Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

HYDROXYUREA 500 MG CAPSULE [10236]

Facility

IP

$5.00

Service Code	NDC 49884072401
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

HYDROXYUREA 500 MG CAPSULE [10236]

Facility

OP

$4.00

Service Code	NDC 68084028411
Hospital Revenue Code	637
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$1.24
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$1.36
Rate for Payer: Hawaii Medical Service Association Medicare	$1.24
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$1.24
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$1.24
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$1.24
Rate for Payer: Ohana Health Plan Medicare	$1.24
Rate for Payer: UnitedHealthcare Medicare	$1.24
Rate for Payer: University Health Alliance Commercial	$2.92

HYDROXYUREA 500 MG CAPSULE [10236]

Facility

OP

$5.00

Service Code	NDC 49884072401
Hospital Revenue Code	637
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$1.55
Rate for Payer: Cash Price	$3.00
Rate for Payer: Devoted Health Medicare	$1.70
Rate for Payer: Hawaii Medical Service Association Medicare	$1.55
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$1.55
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$1.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$1.55
Rate for Payer: Ohana Health Plan Medicare	$1.55
Rate for Payer: UnitedHealthcare Medicare	$1.55
Rate for Payer: University Health Alliance Commercial	$3.64

HYDROXYUREA 500 MG CAPSULE [10236]

Facility

IP

$4.00

Service Code	NDC 68084028411
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

HYDROXYUREA 500 MG CAPSULE [10236]

Facility

IP

$4.00

Service Code	NDC 68084028401
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

HYDROXYUREA 500 MG CAPSULE [10236]

Facility

OP

$4.00

Service Code	NDC 68084028401
Hospital Revenue Code	637
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$1.24
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$1.36
Rate for Payer: Hawaii Medical Service Association Medicare	$1.24
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$1.24
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$1.24
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$1.24
Rate for Payer: Ohana Health Plan Medicare	$1.24
Rate for Payer: UnitedHealthcare Medicare	$1.24
Rate for Payer: University Health Alliance Commercial	$2.92

HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]

Facility

OP

$390.00

Service Code	NDC 54838050280
Hospital Revenue Code	637
Min. Negotiated Rate	$120.90
Max. Negotiated Rate	$378.30
Rate for Payer: AlohaCare Medicaid	$195.00
Rate for Payer: AlohaCare Medicare	$120.90
Rate for Payer: Cash Price	$234.00
Rate for Payer: Devoted Health Medicare	$132.60
Rate for Payer: Hawaii Medical Service Association Medicare	$120.90
Rate for Payer: Hawaii Western Management Group Commercial	$370.50
Rate for Payer: Health Management Network Commercial	$331.50
Rate for Payer: Humana Medicare	$120.90
Rate for Payer: Kaiser Permanente Commercial	$351.00
Rate for Payer: Kaiser Permanente Medicaid	$198.90
Rate for Payer: Kaiser Permanente Medicare	$120.90
Rate for Payer: MDX Hawaii PPO	$378.30
Rate for Payer: Ohana Health Plan Medicaid	$120.90
Rate for Payer: Ohana Health Plan Medicare	$120.90
Rate for Payer: UnitedHealthcare Medicare	$120.90
Rate for Payer: University Health Alliance Commercial	$284.27

HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]

Facility

IP

$390.00

Service Code	NDC 54838050280
Hospital Revenue Code	250
Min. Negotiated Rate	$331.50
Max. Negotiated Rate	$378.30
Rate for Payer: Cash Price	$234.00
Rate for Payer: Health Management Network Commercial	$331.50
Rate for Payer: Kaiser Permanente Commercial	$351.00
Rate for Payer: MDX Hawaii PPO	$378.30

HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]

Facility

IP

$887.00

Service Code	NDC 62135075047
Hospital Revenue Code	250
Min. Negotiated Rate	$753.95
Max. Negotiated Rate	$860.39
Rate for Payer: Cash Price	$532.20
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: MDX Hawaii PPO	$860.39

HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]

