Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

PEDI FAT EMULSION 20% IV

Facility

IP

$129.78

Service Code	NDC 00264446030
Hospital Revenue Code	250
Min. Negotiated Rate	$110.31
Max. Negotiated Rate	$125.89
Rate for Payer: Cash Price	$84.36
Rate for Payer: Health Management Network Commercial	$110.31
Rate for Payer: MDX Hawaii PPO	$125.89

PEDI FOSPHENYTOIN MAINTENANCE DOSE ORDERABLE

Facility

IP

$26.50

Service Code	NDC 00641613625
Hospital Revenue Code	250
Min. Negotiated Rate	$22.52
Max. Negotiated Rate	$25.70
Rate for Payer: Cash Price	$17.23
Rate for Payer: Health Management Network Commercial	$22.52
Rate for Payer: MDX Hawaii PPO	$25.70

PEDI FOSPHENYTOIN MAINTENANCE DOSE ORDERABLE

Facility

OP

$26.50

Service Code	NDC 00641613625
Hospital Revenue Code	250
Min. Negotiated Rate	$13.52
Max. Negotiated Rate	$25.70
Rate for Payer: Cash Price	$17.23
Rate for Payer: Hawaii Western Management Group Commercial	$25.18
Rate for Payer: Health Management Network Commercial	$22.52
Rate for Payer: Kaiser Permanente Commercial	$16.70
Rate for Payer: Kaiser Permanente Medicaid	$13.52
Rate for Payer: MDX Hawaii PPO	$25.70
Rate for Payer: UnitedHealthcare Medicaid	$15.90
Rate for Payer: University Health Alliance Commercial	$19.32

PEDI FOSPHENYTOIN MAINTENANCE DOSE ORDERABLE

Facility

IP

$30.20

Service Code	NDC 63323040302
Hospital Revenue Code	250
Min. Negotiated Rate	$25.67
Max. Negotiated Rate	$29.29
Rate for Payer: Cash Price	$19.63
Rate for Payer: Health Management Network Commercial	$25.67
Rate for Payer: MDX Hawaii PPO	$29.29

PEDI FOSPHENYTOIN MAINTENANCE DOSE ORDERABLE

Facility

OP

$30.20

Service Code	NDC 63323040301
Hospital Revenue Code	250
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$29.29
Rate for Payer: Cash Price	$19.63
Rate for Payer: Hawaii Western Management Group Commercial	$28.69
Rate for Payer: Health Management Network Commercial	$25.67
Rate for Payer: Kaiser Permanente Commercial	$19.03
Rate for Payer: Kaiser Permanente Medicaid	$15.40
Rate for Payer: MDX Hawaii PPO	$29.29
Rate for Payer: UnitedHealthcare Medicaid	$18.12
Rate for Payer: University Health Alliance Commercial	$22.01

PEDI FOSPHENYTOIN MAINTENANCE DOSE ORDERABLE

Facility

OP

$26.50

Service Code	NDC 00641613601
Hospital Revenue Code	250
Min. Negotiated Rate	$13.52
Max. Negotiated Rate	$25.70
Rate for Payer: Cash Price	$17.23
Rate for Payer: Hawaii Western Management Group Commercial	$25.18
Rate for Payer: Health Management Network Commercial	$22.52
Rate for Payer: Kaiser Permanente Commercial	$16.70
Rate for Payer: Kaiser Permanente Medicaid	$13.52
Rate for Payer: MDX Hawaii PPO	$25.70
Rate for Payer: UnitedHealthcare Medicaid	$15.90
Rate for Payer: University Health Alliance Commercial	$19.32

PEDI FOSPHENYTOIN MAINTENANCE DOSE ORDERABLE

Facility

IP

$26.50

Service Code	NDC 00641613601
Hospital Revenue Code	250
Min. Negotiated Rate	$22.52
Max. Negotiated Rate	$25.70
Rate for Payer: Cash Price	$17.23
Rate for Payer: Health Management Network Commercial	$22.52
Rate for Payer: MDX Hawaii PPO	$25.70

PEDI FOSPHENYTOIN MAINTENANCE DOSE ORDERABLE

Facility

IP

$30.20

Service Code	NDC 63323040301
Hospital Revenue Code	250
Min. Negotiated Rate	$25.67
Max. Negotiated Rate	$29.29
Rate for Payer: Cash Price	$19.63
Rate for Payer: Health Management Network Commercial	$25.67
Rate for Payer: MDX Hawaii PPO	$29.29

PEDI FOSPHENYTOIN MAINTENANCE DOSE ORDERABLE

Facility

OP

$30.20

Service Code	NDC 63323040302
Hospital Revenue Code	250
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$29.29
Rate for Payer: Cash Price	$19.63
Rate for Payer: Hawaii Western Management Group Commercial	$28.69
Rate for Payer: Health Management Network Commercial	$25.67
Rate for Payer: Kaiser Permanente Commercial	$19.03
Rate for Payer: Kaiser Permanente Medicaid	$15.40
Rate for Payer: MDX Hawaii PPO	$29.29
Rate for Payer: UnitedHealthcare Medicaid	$18.12
Rate for Payer: University Health Alliance Commercial	$22.01

