Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

hydrogen peroxide 3% 473 mL [HHSC]

Facility

OP

$11.07

Service Code	NDC 46122077334
Hospital Charge Code	2500397
Hospital Revenue Code	250
Min. Negotiated Rate	$5.54
Max. Negotiated Rate	$10.74
Rate for Payer: AlohaCare Medicaid	$5.54
Rate for Payer: AlohaCare Medicare	$5.54
Rate for Payer: Cash Price	$7.20
Rate for Payer: Devoted Health Medicare	$6.09
Rate for Payer: Hawaii Medical Service Association Medicare	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$10.52
Rate for Payer: Health Management Network Commercial	$9.41
Rate for Payer: Humana Medicare	$5.54
Rate for Payer: Kaiser Permanente Commercial	$9.96
Rate for Payer: Kaiser Permanente Medicaid	$5.65
Rate for Payer: Kaiser Permanente Medicare	$5.54
Rate for Payer: MDX Hawaii PPO	$10.74
Rate for Payer: Ohana Health Plan Medicaid	$5.54
Rate for Payer: Ohana Health Plan Medicare	$5.54
Rate for Payer: UnitedHealthcare Medicaid	$6.64
Rate for Payer: UnitedHealthcare Medicare	$5.54
Rate for Payer: University Health Alliance Commercial	$8.07

hydrogen peroxide 3% 473 mL [HHSC]

Facility

IP

$3.00

Service Code	NDC 00869087143
Hospital Charge Code	2500397
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

hydrogen peroxide 3% 473 mL [HHSC]

Facility

OP

$3.00

Service Code	NDC 00869087143
Hospital Charge Code	2500397
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

$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

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

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

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

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

$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

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

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 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

$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

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

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 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

$13,699.76

Service Code	MSDRG 304
Min. Negotiated Rate	$13,699.76
Max. Negotiated Rate	$13,699.76
Rate for Payer: Hawaii Medical Service Association Commercial	$13,699.76

HYPERTENSION WITHOUT MCC

Facility

IP

$13,699.76

Service Code	MSDRG 305
Min. Negotiated Rate	$13,699.76
Max. Negotiated Rate	$13,699.76
Rate for Payer: Hawaii Medical Service Association Commercial	$13,699.76

ibuprofen 100 mg/5 mL cup [HHSC]

Facility

IP

$3.34

Service Code	NDC 68094049462
Hospital Charge Code	2500407
Hospital Revenue Code	250
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$3.24
Rate for Payer: Cash Price	$2.17
Rate for Payer: Health Management Network Commercial	$2.84
Rate for Payer: Kaiser Permanente Commercial	$3.01
Rate for Payer: MDX Hawaii PPO	$3.24

ibuprofen 100 mg/5 mL cup [HHSC]

Facility

OP

$4.87

Service Code	NDC 60687074317
Hospital Charge Code	2500407
Hospital Revenue Code	250
Min. Negotiated Rate	$2.44
Max. Negotiated Rate	$4.72
Rate for Payer: AlohaCare Medicaid	$2.44
Rate for Payer: AlohaCare Medicare	$2.44
Rate for Payer: Cash Price	$3.17
Rate for Payer: Devoted Health Medicare	$2.68
Rate for Payer: Hawaii Medical Service Association Medicare	$2.44
Rate for Payer: Hawaii Western Management Group Commercial	$4.63
Rate for Payer: Health Management Network Commercial	$4.14
Rate for Payer: Humana Medicare	$2.44
Rate for Payer: Kaiser Permanente Commercial	$4.38
Rate for Payer: Kaiser Permanente Medicaid	$2.48
Rate for Payer: Kaiser Permanente Medicare	$2.44
Rate for Payer: MDX Hawaii PPO	$4.72
Rate for Payer: Ohana Health Plan Medicaid	$2.44
Rate for Payer: Ohana Health Plan Medicare	$2.44
Rate for Payer: UnitedHealthcare Medicaid	$2.92
Rate for Payer: UnitedHealthcare Medicare	$2.44
Rate for Payer: University Health Alliance Commercial	$3.55

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

ibuprofen 100 mg/5 mL cup [HHSC]

Facility

OP

$3.34

Service Code	NDC 68094049462
Hospital Charge Code	2500407
Hospital Revenue Code	250
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$3.24
Rate for Payer: AlohaCare Medicaid	$1.67
Rate for Payer: AlohaCare Medicare	$1.67
Rate for Payer: Cash Price	$2.17
Rate for Payer: Devoted Health Medicare	$1.84
Rate for Payer: Hawaii Medical Service Association Medicare	$1.67
Rate for Payer: Hawaii Western Management Group Commercial	$3.17
Rate for Payer: Health Management Network Commercial	$2.84
Rate for Payer: Humana Medicare	$1.67
Rate for Payer: Kaiser Permanente Commercial	$3.01
Rate for Payer: Kaiser Permanente Medicaid	$1.70
Rate for Payer: Kaiser Permanente Medicare	$1.67
Rate for Payer: MDX Hawaii PPO	$3.24
Rate for Payer: Ohana Health Plan Medicaid	$1.67
Rate for Payer: Ohana Health Plan Medicare	$1.67
Rate for Payer: UnitedHealthcare Medicaid	$2.00
Rate for Payer: UnitedHealthcare Medicare	$1.67
Rate for Payer: University Health Alliance Commercial	$2.43

ibuprofen 100 mg/5 mL cup [HHSC]

Facility

IP

$5.20

Service Code	NDC 68094060062
Hospital Charge Code	2500407
Hospital Revenue Code	250
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$5.04
Rate for Payer: Cash Price	$3.38
Rate for Payer: Health Management Network Commercial	$4.42
Rate for Payer: Kaiser Permanente Commercial	$4.68
Rate for Payer: MDX Hawaii PPO	$5.04

ibuprofen 100 mg/5 mL cup [HHSC]

Facility

OP

$4.85

Service Code	NDC 68094049461
Hospital Charge Code	2500407
Hospital Revenue Code	250
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$4.70
Rate for Payer: AlohaCare Medicaid	$2.42
Rate for Payer: AlohaCare Medicare	$2.42
Rate for Payer: Cash Price	$3.15
Rate for Payer: Devoted Health Medicare	$2.67
Rate for Payer: Hawaii Medical Service Association Medicare	$2.42
Rate for Payer: Hawaii Western Management Group Commercial	$4.61
Rate for Payer: Health Management Network Commercial	$4.12
Rate for Payer: Humana Medicare	$2.42
Rate for Payer: Kaiser Permanente Commercial	$4.37
Rate for Payer: Kaiser Permanente Medicaid	$2.47
Rate for Payer: Kaiser Permanente Medicare	$2.42
Rate for Payer: MDX Hawaii PPO	$4.70
Rate for Payer: Ohana Health Plan Medicaid	$2.42
Rate for Payer: Ohana Health Plan Medicare	$2.42
Rate for Payer: UnitedHealthcare Medicaid	$2.91
Rate for Payer: UnitedHealthcare Medicare	$2.42
Rate for Payer: University Health Alliance Commercial	$3.54

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