Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

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

$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

$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

$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 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

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-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 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 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

$2,678.33

Service Code	MSDRG 795
Min. Negotiated Rate	$2,678.33
Max. Negotiated Rate	$2,678.33
Rate for Payer: Hawaii Medical Service Association Commercial	$2,678.33

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

OASIS DRAIN, SINGLE W/AC 6/CS

Facility

OP

$207.00

Hospital Charge Code	12115681
Hospital Revenue Code	272
Min. Negotiated Rate	$103.50
Max. Negotiated Rate	$200.79
Rate for Payer: AlohaCare Medicaid	$103.50
Rate for Payer: AlohaCare Medicare	$103.50
Rate for Payer: Cash Price	$134.55
Rate for Payer: Devoted Health Medicare	$113.85
Rate for Payer: Hawaii Medical Service Association Medicare	$103.50
Rate for Payer: Hawaii Western Management Group Commercial	$196.65
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Humana Medicare	$103.50
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: Kaiser Permanente Medicare	$103.50
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: Ohana Health Plan Medicaid	$103.50
Rate for Payer: Ohana Health Plan Medicare	$103.50
Rate for Payer: UnitedHealthcare Medicare	$103.50
Rate for Payer: University Health Alliance Commercial	$150.88

OASIS DRAIN, SINGLE W/AC 6/CS

Facility

IP

$207.00

Hospital Charge Code	12115681
Hospital Revenue Code	272
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$134.55
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79

OB:AVALON CL FETAL AND MATERNAL PATCH

Facility

IP

$218.00

Hospital Charge Code	11557654
Hospital Revenue Code	272
Min. Negotiated Rate	$185.30
Max. Negotiated Rate	$211.46
Rate for Payer: Cash Price	$141.70
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Kaiser Permanente Commercial	$196.20
Rate for Payer: MDX Hawaii PPO	$211.46

OB:AVALON CL FETAL AND MATERNAL PATCH

Facility

OP

$218.00

Hospital Charge Code	11557654
Hospital Revenue Code	272
Min. Negotiated Rate	$109.00
Max. Negotiated Rate	$211.46
Rate for Payer: AlohaCare Medicaid	$109.00
Rate for Payer: AlohaCare Medicare	$109.00
Rate for Payer: Cash Price	$141.70
Rate for Payer: Devoted Health Medicare	$119.90
Rate for Payer: Hawaii Medical Service Association Medicare	$109.00
Rate for Payer: Hawaii Western Management Group Commercial	$207.10
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Humana Medicare	$109.00
Rate for Payer: Kaiser Permanente Commercial	$196.20
Rate for Payer: Kaiser Permanente Medicaid	$111.18
Rate for Payer: Kaiser Permanente Medicare	$109.00
Rate for Payer: MDX Hawaii PPO	$211.46
Rate for Payer: Ohana Health Plan Medicaid	$109.00
Rate for Payer: Ohana Health Plan Medicare	$109.00
Rate for Payer: UnitedHealthcare Medicare	$109.00
Rate for Payer: University Health Alliance Commercial	$158.90

OB Check Level 1 Charge

Facility

IP

$346.00

Service Code	HCPCS 99211
Hospital Charge Code	8140428
Hospital Revenue Code	760
Min. Negotiated Rate	$294.10
Max. Negotiated Rate	$335.62
Rate for Payer: Cash Price	$224.90
Rate for Payer: Health Management Network Commercial	$294.10
Rate for Payer: Kaiser Permanente Commercial	$311.40
Rate for Payer: MDX Hawaii PPO	$335.62

OB Check Level 1 Charge

Facility

OP

$346.00

Service Code	HCPCS 99211
Hospital Charge Code	8140428
Hospital Revenue Code	760
Min. Negotiated Rate	$9.17
Max. Negotiated Rate	$335.62
Rate for Payer: AlohaCare Medicaid	$173.00
Rate for Payer: AlohaCare Medicare	$173.00
Rate for Payer: Cash Price	$224.90
Rate for Payer: Cash Price	$224.90
Rate for Payer: Devoted Health Medicare	$190.30
Rate for Payer: Hawaii Medical Service Association Medicare	$173.00
Rate for Payer: Hawaii Western Management Group Commercial	$328.70
Rate for Payer: Health Management Network Commercial	$294.10
Rate for Payer: Humana Medicare	$173.00
Rate for Payer: Kaiser Permanente Commercial	$311.40
Rate for Payer: Kaiser Permanente Medicaid	$176.46
Rate for Payer: Kaiser Permanente Medicare	$173.00
Rate for Payer: MDX Hawaii PPO	$335.62
Rate for Payer: Ohana Health Plan Medicaid	$173.00
Rate for Payer: Ohana Health Plan Medicare	$173.00
Rate for Payer: UnitedHealthcare Medicaid	$9.17
Rate for Payer: UnitedHealthcare Medicare	$173.00
Rate for Payer: University Health Alliance Commercial	$193.76

OB Check Level 2 Charge

Facility

IP

$422.00

Service Code	HCPCS 99212
Hospital Charge Code	8140429
Hospital Revenue Code	760
Min. Negotiated Rate	$358.70
Max. Negotiated Rate	$409.34
Rate for Payer: Cash Price	$274.30
Rate for Payer: Health Management Network Commercial	$358.70
Rate for Payer: Kaiser Permanente Commercial	$379.80
Rate for Payer: MDX Hawaii PPO	$409.34

OB Check Level 2 Charge

Facility

OP

$422.00

Service Code	HCPCS 99212
Hospital Charge Code	8140429
Hospital Revenue Code	760
Min. Negotiated Rate	$24.13
Max. Negotiated Rate	$409.34
Rate for Payer: AlohaCare Medicaid	$211.00
Rate for Payer: AlohaCare Medicare	$211.00
Rate for Payer: Cash Price	$274.30
Rate for Payer: Cash Price	$274.30
Rate for Payer: Devoted Health Medicare	$232.10
Rate for Payer: Hawaii Medical Service Association Medicare	$211.00
Rate for Payer: Hawaii Western Management Group Commercial	$400.90
Rate for Payer: Health Management Network Commercial	$358.70
Rate for Payer: Humana Medicare	$211.00
Rate for Payer: Kaiser Permanente Commercial	$379.80
Rate for Payer: Kaiser Permanente Medicaid	$215.22
Rate for Payer: Kaiser Permanente Medicare	$211.00
Rate for Payer: MDX Hawaii PPO	$409.34
Rate for Payer: Ohana Health Plan Medicaid	$211.00
Rate for Payer: Ohana Health Plan Medicare	$211.00
Rate for Payer: UnitedHealthcare Medicaid	$24.13
Rate for Payer: UnitedHealthcare Medicare	$211.00
Rate for Payer: University Health Alliance Commercial	$236.32

OB Check Level 3 Charge

Facility

OP

$488.00

Service Code	HCPCS 99213
Hospital Charge Code	8140430
Hospital Revenue Code	760
Min. Negotiated Rate	$36.31
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	$36.31
Rate for Payer: UnitedHealthcare Medicare	$244.00
Rate for Payer: University Health Alliance Commercial	$273.28

OB Check Level 3 Charge

Facility

IP

$488.00

Service Code	HCPCS 99213
Hospital Charge Code	8140430
Hospital Revenue Code	760
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

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