Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

Non-Selective Debridement Charge

Facility

IP

$488.00

Service Code	HCPCS 97602 GP,CQ
Hospital Charge Code	8111712
Hospital Revenue Code	420
Min. Negotiated Rate	$414.80
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$317.20
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: MDX Hawaii PPO	$473.36

Non-Selective Debridement Charge

Facility

OP

$488.00

Service Code	HCPCS 97602 GP,CQ
Hospital Charge Code	8111712
Hospital Revenue Code	420
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$473.36
Rate for Payer: AlohaCare Medicaid	$244.00
Rate for Payer: AlohaCare Medicare	$244.00
Rate for Payer: Cash Price	$317.20
Rate for Payer: Cash Price	$317.20
Rate for Payer: Devoted Health Medicare	$268.40
Rate for Payer: Hawaii Medical Service Association Medicare	$244.00
Rate for Payer: Hawaii Western Management Group Commercial	$463.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Humana Medicare	$244.00
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: Kaiser Permanente Medicaid	$248.88
Rate for Payer: Kaiser Permanente Medicare	$244.00
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: Ohana Health Plan Medicaid	$244.00
Rate for Payer: Ohana Health Plan Medicare	$244.00
Rate for Payer: UnitedHealthcare Medicaid	$20.46
Rate for Payer: UnitedHealthcare Medicare	$244.00
Rate for Payer: University Health Alliance Commercial	$355.70

NONTRAUMATIC STUPOR AND COMA WITH MCC

Facility

IP

$35,031.50

Service Code	MSDRG 080
Min. Negotiated Rate	$35,031.50
Max. Negotiated Rate	$35,031.50
Rate for Payer: Hawaii Medical Service Association Commercial	$35,031.50

NONTRAUMATIC STUPOR AND COMA WITHOUT MCC

Facility

IP

$35,031.50

Service Code	MSDRG 081
Min. Negotiated Rate	$35,031.50
Max. Negotiated Rate	$35,031.50
Rate for Payer: Hawaii Medical Service Association Commercial	$35,031.50

norEPINEPHrine 4 mg/4 ml vial [HHSC]

Facility

IP

$70.82

Service Code	NDC 63323094004
Hospital Charge Code	2500593
Hospital Revenue Code	250
Min. Negotiated Rate	$60.20
Max. Negotiated Rate	$68.70
Rate for Payer: Cash Price	$46.03
Rate for Payer: Health Management Network Commercial	$60.20
Rate for Payer: Kaiser Permanente Commercial	$63.74
Rate for Payer: MDX Hawaii PPO	$68.70

norEPINEPHrine 4 mg/4 ml vial [HHSC]

Facility

IP

$115.34

Service Code	NDC 00409337504
Hospital Charge Code	2500593
Hospital Revenue Code	250
Min. Negotiated Rate	$98.04
Max. Negotiated Rate	$111.88
Rate for Payer: Cash Price	$74.97
Rate for Payer: Health Management Network Commercial	$98.04
Rate for Payer: Kaiser Permanente Commercial	$103.81
Rate for Payer: MDX Hawaii PPO	$111.88

norEPINEPHrine 4 mg/4 ml vial [HHSC]

Facility

OP

$70.82

Service Code	NDC 63323094004
Hospital Charge Code	2500593
Hospital Revenue Code	250
Min. Negotiated Rate	$35.41
Max. Negotiated Rate	$68.70
Rate for Payer: AlohaCare Medicaid	$35.41
Rate for Payer: AlohaCare Medicare	$35.41
Rate for Payer: Cash Price	$46.03
Rate for Payer: Devoted Health Medicare	$38.95
Rate for Payer: Hawaii Medical Service Association Medicare	$35.41
Rate for Payer: Hawaii Western Management Group Commercial	$67.28
Rate for Payer: Health Management Network Commercial	$60.20
Rate for Payer: Humana Medicare	$35.41
Rate for Payer: Kaiser Permanente Commercial	$63.74
Rate for Payer: Kaiser Permanente Medicaid	$36.12
Rate for Payer: Kaiser Permanente Medicare	$35.41
Rate for Payer: MDX Hawaii PPO	$68.70
Rate for Payer: Ohana Health Plan Medicaid	$35.41
Rate for Payer: Ohana Health Plan Medicare	$35.41
Rate for Payer: UnitedHealthcare Medicaid	$42.49
Rate for Payer: UnitedHealthcare Medicare	$35.41
Rate for Payer: University Health Alliance Commercial	$51.62

norEPINEPHrine 4 mg/4 ml vial [HHSC]

