Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

LISINOPRIL 2.5 MG TABLET [13089]

Facility

OP

$3.00

Service Code	NDC 68001033200
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: University Health Alliance Commercial	$2.19

LISINOPRIL 2.5 MG TABLET [13089]

Facility

IP

$3.00

Service Code	NDC 60687065621
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

LISINOPRIL 2.5 MG TABLET [13089]

Facility

IP

$3.00

Service Code	NDC 68001033200
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

LISINOPRIL 2.5 MG TABLET [13089]

Facility

OP

$3.00

Service Code	NDC 60687065611
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: University Health Alliance Commercial	$2.19

LISINOPRIL 2.5 MG TABLET [13089]

Facility

IP

$3.00

Service Code	NDC 00591040501
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

LISINOPRIL 5 MG TABLET [10451]

Facility

OP

$4.00

Service Code	NDC 60687066711
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.92

LISINOPRIL 5 MG TABLET [10451]

Facility

OP

$1.00

Service Code	NDC 00904679761
Hospital Revenue Code	637
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: University Health Alliance Commercial	$0.73

LISINOPRIL 5 MG TABLET [10451]

Facility

IP

$4.00

Service Code	NDC 60687066711
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

LISINOPRIL 5 MG TABLET [10451]

Facility

IP

$1.00

Service Code	NDC 00904679761
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: MDX Hawaii PPO	$0.97

LISINOPRIL 5 MG TABLET [10451]

Facility

OP

$4.00

Service Code	NDC 68084019601
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.92

LISINOPRIL 5 MG TABLET [10451]

Facility

IP

$4.00

Service Code	NDC 68084019601
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

LITHIUM CARBONATE 150 MG CAPSULE [4528]

Facility

OP

$1.00

Service Code	NDC 68462022001
Hospital Revenue Code	637
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: University Health Alliance Commercial	$0.73

LITHIUM CARBONATE 150 MG CAPSULE [4528]

Facility

IP

$1.00

Service Code	NDC 68462022001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: MDX Hawaii PPO	$0.97

LITHIUM CARBONATE 300 MG CAPSULE [4529]

Facility

OP

$2.00

Service Code	NDC 00054852725
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

LITHIUM CARBONATE 300 MG CAPSULE [4529]

Facility

IP

$2.00

Service Code	NDC 00054852725
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]

Facility

IP

$2.00

Service Code	NDC 68462022301
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]

Facility

OP

$2.00

Service Code	NDC 68084064011
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]

Facility

OP

$2.00

Service Code	NDC 68462022301
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]

Facility

IP

$2.00

Service Code	NDC 68084064011
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE [10455]

Facility

IP

$2.00

Service Code	NDC 68462022401
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE [10455]

Facility

OP

$2.00

Service Code	NDC 68462022401
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

LITHIUM CITRATE 8 MEQ/5 ML ORAL SOLUTION [126234]

Facility

OP

$486.00

Service Code	NDC 72888017246
Hospital Revenue Code	637
Min. Negotiated Rate	$247.86
Max. Negotiated Rate	$471.42
Rate for Payer: Cash Price	$291.60
Rate for Payer: Hawaii Western Management Group Commercial	$461.70
Rate for Payer: Health Management Network Commercial	$413.10
Rate for Payer: Kaiser Permanente Commercial	$306.18
Rate for Payer: Kaiser Permanente Medicaid	$247.86
Rate for Payer: MDX Hawaii PPO	$471.42
Rate for Payer: University Health Alliance Commercial	$354.25

LITHIUM CITRATE 8 MEQ/5 ML ORAL SOLUTION [126234]

Facility

IP

$486.00

Service Code	NDC 72888017246
Hospital Revenue Code	250
Min. Negotiated Rate	$413.10
Max. Negotiated Rate	$471.42
Rate for Payer: Cash Price	$291.60
Rate for Payer: Health Management Network Commercial	$413.10
Rate for Payer: MDX Hawaii PPO	$471.42

LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM)

Facility

OP

$8,270.00

Service Code	CPT 52318
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22
Rate for Payer: University Health Alliance Commercial	$5,160.40

LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM)

Facility

OP

$5,509.00

Service Code	CPT 52317
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22

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