Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

HYDROmorphone 2 mg tablet [HHSC]

Facility

OP

$3.96

Service Code	NDC 60687057901
Hospital Charge Code	2500401
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$3.84
Rate for Payer: AlohaCare Medicaid	$1.98
Rate for Payer: AlohaCare Medicare	$1.98
Rate for Payer: Cash Price	$2.57
Rate for Payer: Devoted Health Medicare	$2.18
Rate for Payer: Hawaii Medical Service Association Medicare	$1.98
Rate for Payer: Hawaii Western Management Group Commercial	$3.76
Rate for Payer: Health Management Network Commercial	$3.37
Rate for Payer: Humana Medicare	$1.98
Rate for Payer: Kaiser Permanente Commercial	$3.56
Rate for Payer: Kaiser Permanente Medicaid	$2.02
Rate for Payer: Kaiser Permanente Medicare	$1.98
Rate for Payer: MDX Hawaii PPO	$3.84
Rate for Payer: Ohana Health Plan Medicaid	$1.98
Rate for Payer: Ohana Health Plan Medicare	$1.98
Rate for Payer: UnitedHealthcare Medicaid	$2.38
Rate for Payer: UnitedHealthcare Medicare	$1.98
Rate for Payer: University Health Alliance Commercial	$2.89

HYDROmorphone 2 mg tablet [HHSC]

Facility

IP

$3.00

Service Code	NDC 68084042301
Hospital Charge Code	2500401
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
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

hydrOXYzine 25 mg tablet [HHSC]

Facility

IP

$3.00

Service Code	NDC 60687067501
Hospital Charge Code	2500404
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
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

hydrOXYzine 25 mg tablet [HHSC]

Facility

IP

$3.00

Service Code	NDC 63739048610
Hospital Charge Code	2500404
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
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

hydrOXYzine 25 mg tablet [HHSC]

Facility

OP

$3.00

Service Code	NDC 60687067501
Hospital Charge Code	2500404
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

hydrOXYzine 25 mg tablet [HHSC]

Facility

OP

$3.00

Service Code	NDC 63739048610
Hospital Charge Code	2500404
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

hydrOXYzine 25 mg tablet [HHSC]

Facility

IP

$5.09

Service Code	NDC 00093506101
Hospital Charge Code	2500404
Hospital Revenue Code	250
Min. Negotiated Rate	$4.33
Max. Negotiated Rate	$4.94
Rate for Payer: Cash Price	$3.31
Rate for Payer: Health Management Network Commercial	$4.33
Rate for Payer: Kaiser Permanente Commercial	$4.58
Rate for Payer: MDX Hawaii PPO	$4.94

hydrOXYzine 25 mg tablet [HHSC]

Facility

IP

$3.00

Service Code	NDC 68084025401
Hospital Charge Code	2500404
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
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

hydrOXYzine 25 mg tablet [HHSC]

Facility

IP

$5.11

Service Code	NDC 42806016001
Hospital Charge Code	2500404
Hospital Revenue Code	250
Min. Negotiated Rate	$4.34
Max. Negotiated Rate	$4.96
Rate for Payer: Cash Price	$3.32
Rate for Payer: Health Management Network Commercial	$4.34
Rate for Payer: Kaiser Permanente Commercial	$4.60
Rate for Payer: MDX Hawaii PPO	$4.96

hydrOXYzine 25 mg tablet [HHSC]

Facility

IP

$3.00

Service Code	NDC 00904661761
Hospital Charge Code	2500404
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
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

hydrOXYzine 25 mg tablet [HHSC]