Facility

OP

$115.34

Service Code	NDC 00409337504
Hospital Charge Code	2500593
Hospital Revenue Code	250
Min. Negotiated Rate	$57.67
Max. Negotiated Rate	$111.88
Rate for Payer: AlohaCare Medicaid	$57.67
Rate for Payer: AlohaCare Medicare	$57.67
Rate for Payer: Cash Price	$74.97
Rate for Payer: Devoted Health Medicare	$63.44
Rate for Payer: Hawaii Medical Service Association Medicare	$57.67
Rate for Payer: Hawaii Western Management Group Commercial	$109.57
Rate for Payer: Health Management Network Commercial	$98.04
Rate for Payer: Humana Medicare	$57.67
Rate for Payer: Kaiser Permanente Commercial	$103.81
Rate for Payer: Kaiser Permanente Medicaid	$58.82
Rate for Payer: Kaiser Permanente Medicare	$57.67
Rate for Payer: MDX Hawaii PPO	$111.88
Rate for Payer: Ohana Health Plan Medicaid	$57.67
Rate for Payer: Ohana Health Plan Medicare	$57.67
Rate for Payer: UnitedHealthcare Medicaid	$69.20
Rate for Payer: UnitedHealthcare Medicare	$57.67
Rate for Payer: University Health Alliance Commercial	$84.07

norEPINEPHrine 4 mg/4 ml vial [HHSC]

Facility

IP

$115.39

Service Code	NDC 00409337525
Hospital Charge Code	2500593
Hospital Revenue Code	250
Min. Negotiated Rate	$98.08
Max. Negotiated Rate	$111.93
Rate for Payer: Cash Price	$75.00
Rate for Payer: Health Management Network Commercial	$98.08
Rate for Payer: Kaiser Permanente Commercial	$103.85
Rate for Payer: MDX Hawaii PPO	$111.93

norEPINEPHrine 4 mg/4 ml vial [HHSC]

Facility

OP

$108.54

Service Code	NDC 00703115303
Hospital Charge Code	2500593
Hospital Revenue Code	250
Min. Negotiated Rate	$54.27
Max. Negotiated Rate	$105.28
Rate for Payer: AlohaCare Medicaid	$54.27
Rate for Payer: AlohaCare Medicare	$54.27
Rate for Payer: Cash Price	$70.55
Rate for Payer: Devoted Health Medicare	$59.70
Rate for Payer: Hawaii Medical Service Association Medicare	$54.27
Rate for Payer: Hawaii Western Management Group Commercial	$103.11
Rate for Payer: Health Management Network Commercial	$92.26
Rate for Payer: Humana Medicare	$54.27
Rate for Payer: Kaiser Permanente Commercial	$97.69
Rate for Payer: Kaiser Permanente Medicaid	$55.36
Rate for Payer: Kaiser Permanente Medicare	$54.27
Rate for Payer: MDX Hawaii PPO	$105.28
Rate for Payer: Ohana Health Plan Medicaid	$54.27
Rate for Payer: Ohana Health Plan Medicare	$54.27
Rate for Payer: UnitedHealthcare Medicaid	$65.12
Rate for Payer: UnitedHealthcare Medicare	$54.27
Rate for Payer: University Health Alliance Commercial	$79.11

norEPINEPHrine 4 mg/4 ml vial [HHSC]

Facility

IP

$105.73

Service Code	NDC 72078000204
Hospital Charge Code	2500593
Hospital Revenue Code	250
Min. Negotiated Rate	$89.87
Max. Negotiated Rate	$102.56
Rate for Payer: Cash Price	$68.72
Rate for Payer: Health Management Network Commercial	$89.87
Rate for Payer: Kaiser Permanente Commercial	$95.16
Rate for Payer: MDX Hawaii PPO	$102.56

norEPINEPHrine 4 mg/4 ml vial [HHSC]

