Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

OP

$227.00

Service Code	NDC 59762013104
Hospital Revenue Code	637
Min. Negotiated Rate	$115.77
Max. Negotiated Rate	$220.19
Rate for Payer: Cash Price	$136.20
Rate for Payer: Hawaii Western Management Group Commercial	$215.65
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Kaiser Permanente Commercial	$143.01
Rate for Payer: Kaiser Permanente Medicaid	$115.77
Rate for Payer: MDX Hawaii PPO	$220.19
Rate for Payer: University Health Alliance Commercial	$165.46

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

OP

$102.00

Service Code	NDC 61570013185
Hospital Revenue Code	637
Min. Negotiated Rate	$52.02
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$61.20
Rate for Payer: Hawaii Western Management Group Commercial	$96.90
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Kaiser Permanente Commercial	$64.26
Rate for Payer: Kaiser Permanente Medicaid	$52.02
Rate for Payer: MDX Hawaii PPO	$98.94
Rate for Payer: University Health Alliance Commercial	$74.35

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

OP

$48.00

Service Code	NDC 67877012425
Hospital Revenue Code	637
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$28.80
Rate for Payer: Hawaii Western Management Group Commercial	$45.60
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$30.24
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: University Health Alliance Commercial	$34.99

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

OP

$292.00

Service Code	NDC 67877012440
Hospital Revenue Code	637
Min. Negotiated Rate	$148.92
Max. Negotiated Rate	$283.24
Rate for Payer: Cash Price	$175.20
Rate for Payer: Hawaii Western Management Group Commercial	$277.40
Rate for Payer: Health Management Network Commercial	$248.20
Rate for Payer: Kaiser Permanente Commercial	$183.96
Rate for Payer: Kaiser Permanente Medicaid	$148.92
Rate for Payer: MDX Hawaii PPO	$283.24
Rate for Payer: University Health Alliance Commercial	$212.84

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

OP

$88.00

Service Code	NDC 43598021085
Hospital Revenue Code	637
Min. Negotiated Rate	$44.88
Max. Negotiated Rate	$85.36
Rate for Payer: Cash Price	$52.80
Rate for Payer: Hawaii Western Management Group Commercial	$83.60
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Kaiser Permanente Commercial	$55.44
Rate for Payer: Kaiser Permanente Medicaid	$44.88
Rate for Payer: MDX Hawaii PPO	$85.36
Rate for Payer: University Health Alliance Commercial	$64.14

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

IP

$88.00

Service Code	NDC 43598021085
Hospital Revenue Code	250
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$85.36
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: MDX Hawaii PPO	$85.36

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

IP

$292.00

Service Code	NDC 67877012440
Hospital Revenue Code	250
Min. Negotiated Rate	$248.20
Max. Negotiated Rate	$283.24
Rate for Payer: Cash Price	$175.20
Rate for Payer: Health Management Network Commercial	$248.20
Rate for Payer: MDX Hawaii PPO	$283.24

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

IP

$48.00

Service Code	NDC 67877012425
Hospital Revenue Code	250
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$28.80
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: MDX Hawaii PPO	$46.56

SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]

Facility

OP

$10.00

Service Code	NDC 00536130375
Hospital Revenue Code	637
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: University Health Alliance Commercial	$7.29

SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]

Facility

OP

$10.00

Service Code	NDC 71399004101
Hospital Revenue Code	637
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: University Health Alliance Commercial	$7.29

SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]

Facility

IP

$10.00

Service Code	NDC 00536130375
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: MDX Hawaii PPO	$9.70

SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION [7228]

Facility

IP

$10.00

Service Code	NDC 71399004101
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: MDX Hawaii PPO	$9.70

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

IP

$1.00

Service Code	NDC 77333081210
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

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

OP

$1.00

Service Code	NDC 77333081225
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

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

OP

$1.00

Service Code	NDC 77333081210
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

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

IP

$1.00

Service Code	NDC 77333081225
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

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

IP

$24,363.06

Service Code	MSDRG 194
Min. Negotiated Rate	$9,166.53
Max. Negotiated Rate	$24,363.06
Rate for Payer: AlohaCare Medicare	$9,166.53
Rate for Payer: Devoted Health Medicare	$10,083.18
Rate for Payer: Hawaii Medical Service Association Commercial	$24,363.06
Rate for Payer: Hawaii Medical Service Association Medicare	$9,166.53
Rate for Payer: Humana Medicare	$9,166.53
Rate for Payer: Kaiser Permanente Commercial	$13,901.77
Rate for Payer: Kaiser Permanente Medicare	$9,166.53
Rate for Payer: Ohana Health Plan Medicare	$9,166.53
Rate for Payer: UnitedHealthcare Medicare	$9,166.53