Facility

OP

$5.11

Service Code	NDC 42806016001
Hospital Charge Code	2500404
Hospital Revenue Code	250
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$4.96
Rate for Payer: AlohaCare Medicaid	$2.56
Rate for Payer: AlohaCare Medicare	$2.56
Rate for Payer: Cash Price	$3.32
Rate for Payer: Devoted Health Medicare	$2.81
Rate for Payer: Hawaii Medical Service Association Medicare	$2.56
Rate for Payer: Hawaii Western Management Group Commercial	$4.85
Rate for Payer: Health Management Network Commercial	$4.34
Rate for Payer: Humana Medicare	$2.56
Rate for Payer: Kaiser Permanente Commercial	$4.60
Rate for Payer: Kaiser Permanente Medicaid	$2.61
Rate for Payer: Kaiser Permanente Medicare	$2.56
Rate for Payer: MDX Hawaii PPO	$4.96
Rate for Payer: Ohana Health Plan Medicaid	$2.56
Rate for Payer: Ohana Health Plan Medicare	$2.56
Rate for Payer: UnitedHealthcare Medicaid	$3.07
Rate for Payer: UnitedHealthcare Medicare	$2.56
Rate for Payer: University Health Alliance Commercial	$3.72

hydrOXYzine 25 mg tablet [HHSC]

Facility

OP

$3.00

Service Code	NDC 68084025401
Hospital Charge Code	2500404
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

hydrOXYzine 25 mg tablet [HHSC]

Facility

OP

$5.09

Service Code	NDC 00093506101
Hospital Charge Code	2500404
Hospital Revenue Code	250
Min. Negotiated Rate	$2.54
Max. Negotiated Rate	$4.94
Rate for Payer: AlohaCare Medicaid	$2.54
Rate for Payer: AlohaCare Medicare	$2.54
Rate for Payer: Cash Price	$3.31
Rate for Payer: Devoted Health Medicare	$2.80
Rate for Payer: Hawaii Medical Service Association Medicare	$2.54
Rate for Payer: Hawaii Western Management Group Commercial	$4.84
Rate for Payer: Health Management Network Commercial	$4.33
Rate for Payer: Humana Medicare	$2.54
Rate for Payer: Kaiser Permanente Commercial	$4.58
Rate for Payer: Kaiser Permanente Medicaid	$2.60
Rate for Payer: Kaiser Permanente Medicare	$2.54
Rate for Payer: MDX Hawaii PPO	$4.94
Rate for Payer: Ohana Health Plan Medicaid	$2.54
Rate for Payer: Ohana Health Plan Medicare	$2.54
Rate for Payer: UnitedHealthcare Medicaid	$3.05
Rate for Payer: UnitedHealthcare Medicare	$2.54
Rate for Payer: University Health Alliance Commercial	$3.71

hydrOXYzine 25 mg tablet [HHSC]

Facility

OP

$3.00

Service Code	NDC 00904661761
Hospital Charge Code	2500404
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

hydrOXYzine HCl 50 mg/1 mL vial [HHSC]

Facility

IP

$166.32

Service Code	HCPCS J3410
Hospital Charge Code	2500405
Hospital Revenue Code	250
Min. Negotiated Rate	$141.37
Max. Negotiated Rate	$161.33
Rate for Payer: Cash Price	$108.11
Rate for Payer: Health Management Network Commercial	$141.37
Rate for Payer: Kaiser Permanente Commercial	$149.69
Rate for Payer: MDX Hawaii PPO	$161.33

hydrOXYzine HCl 50 mg/1 mL vial [HHSC]

Facility

OP

$166.32

Service Code	HCPCS J3410
Hospital Charge Code	2500405
Hospital Revenue Code	636
Min. Negotiated Rate	$16.93
Max. Negotiated Rate	$161.33
Rate for Payer: AlohaCare Medicaid	$83.16
Rate for Payer: AlohaCare Medicare	$83.16
Rate for Payer: Cash Price	$108.11
Rate for Payer: Cash Price	$108.11
Rate for Payer: Devoted Health Medicare	$91.48
Rate for Payer: Hawaii Medical Service Association ABD	$16.93
Rate for Payer: Hawaii Medical Service Association Medicare	$83.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.93
Rate for Payer: Hawaii Western Management Group Commercial	$158.00
Rate for Payer: Health Management Network Commercial	$141.37
Rate for Payer: Humana Medicare	$83.16
Rate for Payer: Kaiser Permanente Commercial	$149.69
Rate for Payer: Kaiser Permanente Medicaid	$84.82
Rate for Payer: Kaiser Permanente Medicare	$83.16
Rate for Payer: MDX Hawaii PPO	$161.33
Rate for Payer: Ohana Health Plan Medicaid	$83.16
Rate for Payer: Ohana Health Plan Medicare	$83.16
Rate for Payer: UnitedHealthcare Medicaid	$99.79
Rate for Payer: UnitedHealthcare Medicare	$83.16
Rate for Payer: University Health Alliance Commercial	$121.23