Facility

OP

$115.39

Service Code	NDC 00409337525
Hospital Charge Code	2500593
Hospital Revenue Code	250
Min. Negotiated Rate	$57.70
Max. Negotiated Rate	$111.93
Rate for Payer: AlohaCare Medicaid	$57.70
Rate for Payer: AlohaCare Medicare	$57.70
Rate for Payer: Cash Price	$75.00
Rate for Payer: Devoted Health Medicare	$63.46
Rate for Payer: Hawaii Medical Service Association Medicare	$57.70
Rate for Payer: Hawaii Western Management Group Commercial	$109.62
Rate for Payer: Health Management Network Commercial	$98.08
Rate for Payer: Humana Medicare	$57.70
Rate for Payer: Kaiser Permanente Commercial	$103.85
Rate for Payer: Kaiser Permanente Medicaid	$58.85
Rate for Payer: Kaiser Permanente Medicare	$57.70
Rate for Payer: MDX Hawaii PPO	$111.93
Rate for Payer: Ohana Health Plan Medicaid	$57.70
Rate for Payer: Ohana Health Plan Medicare	$57.70
Rate for Payer: UnitedHealthcare Medicaid	$69.23
Rate for Payer: UnitedHealthcare Medicare	$57.70
Rate for Payer: University Health Alliance Commercial	$84.11

norEPINEPHrine 4 mg/4 ml vial [HHSC]

Facility

OP

$105.73

Service Code	NDC 72078000204
Hospital Charge Code	2500593
Hospital Revenue Code	250
Min. Negotiated Rate	$52.87
Max. Negotiated Rate	$102.56
Rate for Payer: AlohaCare Medicaid	$52.87
Rate for Payer: AlohaCare Medicare	$52.87
Rate for Payer: Cash Price	$68.72
Rate for Payer: Devoted Health Medicare	$58.15
Rate for Payer: Hawaii Medical Service Association Medicare	$52.87
Rate for Payer: Hawaii Western Management Group Commercial	$100.44
Rate for Payer: Health Management Network Commercial	$89.87
Rate for Payer: Humana Medicare	$52.87
Rate for Payer: Kaiser Permanente Commercial	$95.16
Rate for Payer: Kaiser Permanente Medicaid	$53.92
Rate for Payer: Kaiser Permanente Medicare	$52.87
Rate for Payer: MDX Hawaii PPO	$102.56
Rate for Payer: Ohana Health Plan Medicaid	$52.87
Rate for Payer: Ohana Health Plan Medicare	$52.87
Rate for Payer: UnitedHealthcare Medicaid	$63.44
Rate for Payer: UnitedHealthcare Medicare	$52.87
Rate for Payer: University Health Alliance Commercial	$77.07

norEPINEPHrine 4 mg/4 ml vial [HHSC]

Facility

IP

$108.54

Service Code	NDC 00703115303
Hospital Charge Code	2500593
Hospital Revenue Code	250
Min. Negotiated Rate	$92.26
Max. Negotiated Rate	$105.28
Rate for Payer: Cash Price	$70.55
Rate for Payer: Health Management Network Commercial	$92.26
Rate for Payer: Kaiser Permanente Commercial	$97.69
Rate for Payer: MDX Hawaii PPO	$105.28

norEPINEPHrine 4 mg/4 ml vial [HHSC]

Facility

IP

$109.37

Service Code	NDC 67457085204
Hospital Charge Code	2500593
Hospital Revenue Code	250
Min. Negotiated Rate	$92.96
Max. Negotiated Rate	$106.09
Rate for Payer: Cash Price	$71.09
Rate for Payer: Health Management Network Commercial	$92.96
Rate for Payer: Kaiser Permanente Commercial	$98.43
Rate for Payer: MDX Hawaii PPO	$106.09

norEPINEPHrine 4 mg/4 ml vial [HHSC]

Facility

OP

$109.37

Service Code	NDC 67457085204
Hospital Charge Code	2500593
Hospital Revenue Code	250
Min. Negotiated Rate	$54.69
Max. Negotiated Rate	$106.09
Rate for Payer: AlohaCare Medicaid	$54.69
Rate for Payer: AlohaCare Medicare	$54.69
Rate for Payer: Cash Price	$71.09
Rate for Payer: Devoted Health Medicare	$60.15
Rate for Payer: Hawaii Medical Service Association Medicare	$54.69
Rate for Payer: Hawaii Western Management Group Commercial	$103.90
Rate for Payer: Health Management Network Commercial	$92.96
Rate for Payer: Humana Medicare	$54.69
Rate for Payer: Kaiser Permanente Commercial	$98.43
Rate for Payer: Kaiser Permanente Medicaid	$55.78
Rate for Payer: Kaiser Permanente Medicare	$54.69
Rate for Payer: MDX Hawaii PPO	$106.09
Rate for Payer: Ohana Health Plan Medicaid	$54.69
Rate for Payer: Ohana Health Plan Medicare	$54.69
Rate for Payer: UnitedHealthcare Medicaid	$65.62
Rate for Payer: UnitedHealthcare Medicare	$54.69
Rate for Payer: University Health Alliance Commercial	$79.72