PEDI LINEZOLID IVPB

Facility

IP

$154.62

Service Code	HCPCS J2020
Hospital Revenue Code	250
Min. Negotiated Rate	$131.43
Max. Negotiated Rate	$149.98
Rate for Payer: Cash Price	$100.50
Rate for Payer: Health Management Network Commercial	$131.43
Rate for Payer: MDX Hawaii PPO	$149.98

PEDI LINEZOLID IVPB

Facility

OP

$154.62

Service Code	HCPCS J2020
Hospital Revenue Code	636
Min. Negotiated Rate	$3.47
Max. Negotiated Rate	$149.98
Rate for Payer: Cash Price	$100.50
Rate for Payer: Cash Price	$100.50
Rate for Payer: Hawaii Medical Service Association ABD	$3.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.47
Rate for Payer: Hawaii Western Management Group Commercial	$146.89
Rate for Payer: Health Management Network Commercial	$131.43
Rate for Payer: Kaiser Permanente Commercial	$97.41
Rate for Payer: Kaiser Permanente Medicaid	$78.86
Rate for Payer: MDX Hawaii PPO	$149.98
Rate for Payer: UnitedHealthcare Medicaid	$92.77
Rate for Payer: University Health Alliance Commercial	$112.70

PEDI METHYLPREDNISOLONE 10 MG/ML INJ

Facility

OP

$40.89

Service Code	NDC 00009003928
Hospital Revenue Code	250
Min. Negotiated Rate	$20.85
Max. Negotiated Rate	$39.66
Rate for Payer: Cash Price	$26.58
Rate for Payer: Hawaii Western Management Group Commercial	$38.85
Rate for Payer: Health Management Network Commercial	$34.76
Rate for Payer: Kaiser Permanente Commercial	$25.76
Rate for Payer: Kaiser Permanente Medicaid	$20.85
Rate for Payer: MDX Hawaii PPO	$39.66
Rate for Payer: UnitedHealthcare Medicaid	$24.53
Rate for Payer: University Health Alliance Commercial	$29.80

PEDI METHYLPREDNISOLONE 10 MG/ML INJ

Facility

OP

$40.89

Service Code	NDC 00009003930
Hospital Revenue Code	250
Min. Negotiated Rate	$20.85
Max. Negotiated Rate	$39.66
Rate for Payer: Cash Price	$26.58
Rate for Payer: Hawaii Western Management Group Commercial	$38.85
Rate for Payer: Health Management Network Commercial	$34.76
Rate for Payer: Kaiser Permanente Commercial	$25.76
Rate for Payer: Kaiser Permanente Medicaid	$20.85
Rate for Payer: MDX Hawaii PPO	$39.66
Rate for Payer: UnitedHealthcare Medicaid	$24.53
Rate for Payer: University Health Alliance Commercial	$29.80

PEDI METHYLPREDNISOLONE 10 MG/ML INJ

Facility

IP

$40.89

Service Code	NDC 00009003930
Hospital Revenue Code	250
Min. Negotiated Rate	$34.76
Max. Negotiated Rate	$39.66
Rate for Payer: Cash Price	$26.58
Rate for Payer: Health Management Network Commercial	$34.76
Rate for Payer: MDX Hawaii PPO	$39.66

PEDI METHYLPREDNISOLONE 10 MG/ML INJ

Facility

IP

$40.89

Service Code	NDC 00009003928
Hospital Revenue Code	250
Min. Negotiated Rate	$34.76
Max. Negotiated Rate	$39.66
Rate for Payer: Cash Price	$26.58
Rate for Payer: Health Management Network Commercial	$34.76
Rate for Payer: MDX Hawaii PPO	$39.66

PEDI MILRINONE 200 MCG/ML IN D5W 100 ML

Facility

OP

$80.93

Service Code	NDC 00143971901
Hospital Revenue Code	250
Min. Negotiated Rate	$41.27
Max. Negotiated Rate	$78.50
Rate for Payer: Cash Price	$52.60
Rate for Payer: Hawaii Western Management Group Commercial	$76.88
Rate for Payer: Health Management Network Commercial	$68.79
Rate for Payer: Kaiser Permanente Commercial	$50.99
Rate for Payer: Kaiser Permanente Medicaid	$41.27
Rate for Payer: MDX Hawaii PPO	$78.50
Rate for Payer: UnitedHealthcare Medicaid	$48.56
Rate for Payer: University Health Alliance Commercial	$58.99

PEDI MILRINONE 200 MCG/ML IN D5W 100 ML

Facility

OP

$80.93

Service Code	NDC 00143971910
Hospital Revenue Code	250
Min. Negotiated Rate	$41.27
Max. Negotiated Rate	$78.50
Rate for Payer: Cash Price	$52.60
Rate for Payer: Hawaii Western Management Group Commercial	$76.88
Rate for Payer: Health Management Network Commercial	$68.79
Rate for Payer: Kaiser Permanente Commercial	$50.99
Rate for Payer: Kaiser Permanente Medicaid	$41.27
Rate for Payer: MDX Hawaii PPO	$78.50
Rate for Payer: UnitedHealthcare Medicaid	$48.56
Rate for Payer: University Health Alliance Commercial	$58.99