Facility

OP

$887.00

Service Code	NDC 62135075047
Hospital Revenue Code	637
Min. Negotiated Rate	$274.97
Max. Negotiated Rate	$860.39
Rate for Payer: AlohaCare Medicaid	$443.50
Rate for Payer: AlohaCare Medicare	$274.97
Rate for Payer: Cash Price	$532.20
Rate for Payer: Devoted Health Medicare	$301.58
Rate for Payer: Hawaii Medical Service Association Medicare	$274.97
Rate for Payer: Hawaii Western Management Group Commercial	$842.65
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Humana Medicare	$274.97
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: Kaiser Permanente Medicaid	$452.37
Rate for Payer: Kaiser Permanente Medicare	$274.97
Rate for Payer: MDX Hawaii PPO	$860.39
Rate for Payer: Ohana Health Plan Medicaid	$274.97
Rate for Payer: Ohana Health Plan Medicare	$274.97
Rate for Payer: UnitedHealthcare Medicare	$274.97
Rate for Payer: University Health Alliance Commercial	$646.53

HYDROXYZINE HCL 10 MG TABLET [3772]

Facility

OP

$1.00

Service Code	NDC 60687066411
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

HYDROXYZINE HCL 10 MG TABLET [3772]

Facility

OP

$1.00

Service Code	NDC 60687066401
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

HYDROXYZINE HCL 10 MG TABLET [3772]

Facility

IP

$1.00

Service Code	NDC 60687066411
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

HYDROXYZINE HCL 10 MG TABLET [3772]

Facility

IP

$1.00

Service Code	NDC 60687066401
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

HYDROXYZINE HCL 25 MG TABLET [3774]

Facility

OP

$2.00

Service Code	NDC 60687067501
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

HYDROXYZINE HCL 25 MG TABLET [3774]

Facility

OP

$2.00

Service Code	NDC 60687067511
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

HYDROXYZINE HCL 25 MG TABLET [3774]

Facility

IP

$2.00

Service Code	NDC 60687067501
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

HYDROXYZINE HCL 25 MG TABLET [3774]

Facility

IP

$4.00

Service Code	NDC 00093506101
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

HYDROXYZINE HCL 25 MG TABLET [3774]

Facility

OP

$4.00

Service Code	NDC 00093506101
Hospital Revenue Code	637
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$1.24
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$1.36
Rate for Payer: Hawaii Medical Service Association Medicare	$1.24
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$1.24
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$1.24
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$1.24
Rate for Payer: Ohana Health Plan Medicare	$1.24
Rate for Payer: UnitedHealthcare Medicare	$1.24
Rate for Payer: University Health Alliance Commercial	$2.92

HYDROXYZINE HCL 25 MG TABLET [3774]

Facility

IP

$2.00

Service Code	NDC 60687067511
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION [3770]

Facility

IP

$102.00

Service Code	HCPCS J3410
Hospital Revenue Code	250
Min. Negotiated Rate	$86.70
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$61.20
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Kaiser Permanente Commercial	$91.80
Rate for Payer: MDX Hawaii PPO	$98.94

HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION [3770]

Facility

OP

$102.00

Service Code	HCPCS J3410
Hospital Revenue Code	636
Min. Negotiated Rate	$16.93
Max. Negotiated Rate	$98.94
Rate for Payer: AlohaCare Medicaid	$51.00
Rate for Payer: AlohaCare Medicare	$31.62
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cash Price	$61.20
Rate for Payer: Devoted Health Medicare	$34.68
Rate for Payer: Hawaii Medical Service Association ABD	$16.93
Rate for Payer: Hawaii Medical Service Association Medicare	$31.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.93
Rate for Payer: Hawaii Western Management Group Commercial	$96.90
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Humana Medicare	$31.62
Rate for Payer: Kaiser Permanente Commercial	$91.80
Rate for Payer: Kaiser Permanente Medicaid	$52.02
Rate for Payer: Kaiser Permanente Medicare	$31.62
Rate for Payer: MDX Hawaii PPO	$98.94
Rate for Payer: Ohana Health Plan Medicaid	$31.62
Rate for Payer: Ohana Health Plan Medicare	$31.62
Rate for Payer: UnitedHealthcare Medicaid	$61.20
Rate for Payer: UnitedHealthcare Medicare	$31.62
Rate for Payer: University Health Alliance Commercial	$74.35

HYDROXYZINE HCL TABLETS (ATARAX) 25 MG (TAKE HOME) [4080366]

Facility

IP

$15.00

Service Code	NDC 00004080154
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

HYDROXYZINE HCL TABLETS (ATARAX) 25 MG (TAKE HOME) [4080366]

Facility

OP

$15.00

Service Code	NDC 00004080154
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

HYOSCYAMINE SULFATE 0.125 MG TABLET [3783]

Facility

OP

$3.00

Service Code	NDC 42192034001
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

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