norEPINEPHrine-D5W 4 mg/250 mL premix [HHSC]

Facility

IP

$143.55

Service Code	NDC 00338011220
Hospital Charge Code	2501109
Hospital Revenue Code	250
Min. Negotiated Rate	$122.02
Max. Negotiated Rate	$139.24
Rate for Payer: Cash Price	$93.31
Rate for Payer: Health Management Network Commercial	$122.02
Rate for Payer: Kaiser Permanente Commercial	$129.19
Rate for Payer: MDX Hawaii PPO	$139.24

norEPINEPHrine-D5W 4 mg/250 mL premix [HHSC]

Facility

OP

$143.55

Service Code	NDC 00338011220
Hospital Charge Code	2501109
Hospital Revenue Code	250
Min. Negotiated Rate	$71.78
Max. Negotiated Rate	$139.24
Rate for Payer: AlohaCare Medicaid	$71.78
Rate for Payer: AlohaCare Medicare	$71.78
Rate for Payer: Cash Price	$93.31
Rate for Payer: Devoted Health Medicare	$78.95
Rate for Payer: Hawaii Medical Service Association Medicare	$71.78
Rate for Payer: Hawaii Western Management Group Commercial	$136.37
Rate for Payer: Health Management Network Commercial	$122.02
Rate for Payer: Humana Medicare	$71.78
Rate for Payer: Kaiser Permanente Commercial	$129.19
Rate for Payer: Kaiser Permanente Medicaid	$73.21
Rate for Payer: Kaiser Permanente Medicare	$71.78
Rate for Payer: MDX Hawaii PPO	$139.24
Rate for Payer: Ohana Health Plan Medicaid	$71.78
Rate for Payer: Ohana Health Plan Medicare	$71.78
Rate for Payer: UnitedHealthcare Medicaid	$86.13
Rate for Payer: UnitedHealthcare Medicare	$71.78
Rate for Payer: University Health Alliance Commercial	$104.63

norEPINEPHrine-D5W 8 mg/250 mL premix [HHSC]

Facility

OP

$193.71

Service Code	NDC 00338010820
Hospital Charge Code	2501110
Hospital Revenue Code	250
Min. Negotiated Rate	$96.86
Max. Negotiated Rate	$187.90
Rate for Payer: AlohaCare Medicaid	$96.86
Rate for Payer: AlohaCare Medicare	$96.86
Rate for Payer: Cash Price	$125.91
Rate for Payer: Devoted Health Medicare	$106.54
Rate for Payer: Hawaii Medical Service Association Medicare	$96.86
Rate for Payer: Hawaii Western Management Group Commercial	$184.02
Rate for Payer: Health Management Network Commercial	$164.65
Rate for Payer: Humana Medicare	$96.86
Rate for Payer: Kaiser Permanente Commercial	$174.34
Rate for Payer: Kaiser Permanente Medicaid	$98.79
Rate for Payer: Kaiser Permanente Medicare	$96.86
Rate for Payer: MDX Hawaii PPO	$187.90
Rate for Payer: Ohana Health Plan Medicaid	$96.86
Rate for Payer: Ohana Health Plan Medicare	$96.86
Rate for Payer: UnitedHealthcare Medicaid	$116.23
Rate for Payer: UnitedHealthcare Medicare	$96.86
Rate for Payer: University Health Alliance Commercial	$141.20

norEPINEPHrine-D5W 8 mg/250 mL premix [HHSC]

Facility

IP

$193.71

Service Code	NDC 00338010820
Hospital Charge Code	2501110
Hospital Revenue Code	250
Min. Negotiated Rate	$164.65
Max. Negotiated Rate	$187.90
Rate for Payer: Cash Price	$125.91
Rate for Payer: Health Management Network Commercial	$164.65
Rate for Payer: Kaiser Permanente Commercial	$174.34
Rate for Payer: MDX Hawaii PPO	$187.90

