payer: Cash Price	$11.40
Rate for Payer: Devoted Health Medicare	$6.46
Rate for Payer: Hawaii Medical Service Association Medicare	$5.89
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Humana Medicare	$5.89
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: Kaiser Permanente Medicare	$5.89
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: Ohana Health Plan Medicaid	$5.89
Rate for Payer: Ohana Health Plan Medicare	$5.89
Rate for Payer: UnitedHealthcare Medicare	$5.89
Rate for Payer: University Health Alliance Commercial	$13.85

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]

Facility

OP

$19.00

Service Code	NDC 00121048900
Hospital Revenue Code	637
Min. Negotiated Rate	$5.89
Max. Negotiated Rate	$18.43
Rate for Payer: AlohaCare Medicaid	$9.50
Rate for Payer: AlohaCare Medicare	$5.89
Rate for Payer: Cash Price	$11.40
Rate for Payer: Devoted Health Medicare	$6.46
Rate for Payer: Hawaii Medical Service Association Medicare	$5.89
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Humana Medicare	$5.89
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: Kaiser Permanente Medicare	$5.89
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: Ohana Health Plan Medicaid	$5.89
Rate for Payer: Ohana Health Plan Medicare	$5.89
Rate for Payer: UnitedHealthcare Medicare	$5.89
Rate for Payer: University Health Alliance Commercial	$13.85

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]

Facility

IP

$19.00

Service Code	NDC 00121048905
Hospital Revenue Code	250
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: MDX Hawaii PPO	$18.43

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]

Facility

IP

$19.00

Service Code	NDC 00121048900
Hospital Revenue Code	250
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: MDX Hawaii PPO	$18.43

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]

Facility

OP

$9.00

Service Code	NDC 69339015105
Hospital Revenue Code	637
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$2.79
Rate for Payer: Cash Price	$5.40
Rate for Payer: Devoted Health Medicare	$3.06
Rate for Payer: Hawaii Medical Service Association Medicare	$2.79
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$2.79
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$2.79
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$2.79
Rate for Payer: Ohana Health Plan Medicare	$2.79
Rate for Payer: UnitedHealthcare Medicare	$2.79
Rate for Payer: University Health Alliance Commercial	$6.56

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]

Facility

IP

$9.00

Service Code	NDC 69339015119
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]

Facility

IP

$9.00

Service Code	NDC 69339015105
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]

Facility

OP

$9.00

Service Code	NDC 69339015119
Hospital Revenue Code	637
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$2.79
Rate for Payer: Cash Price	$5.40
Rate for Payer: Devoted Health Medicare	$3.06
Rate for Payer: Hawaii Medical Service Association Medicare	$2.79
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$2.79
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$2.79
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$2.79
Rate for Payer: Ohana Health Plan Medicare	$2.79
Rate for Payer: UnitedHealthcare Medicare	$2.79
Rate for Payer: University Health Alliance Commercial	$6.56

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]

Facility

IP

$10.00

Service Code	NDC 00904698520
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

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]

Facility

OP

$10.00

Service Code	NDC 00904698520
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

DIPHENHYDRAMINE 25 MG CAPSULE [2509]

Facility

IP

$1.00

Service Code	HCPCS Q0163
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

DIPHENHYDRAMINE 25 MG CAPSULE [2509]

Facility

OP

$1.00

Service Code	HCPCS Q0163
Hospital Revenue Code	637
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.31
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.34
Rate for Payer: Hawaii Medical Service Association Medicare	$0.31
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.31
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.31
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.31
Rate for Payer: Ohana Health Plan Medicare	$0.31
Rate for Payer: UnitedHealthcare Medicare	$0.31
Rate for Payer: University Health Alliance Commercial	$0.73

DIPHENHYDRAMINE 50 MG CAPSULE [2510]

Facility

OP

$1.00

Service Code	HCPCS Q0163
Hospital Revenue Code	637
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.31
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.34
Rate for Payer: Hawaii Medical Service Association Medicare	$0.31
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.31
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.31
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.31
Rate for Payer: Ohana Health Plan Medicare	$0.31
Rate for Payer: UnitedHealthcare Medicare	$0.31
Rate for Payer: University Health Alliance Commercial	$0.73

DIPHENHYDRAMINE 50 MG CAPSULE [2510]

Facility

IP

$1.00

Service Code	HCPCS Q0163
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

DIPHENHYDRAMINE 50 MG IN 50 MG NS IVPB-CNR (SIMPLE) [4080017]

Facility

OP

$6.00

Service Code	HCPCS J1200
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$1.86
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$3.60
Rate for Payer: Devoted Health Medicare	$2.04
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Medicare	$1.86
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$1.86
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$1.86
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$1.86
Rate for Payer: Ohana Health Plan Medicare	$1.86
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: UnitedHealthcare Medicare	$1.86
Rate for Payer: University Health Alliance Commercial	$4.37

