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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION [88504]

Facility

OP

$6.00

Service Code	NDC 68094033059
Hospital Revenue Code	637
Min. Negotiated Rate	$1.86
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: Devoted Health Medicare	$2.04
Rate for Payer: Hawaii Medical Service Association Medicare	$1.86
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 Medicare	$1.86
Rate for Payer: University Health Alliance Commercial	$4.37

ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION [88504]

Facility

OP

$6.00

Service Code	NDC 68094033061
Hospital Revenue Code	637
Min. Negotiated Rate	$1.86
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: Devoted Health Medicare	$2.04
Rate for Payer: Hawaii Medical Service Association Medicare	$1.86
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 Medicare	$1.86
Rate for Payer: University Health Alliance Commercial	$4.37

ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION [88504]

Facility

IP

$5.00

Service Code	NDC 00121188200
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

ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION [88504]

Facility

IP

$6.00

Service Code	NDC 68094033062
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

ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION [88504]

Facility

IP

$6.00

Service Code	NDC 68094033059
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

ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION [88504]

Facility

OP

$5.00

Service Code	NDC 00121188200
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

ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION [88504]

Facility

IP

$6.00

Service Code	NDC 68094033061
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

ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION [88504]

Facility

OP

$6.00

Service Code	NDC 68094033062
Hospital Revenue Code	637
Min. Negotiated Rate	$1.86
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: Devoted Health Medicare	$2.04
Rate for Payer: Hawaii Medical Service Association Medicare	$1.86
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 Medicare	$1.86
Rate for Payer: University Health Alliance Commercial	$4.37

ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY [104]

Facility

OP

$5.00

Service Code	NDC 51672211602
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

ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY [104]

Facility

IP

$5.00

Service Code	NDC 51672211600
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

ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY [104]

Facility

OP

$5.00

Service Code	NDC 51672211600
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

ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY [104]

Facility

IP

$5.00

Service Code	NDC 51672211602
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

ACETAMINOPHEN 325 MG TABLET [101]

Facility

IP

$1.00

Service Code	NDC 00536132710
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

ACETAMINOPHEN 325 MG TABLET [101]

Facility

OP

$1.00

Service Code	NDC 00536132710
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

ACETAMINOPHEN 325 MG TABLET [101]

Facility

OP

$1.00

Service Code	NDC 00904677361
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

ACETAMINOPHEN 325 MG TABLET [101]

Facility

IP

$1.00

Service Code	NDC 50580045811
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

ACETAMINOPHEN 325 MG TABLET [101]

Facility

OP

$1.00

Service Code	NDC 50580045811
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

ACETAMINOPHEN 325 MG TABLET [101]

Facility

IP

$1.00

Service Code	NDC 00904677361
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

ACETAMINOPHEN 500 MG/50 ML (10 MG/ML) INTRAVENOUS SOLUTION [205406]

Facility

OP

$26.00

Service Code	HCPCS J0136
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$25.22
Rate for Payer: AlohaCare Medicaid	$13.00
Rate for Payer: AlohaCare Medicare	$8.06
Rate for Payer: Cash Price	$15.60
Rate for Payer: Cash Price	$15.60
Rate for Payer: Devoted Health Medicare	$8.84
Rate for Payer: Hawaii Medical Service Association ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Medicare	$8.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.05
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Humana Medicare	$8.06
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: Kaiser Permanente Medicare	$8.06
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: Ohana Health Plan Medicaid	$8.06
Rate for Payer: Ohana Health Plan Medicare	$8.06
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: UnitedHealthcare Medicare	$8.06
Rate for Payer: University Health Alliance Commercial	$18.95

ACETAMINOPHEN 500 MG/50 ML (10 MG/ML) INTRAVENOUS SOLUTION [205406]

Facility

IP

$26.00

Service Code	HCPCS J0136
Hospital Revenue Code	250
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: MDX Hawaii PPO	$25.22

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]

Facility

IP

$3.00

Service Code	NDC 45802073000
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]

Facility

OP

$3.00

Service Code	NDC 45802073030
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

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]

Facility

IP

$3.00

Service Code	NDC 45802073030
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]

Facility

IP

$2.00

Service Code	NDC 45802073033
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

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]

Facility

OP

$2.00

Service Code	NDC 45802073033
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

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