Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

SODIUM IODIDE-131 (I-131) 3.7 MBQ (100 MICROCI) CAPSULE [209258]

Facility

OP

$59.00

Service Code	HCPCS A9517
Hospital Revenue Code	343
Min. Negotiated Rate	$24.07
Max. Negotiated Rate	$117.25
Rate for Payer: AlohaCare Medicaid	$24.07
Rate for Payer: AlohaCare Medicare	$24.07
Rate for Payer: Cash Price	$35.40
Rate for Payer: Cash Price	$35.40
Rate for Payer: Devoted Health Medicare	$26.48
Rate for Payer: Hawaii Medical Service Association Commercial	$30.09
Rate for Payer: Hawaii Medical Service Association Medicare	$24.07
Rate for Payer: Hawaii Western Management Group Commercial	$56.05
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Humana Medicare	$24.07
Rate for Payer: Kaiser Permanente Commercial	$37.17
Rate for Payer: Kaiser Permanente Medicaid	$30.09
Rate for Payer: Kaiser Permanente Medicare	$24.07
Rate for Payer: MDX Hawaii PPO	$57.23
Rate for Payer: Ohana Health Plan Medicaid	$26.48
Rate for Payer: Ohana Health Plan Medicare	$24.07
Rate for Payer: UnitedHealthcare Medicaid	$117.25
Rate for Payer: UnitedHealthcare Medicare	$24.07
Rate for Payer: University Health Alliance Commercial	$43.01

SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]

Facility

IP

$60.00

Service Code	NDC 72485010501
Hospital Revenue Code	250
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: MDX Hawaii PPO	$58.20

SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [137040]

Facility

IP

$169.00

Service Code	NDC 00409739182
Hospital Revenue Code	250
Min. Negotiated Rate	$143.65
Max. Negotiated Rate	$163.93
Rate for Payer: Cash Price	$101.40
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: MDX Hawaii PPO	$163.93

SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [137040]

Facility

IP

$82.00

Service Code	NDC 63323088406
Hospital Revenue Code	250
Min. Negotiated Rate	$69.70
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$49.20
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: MDX Hawaii PPO	$79.54

SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [137040]

Facility

IP

$169.00

Service Code	NDC 00409739172
Hospital Revenue Code	250
Min. Negotiated Rate	$143.65
Max. Negotiated Rate	$163.93
Rate for Payer: Cash Price	$101.40
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: MDX Hawaii PPO	$163.93

SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [137040]

Facility

IP

$82.00

Service Code	NDC 63323088401
Hospital Revenue Code	250
Min. Negotiated Rate	$69.70
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$49.20
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: MDX Hawaii PPO	$79.54

SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [137040]

Facility

IP

$174.00

Service Code	NDC 63323088116
Hospital Revenue Code	250
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$104.40
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: MDX Hawaii PPO	$168.78

SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [137040]

Facility

IP

$116.00

Service Code	NDC 63323088101
Hospital Revenue Code	250
Min. Negotiated Rate	$98.60
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Cash Price	$104.40
Rate for Payer: Cash Price	$34.80
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: MDX Hawaii PPO	$168.78
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: MDX Hawaii PPO	$112.52
Rate for Payer: MDX Hawaii PPO	$56.26

SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [2805]

Facility

IP

$7.00

Service Code	NDC 00132020140
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: MDX Hawaii PPO	$6.79

SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA [3128]

Facility

IP

$9.00

Service Code	NDC 00132020220
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA [3128]

Facility

OP

$9.00

Service Code	NDC 00132020220
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: University Health Alliance Commercial	$6.56

SODIUM POLYSTYRENE SULFONATE POWDER [7356]

Facility

IP

$56.00

Service Code	NDC 11534016616
Hospital Revenue Code	250
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$33.60
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: MDX Hawaii PPO	$54.32

SODIUM POLYSTYRENE SULFONATE POWDER [7356]

Facility

OP

$56.00

Service Code	NDC 11534016616
Hospital Revenue Code	637
Min. Negotiated Rate	$28.56
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$33.60
Rate for Payer: Hawaii Western Management Group Commercial	$53.20
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$35.28
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: University Health Alliance Commercial	$40.82

SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]

Facility

IP

$231.00

Service Code	NDC 24201020101
Hospital Revenue Code	250
Min. Negotiated Rate	$196.35
Max. Negotiated Rate	$224.07
Rate for Payer: Cash Price	$138.60
Rate for Payer: Health Management Network Commercial	$196.35
Rate for Payer: MDX Hawaii PPO	$224.07

SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]

Facility

IP

$231.00

Service Code	NDC 24201020105
Hospital Revenue Code	250
Min. Negotiated Rate	$196.35
Max. Negotiated Rate	$224.07
Rate for Payer: Cash Price	$138.60
Rate for Payer: Health Management Network Commercial	$196.35
Rate for Payer: MDX Hawaii PPO	$224.07

SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INJECTION SOLUTION [181343]

Facility

IP

$13.00

Service Code	NDC 60267070550
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$243.60
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Health Management Network Commercial	$345.10
Rate for Payer: MDX Hawaii PPO	$393.82
Rate for Payer: MDX Hawaii PPO	$12.61

SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [162642]

Facility

OP

$87.00

Service Code	NDC 00310111001
Hospital Revenue Code	637
Min. Negotiated Rate	$44.37
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Hawaii Western Management Group Commercial	$82.65
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$54.81
Rate for Payer: Kaiser Permanente Medicaid	$44.37
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: University Health Alliance Commercial	$63.41

SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [162642]

Facility

IP

$87.00

Service Code	NDC 00310111001
Hospital Revenue Code	250
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: MDX Hawaii PPO	$84.39

SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [162642]

Facility

IP

$87.00

Service Code	NDC 00310111030
Hospital Revenue Code	250
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: MDX Hawaii PPO	$84.39

SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [162642]

Facility

OP

$87.00

Service Code	NDC 00310111030
Hospital Revenue Code	637
Min. Negotiated Rate	$44.37
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Hawaii Western Management Group Commercial	$82.65
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$54.81
Rate for Payer: Kaiser Permanente Medicaid	$44.37
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: University Health Alliance Commercial	$63.41

SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [162641]

Facility

IP

$87.00

Service Code	NDC 00310110530
Hospital Revenue Code	250
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: MDX Hawaii PPO	$84.39

SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [162641]

Facility

OP

$87.00

Service Code	NDC 00310110530
Hospital Revenue Code	637
Min. Negotiated Rate	$44.37
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Hawaii Western Management Group Commercial	$82.65
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$54.81
Rate for Payer: Kaiser Permanente Medicaid	$44.37
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: University Health Alliance Commercial	$63.41

SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [162641]

Facility

OP

$87.00

Service Code	NDC 00310110501
Hospital Revenue Code	637
Min. Negotiated Rate	$44.37
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Hawaii Western Management Group Commercial	$82.65
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$54.81
Rate for Payer: Kaiser Permanente Medicaid	$44.37
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: University Health Alliance Commercial	$63.41

SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [162641]

Facility

IP

$87.00

Service Code	NDC 00310110501
Hospital Revenue Code	250
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$52.20
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: MDX Hawaii PPO	$84.39

SOFT TISSUE PROCEDURES WITH CC

Facility

IP

$47,512.83

Service Code	MSDRG 501
Min. Negotiated Rate	$19,883.35
Max. Negotiated Rate	$47,512.83
Rate for Payer: AlohaCare Medicare	$19,883.35
Rate for Payer: Devoted Health Medicare	$21,871.69
Rate for Payer: Hawaii Medical Service Association Commercial	$47,512.83
Rate for Payer: Hawaii Medical Service Association Medicare	$19,883.35
Rate for Payer: Humana Medicare	$19,883.35
Rate for Payer: Kaiser Permanente Commercial	$30,154.72
Rate for Payer: Kaiser Permanente Medicare	$19,883.35
Rate for Payer: Ohana Health Plan Medicare	$19,883.35
Rate for Payer: UnitedHealthcare Medicare	$19,883.35

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