PEDI MILRINONE 200 MCG/ML IN D5W 100 ML

Facility

IP

$80.93

Service Code	NDC 00143971901
Hospital Revenue Code	250
Min. Negotiated Rate	$68.79
Max. Negotiated Rate	$78.50
Rate for Payer: Cash Price	$52.60
Rate for Payer: Health Management Network Commercial	$68.79
Rate for Payer: MDX Hawaii PPO	$78.50

PEDI MILRINONE 200 MCG/ML IN D5W 100 ML

Facility

IP

$80.93

Service Code	NDC 00143971910
Hospital Revenue Code	250
Min. Negotiated Rate	$68.79
Max. Negotiated Rate	$78.50
Rate for Payer: Cash Price	$52.60
Rate for Payer: Health Management Network Commercial	$68.79
Rate for Payer: MDX Hawaii PPO	$78.50

PEG 3350-ELECTROLYTES 236-22.74-6.74 -5.86 GRAM PO RECON.SOLN.

Facility

IP

$117.36

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$99.76
Max. Negotiated Rate	$113.84
Rate for Payer: Cash Price	$76.28
Rate for Payer: Health Management Network Commercial	$99.76
Rate for Payer: MDX Hawaii PPO	$113.84

PEG 3350-ELECTROLYTES 236-22.74-6.74 -5.86 GRAM PO RECON.SOLN.

Facility

OP

$117.36

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$59.85
Max. Negotiated Rate	$113.84
Rate for Payer: Cash Price	$76.28
Rate for Payer: Hawaii Western Management Group Commercial	$111.49
Rate for Payer: Health Management Network Commercial	$99.76
Rate for Payer: Kaiser Permanente Commercial	$73.94
Rate for Payer: Kaiser Permanente Medicaid	$59.85
Rate for Payer: MDX Hawaii PPO	$113.84
Rate for Payer: UnitedHealthcare Medicaid	$70.42
Rate for Payer: University Health Alliance Commercial	$85.54

PEG 400-HYPROMELLOSE-GLYCERIN 1-0.2-0.2 % OPHT DROP

Facility

IP

$9.36

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.96
Max. Negotiated Rate	$9.08
Rate for Payer: Cash Price	$6.08
Rate for Payer: Health Management Network Commercial	$7.96
Rate for Payer: MDX Hawaii PPO	$9.08

PEG 400-HYPROMELLOSE-GLYCERIN 1-0.2-0.2 % OPHT DROP

Facility

OP

$9.36

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$9.08
Rate for Payer: Cash Price	$6.08
Rate for Payer: Hawaii Western Management Group Commercial	$8.89
Rate for Payer: Health Management Network Commercial	$7.96
Rate for Payer: Kaiser Permanente Commercial	$5.90
Rate for Payer: Kaiser Permanente Medicaid	$4.77
Rate for Payer: MDX Hawaii PPO	$9.08
Rate for Payer: UnitedHealthcare Medicaid	$5.62
Rate for Payer: University Health Alliance Commercial	$6.82

PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYIN

Facility

OP

$8,819.99

Service Code	HCPCS J2506
Hospital Revenue Code	636
Min. Negotiated Rate	$58.40
Max. Negotiated Rate	$8,555.39
Rate for Payer: AlohaCare Medicaid	$127.38
Rate for Payer: AlohaCare Medicare	$127.38
Rate for Payer: Cash Price	$5,732.99
Rate for Payer: Cash Price	$5,732.99
Rate for Payer: Devoted Health Medicare	$140.12
Rate for Payer: Hawaii Medical Service Association ABD	$58.40
Rate for Payer: Hawaii Medical Service Association Commercial	$159.22
Rate for Payer: Hawaii Medical Service Association Medicare	$127.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$58.40
Rate for Payer: Hawaii Western Management Group Commercial	$8,378.99
Rate for Payer: Health Management Network Commercial	$7,496.99
Rate for Payer: Humana Medicare	$127.38
Rate for Payer: Kaiser Permanente Commercial	$5,556.59
Rate for Payer: Kaiser Permanente Medicaid	$4,498.19
Rate for Payer: Kaiser Permanente Medicare	$127.38
Rate for Payer: MDX Hawaii PPO	$8,555.39
Rate for Payer: Ohana Health Plan Medicaid	$140.12
Rate for Payer: Ohana Health Plan Medicare	$127.38
Rate for Payer: UnitedHealthcare Medicaid	$5,291.99
Rate for Payer: UnitedHealthcare Medicare	$127.38
Rate for Payer: University Health Alliance Commercial	$6,428.89

PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYIN

Facility

IP

$8,819.99

Service Code	HCPCS J2506
Hospital Revenue Code	250
Min. Negotiated Rate	$7,496.99
Max. Negotiated Rate	$8,555.39
Rate for Payer: Cash Price	$5,732.99
Rate for Payer: Health Management Network Commercial	$7,496.99
Rate for Payer: MDX Hawaii PPO	$8,555.39

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