HYPERTENSION WITH MCC

Facility

IP

$14,736.69

Service Code	MSDRG 304
Min. Negotiated Rate	$14,736.69
Max. Negotiated Rate	$14,736.69
Rate for Payer: Hawaii Medical Service Association Commercial	$14,736.69

HYPERTENSION WITHOUT MCC

Facility

IP

$14,736.69

Service Code	MSDRG 305
Min. Negotiated Rate	$14,736.69
Max. Negotiated Rate	$14,736.69
Rate for Payer: Hawaii Medical Service Association Commercial	$14,736.69

HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)

Facility

OP

$24,500.00

Service Code	CPT 58563
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$24,500.00
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$24,500.00

HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY

Facility

OP

$6,743.44

Service Code	CPT 58562
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$1,030.55
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$6,743.44

HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA

Facility

OP

$11,119.00

Service Code	CPT 58561
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$11,119.00
Rate for Payer: AlohaCare Medicaid	$1,030.55
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$11,119.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$6,743.44

HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C

Facility

OP

$7,085.00

Service Code	CPT 58558
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,085.00
Rate for Payer: AlohaCare Medicaid	$1,030.55
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$7,085.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$6,743.44

ibuprofen 100 mg/5 mL cup [HHSC]

Facility

OP

$5.20

Service Code	NDC 68094060062
Hospital Charge Code	2500407
Hospital Revenue Code	250
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$5.04
Rate for Payer: AlohaCare Medicaid	$2.60
Rate for Payer: AlohaCare Medicare	$2.60
Rate for Payer: Cash Price	$3.38
Rate for Payer: Devoted Health Medicare	$2.86
Rate for Payer: Hawaii Medical Service Association Medicare	$2.60
Rate for Payer: Hawaii Western Management Group Commercial	$4.94
Rate for Payer: Health Management Network Commercial	$4.42
Rate for Payer: Humana Medicare	$2.60
Rate for Payer: Kaiser Permanente Commercial	$4.68
Rate for Payer: Kaiser Permanente Medicaid	$2.65
Rate for Payer: Kaiser Permanente Medicare	$2.60
Rate for Payer: MDX Hawaii PPO	$5.04
Rate for Payer: Ohana Health Plan Medicaid	$2.60
Rate for Payer: Ohana Health Plan Medicare	$2.60
Rate for Payer: UnitedHealthcare Medicaid	$3.12
Rate for Payer: UnitedHealthcare Medicare	$2.60
Rate for Payer: University Health Alliance Commercial	$3.79

ibuprofen 100 mg/5 mL cup [HHSC]

Facility

IP

$10.45

Service Code	NDC 00121477405
Hospital Charge Code	2500407
Hospital Revenue Code	250
Min. Negotiated Rate	$8.88
Max. Negotiated Rate	$10.14
Rate for Payer: Cash Price	$6.79
Rate for Payer: Health Management Network Commercial	$8.88
Rate for Payer: Kaiser Permanente Commercial	$9.40
Rate for Payer: MDX Hawaii PPO	$10.14

ibuprofen 100 mg/5 mL cup [HHSC]

Facility

IP

$4.85

Service Code	NDC 68094049461
Hospital Charge Code	2500407
Hospital Revenue Code	250
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$4.70
Rate for Payer: Cash Price	$3.15
Rate for Payer: Health Management Network Commercial	$4.12
Rate for Payer: Kaiser Permanente Commercial	$4.37
Rate for Payer: MDX Hawaii PPO	$4.70

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