NORMAL NEWBORN

Facility

IP

$2,881.05

Service Code	MSDRG 795
Min. Negotiated Rate	$2,881.05
Max. Negotiated Rate	$2,881.05
Rate for Payer: Hawaii Medical Service Association Commercial	$2,881.05

NOVASURE STERILE KIT

Facility

OP

$2,392.00

Hospital Charge Code	9944730
Hospital Revenue Code	272
Min. Negotiated Rate	$1,196.00
Max. Negotiated Rate	$2,320.24
Rate for Payer: AlohaCare Medicaid	$1,196.00
Rate for Payer: AlohaCare Medicare	$1,196.00
Rate for Payer: Cash Price	$1,554.80
Rate for Payer: Devoted Health Medicare	$1,315.60
Rate for Payer: Hawaii Medical Service Association Medicare	$1,196.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,272.40
Rate for Payer: Health Management Network Commercial	$2,033.20
Rate for Payer: Humana Medicare	$1,196.00
Rate for Payer: Kaiser Permanente Commercial	$2,152.80
Rate for Payer: Kaiser Permanente Medicaid	$1,219.92
Rate for Payer: Kaiser Permanente Medicare	$1,196.00
Rate for Payer: MDX Hawaii PPO	$2,320.24
Rate for Payer: Ohana Health Plan Medicaid	$1,196.00
Rate for Payer: Ohana Health Plan Medicare	$1,196.00
Rate for Payer: UnitedHealthcare Medicare	$1,196.00
Rate for Payer: University Health Alliance Commercial	$1,743.53

NOVASURE STERILE KIT

Facility

IP

$2,392.00

Hospital Charge Code	9944730
Hospital Revenue Code	272
Min. Negotiated Rate	$2,033.20
Max. Negotiated Rate	$2,320.24
Rate for Payer: Cash Price	$1,554.80
Rate for Payer: Health Management Network Commercial	$2,033.20
Rate for Payer: Kaiser Permanente Commercial	$2,152.80
Rate for Payer: MDX Hawaii PPO	$2,320.24

NT-proBNP FSI

Facility

OP

$878.00

Service Code	HCPCS 83880
Hospital Charge Code	8225268
Hospital Revenue Code	301
Min. Negotiated Rate	$28.46
Max. Negotiated Rate	$851.66
Rate for Payer: AlohaCare Medicaid	$439.00
Rate for Payer: AlohaCare Medicare	$439.00
Rate for Payer: Cash Price	$570.70
Rate for Payer: Cash Price	$570.70
Rate for Payer: Devoted Health Medicare	$482.90
Rate for Payer: Hawaii Medical Service Association ABD	$28.46
Rate for Payer: Hawaii Medical Service Association Commercial	$49.08
Rate for Payer: Hawaii Medical Service Association Medicare	$439.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$46.89
Rate for Payer: Hawaii Western Management Group Commercial	$39.26
Rate for Payer: Health Management Network Commercial	$746.30
Rate for Payer: Humana Medicare	$439.00
Rate for Payer: Kaiser Permanente Commercial	$790.20
Rate for Payer: Kaiser Permanente Medicaid	$447.78
Rate for Payer: Kaiser Permanente Medicare	$439.00
Rate for Payer: MDX Hawaii PPO	$851.66
Rate for Payer: Ohana Health Plan Medicaid	$439.00
Rate for Payer: Ohana Health Plan Medicare	$439.00
Rate for Payer: UnitedHealthcare Medicaid	$28.46
Rate for Payer: UnitedHealthcare Medicare	$439.00
Rate for Payer: University Health Alliance Commercial	$87.75

NT-proBNP FSI

Facility

IP

$878.00

Service Code	HCPCS 83880
Hospital Charge Code	8225268
Hospital Revenue Code	301
Min. Negotiated Rate	$746.30
Max. Negotiated Rate	$851.66
Rate for Payer: Cash Price	$570.70
Rate for Payer: Health Management Network Commercial	$746.30
Rate for Payer: Kaiser Permanente Commercial	$790.20
Rate for Payer: MDX Hawaii PPO	$851.66

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