DIPHENHYDRAMINE 50 MG IN 50 MG NS IVPB-CNR (SIMPLE) [4080017]

Facility

IP

$6.00

Service Code	HCPCS J1200
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]

Facility

OP

$7.00

Service Code	HCPCS J1200
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$1.55
Rate for Payer: AlohaCare Medicare	$2.17
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$4.20
Rate for Payer: Devoted Health Medicare	$1.70
Rate for Payer: Devoted Health Medicare	$2.38
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Medicare	$1.55
Rate for Payer: Hawaii Medical Service Association Medicare	$2.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$1.55
Rate for Payer: Humana Medicare	$2.17
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$1.55
Rate for Payer: Kaiser Permanente Medicare	$2.17
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$2.17
Rate for Payer: Ohana Health Plan Medicaid	$1.55
Rate for Payer: Ohana Health Plan Medicare	$1.55
Rate for Payer: Ohana Health Plan Medicare	$2.17
Rate for Payer: UnitedHealthcare Medicaid	$3.00
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: UnitedHealthcare Medicare	$2.17
Rate for Payer: UnitedHealthcare Medicare	$1.55
Rate for Payer: University Health Alliance Commercial	$3.64
Rate for Payer: University Health Alliance Commercial	$5.10

DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]

Facility

IP

$5.00

Service Code	HCPCS J1200
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: MDX Hawaii PPO	$6.79

DIPHENHYDRAMINE CAPSULES (BENADRYL) 25 MG (TAKE HOME) [4080356]

Facility

OP

$15.00

Service Code	HCPCS Q0163
Hospital Revenue Code	253
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$4.65
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$5.10
Rate for Payer: Hawaii Medical Service Association Medicare	$4.65
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$4.65
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$4.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$4.65
Rate for Payer: Ohana Health Plan Medicare	$4.65
Rate for Payer: UnitedHealthcare Medicare	$4.65
Rate for Payer: University Health Alliance Commercial	$10.93

DIPHENHYDRAMINE CAPSULES (BENADRYL) 25 MG (TAKE HOME) [4080356]

Facility

IP

$15.00

Service Code	HCPCS Q0163
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

DIPHENHYDRAMINE SOLUTION (BENADRYL) 12.5 MG/5 ML (118 ML) (TAKE HOME) [4080355]

Facility

OP

$15.00

Service Code	NDC 00004080143
Hospital Revenue Code	253
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$4.65
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$5.10
Rate for Payer: Hawaii Medical Service Association Medicare	$4.65
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$4.65
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$4.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$4.65
Rate for Payer: Ohana Health Plan Medicare	$4.65
Rate for Payer: UnitedHealthcare Medicare	$4.65
Rate for Payer: University Health Alliance Commercial	$10.93

DIPHENHYDRAMINE SOLUTION (BENADRYL) 12.5 MG/5 ML (118 ML) (TAKE HOME) [4080355]

Facility

IP

$15.00

Service Code	NDC 00004080143
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

DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]

Facility

IP

$71.00

Service Code	HCPCS 90700
Hospital Revenue Code	250
Min. Negotiated Rate	$60.35
Max. Negotiated Rate	$68.87
Rate for Payer: Cash Price	$42.60
Rate for Payer: Health Management Network Commercial	$60.35
Rate for Payer: Kaiser Permanente Commercial	$63.90
Rate for Payer: MDX Hawaii PPO	$68.87

DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]

Facility

OP

$71.00

Service Code	HCPCS 90700
Hospital Revenue Code	636
Min. Negotiated Rate	$22.01
Max. Negotiated Rate	$68.87
Rate for Payer: AlohaCare Medicaid	$35.50
Rate for Payer: AlohaCare Medicare	$22.01
Rate for Payer: Cash Price	$42.60
Rate for Payer: Cash Price	$42.60
Rate for Payer: Devoted Health Medicare	$24.14
Rate for Payer: Hawaii Medical Service Association ABD	$32.42
Rate for Payer: Hawaii Medical Service Association Medicare	$22.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$32.42
Rate for Payer: Hawaii Western Management Group Commercial	$67.45
Rate for Payer: Health Management Network Commercial	$60.35
Rate for Payer: Humana Medicare	$22.01
Rate for Payer: Kaiser Permanente Commercial	$63.90
Rate for Payer: Kaiser Permanente Medicaid	$36.21
Rate for Payer: Kaiser Permanente Medicare	$22.01
Rate for Payer: MDX Hawaii PPO	$68.87
Rate for Payer: Ohana Health Plan Medicaid	$22.01
Rate for Payer: Ohana Health Plan Medicare	$22.01
Rate for Payer: UnitedHealthcare Medicaid	$42.60
Rate for Payer: UnitedHealthcare Medicare	$22.01
Rate for Payer: University Health Alliance Commercial	$51.75

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