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

IP

$25,212.37

Service Code	MSDRG 193
Min. Negotiated Rate	$14,950.32
Max. Negotiated Rate	$25,212.37
Rate for Payer: AlohaCare Medicare	$14,950.32
Rate for Payer: Devoted Health Medicare	$16,445.35
Rate for Payer: Hawaii Medical Service Association Commercial	$25,212.37
Rate for Payer: Hawaii Medical Service Association Medicare	$14,950.32
Rate for Payer: Humana Medicare	$14,950.32
Rate for Payer: Kaiser Permanente Commercial	$22,673.40
Rate for Payer: Kaiser Permanente Medicare	$14,950.32
Rate for Payer: Ohana Health Plan Medicare	$14,950.32
Rate for Payer: UnitedHealthcare Medicare	$14,950.32

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

IP

$19,388.53

Service Code	MSDRG 195
Min. Negotiated Rate	$7,148.72
Max. Negotiated Rate	$19,388.53
Rate for Payer: AlohaCare Medicare	$7,148.72
Rate for Payer: Devoted Health Medicare	$7,863.59
Rate for Payer: Hawaii Medical Service Association Commercial	$19,388.53
Rate for Payer: Hawaii Medical Service Association Medicare	$7,148.72
Rate for Payer: Humana Medicare	$7,148.72
Rate for Payer: Kaiser Permanente Commercial	$10,841.62
Rate for Payer: Kaiser Permanente Medicare	$7,148.72
Rate for Payer: Ohana Health Plan Medicare	$7,148.72
Rate for Payer: UnitedHealthcare Medicare	$7,148.72

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS

Facility

OP

$2,837.00

Service Code	CPT 12001
Hospital Revenue Code	360
Min. Negotiated Rate	$70.95
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Devoted Health Medicare	$260.72
Rate for Payer: Hawaii Medical Service Association Commercial	$296.27
Rate for Payer: Hawaii Medical Service Association Medicare	$237.02
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicaid	$70.95
Rate for Payer: UnitedHealthcare Medicare	$237.02

SIMPLEX W/GENTAMICN 6195-1-010

Facility

OP

$864.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$440.64
Max. Negotiated Rate	$838.08
Rate for Payer: Cash Price	$518.40
Rate for Payer: Hawaii Western Management Group Commercial	$604.80
Rate for Payer: Health Management Network Commercial	$734.40
Rate for Payer: Kaiser Permanente Commercial	$544.32
Rate for Payer: Kaiser Permanente Medicaid	$440.64
Rate for Payer: MDX Hawaii PPO	$838.08
Rate for Payer: University Health Alliance Commercial	$483.84

SIMPLEX W/GENTAMICN 6195-1-010

Facility

IP

$864.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$483.84
Max. Negotiated Rate	$838.08
Rate for Payer: Cash Price	$518.40
Rate for Payer: Hawaii Western Management Group Commercial	$604.80
Rate for Payer: Health Management Network Commercial	$734.40
Rate for Payer: MDX Hawaii PPO	$838.08
Rate for Payer: University Health Alliance Commercial	$483.84

SIMPLICITI GUIDE PIN 9722908

Facility

IP

$600.00

Hospital Revenue Code	272
Min. Negotiated Rate	$510.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: MDX Hawaii PPO	$582.00

SIMPLICITI GUIDE PIN 9722908

Facility

OP

$600.00

Hospital Revenue Code	272
Min. Negotiated Rate	$306.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Hawaii Western Management Group Commercial	$570.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Kaiser Permanente Commercial	$378.00
Rate for Payer: Kaiser Permanente Medicaid	$306.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: University Health Alliance Commercial	$437.34

SIMPLIDERM SD.090.1020ELP

Facility

IP

$8,247.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$4,618.32
Max. Negotiated Rate	$7,999.59
Rate for Payer: Cash Price	$4,948.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,772.90
Rate for Payer: Health Management Network Commercial	$7,009.95
Rate for Payer: MDX Hawaii PPO	$7,999.59
Rate for Payer: University Health Alliance Commercial	$4,618.32

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