Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE

Facility

OP

$2,837.00

Service Code	CPT 62328
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$833.89
Rate for Payer: AlohaCare Medicare	$833.89
Rate for Payer: Devoted Health Medicare	$917.28
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$833.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$833.89
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$833.89
Rate for Payer: Ohana Health Plan Medicaid	$917.28
Rate for Payer: Ohana Health Plan Medicare	$833.89
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$833.89

SPIRONOLACTONE 100 MG TABLET [11425]

Facility

IP

$5.00

Service Code	NDC 51079098008
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$4.85

SPIRONOLACTONE 100 MG TABLET [11425]

Facility

IP

$5.00

Service Code	NDC 16729022701
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$4.85

SPIRONOLACTONE 100 MG TABLET [11425]

Facility

IP

$5.00

Service Code	NDC 53489032901
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$4.85

SPIRONOLACTONE 100 MG TABLET [11425]

Facility

OP

$5.00

Service Code	NDC 16729022701
Hospital Revenue Code	637
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: University Health Alliance Commercial	$3.64

SPIRONOLACTONE 100 MG TABLET [11425]

Facility

OP

$5.00

Service Code	NDC 51079098008
Hospital Revenue Code	637
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: University Health Alliance Commercial	$3.64

SPIRONOLACTONE 100 MG TABLET [11425]

Facility

OP

$5.00

Service Code	NDC 53489032901
Hospital Revenue Code	637
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: University Health Alliance Commercial	$3.64

SPIRONOLACTONE 25 MG TABLET [7437]

Facility

OP

$1.00

Service Code	NDC 60687046511
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

SPIRONOLACTONE 25 MG TABLET [7437]

Facility

OP

$1.00

Service Code	NDC 60687046501
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

SPIRONOLACTONE 25 MG TABLET [7437]

Facility

IP

$1.00

Service Code	NDC 60687046501
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

SPIRONOLACTONE 25 MG TABLET [7437]

Facility

IP

$1.00

Service Code	NDC 60687046511
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

SPLENECTOMY

Facility

IP

$21,765.83

Service Code	APR-DRG 6504
Min. Negotiated Rate	$21,765.83
Max. Negotiated Rate	$21,765.83
Rate for Payer: AlohaCare Medicaid	$21,765.83
Rate for Payer: Hawaii Medical Service Association ABD	$21,765.83
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21,765.83
Rate for Payer: Kaiser Permanente Medicaid	$21,765.83
Rate for Payer: Ohana Health Plan Medicaid	$21,765.83
Rate for Payer: UnitedHealthcare Medicaid	$21,765.83

SPLENECTOMY

Facility

IP

$14,785.16

Service Code	APR-DRG 6503
Min. Negotiated Rate	$14,785.16
Max. Negotiated Rate	$14,785.16
Rate for Payer: AlohaCare Medicaid	$14,785.16
Rate for Payer: Hawaii Medical Service Association ABD	$14,785.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14,785.16
Rate for Payer: Kaiser Permanente Medicaid	$14,785.16
Rate for Payer: Ohana Health Plan Medicaid	$14,785.16
Rate for Payer: UnitedHealthcare Medicaid	$14,785.16

SPLENECTOMY

Facility

IP

$9,643.92

Service Code	APR-DRG 6502
Min. Negotiated Rate	$9,643.92
Max. Negotiated Rate	$9,643.92
Rate for Payer: AlohaCare Medicaid	$9,643.92
Rate for Payer: Hawaii Medical Service Association ABD	$9,643.92
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,643.92
Rate for Payer: Kaiser Permanente Medicaid	$9,643.92
Rate for Payer: Ohana Health Plan Medicaid	$9,643.92
Rate for Payer: UnitedHealthcare Medicaid	$9,643.92

SPLENECTOMY

Facility

IP

$7,010.67

Service Code	APR-DRG 6501
Min. Negotiated Rate	$7,010.67
Max. Negotiated Rate	$7,010.67
Rate for Payer: AlohaCare Medicaid	$7,010.67
Rate for Payer: Hawaii Medical Service Association ABD	$7,010.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,010.67
Rate for Payer: Kaiser Permanente Medicaid	$7,010.67
Rate for Payer: Ohana Health Plan Medicaid	$7,010.67
Rate for Payer: UnitedHealthcare Medicaid	$7,010.67

SPLENIC PROCEDURES WITH CC

Facility

IP

$48,462.15

Service Code	MSDRG 800
Min. Negotiated Rate	$31,954.84
Max. Negotiated Rate	$48,462.15
Rate for Payer: AlohaCare Medicare	$31,954.84
Rate for Payer: Devoted Health Medicare	$35,150.32
Rate for Payer: Hawaii Medical Service Association Commercial	$44,770.77
Rate for Payer: Hawaii Medical Service Association Medicare	$31,954.84
Rate for Payer: Humana Medicare	$31,954.84
Rate for Payer: Kaiser Permanente Commercial	$48,462.15
Rate for Payer: Kaiser Permanente Medicare	$31,954.84
Rate for Payer: Ohana Health Plan Medicare	$31,954.84
Rate for Payer: UnitedHealthcare Medicare	$31,954.84

SPLENIC PROCEDURES WITH MCC

Facility

IP

$78,123.52

Service Code	MSDRG 799
Min. Negotiated Rate	$44,770.77
Max. Negotiated Rate	$78,123.52
Rate for Payer: AlohaCare Medicare	$51,512.86
Rate for Payer: Devoted Health Medicare	$56,664.15
Rate for Payer: Hawaii Medical Service Association Commercial	$44,770.77
Rate for Payer: Hawaii Medical Service Association Medicare	$51,512.86
Rate for Payer: Humana Medicare	$51,512.86
Rate for Payer: Kaiser Permanente Commercial	$78,123.52
Rate for Payer: Kaiser Permanente Medicare	$51,512.86
Rate for Payer: Ohana Health Plan Medicare	$51,512.86
Rate for Payer: UnitedHealthcare Medicare	$51,512.86

SPLENIC PROCEDURES WITHOUT CC/MCC

Facility

IP

$44,770.77

Service Code	MSDRG 801
Min. Negotiated Rate	$21,712.30
Max. Negotiated Rate	$44,770.77
Rate for Payer: AlohaCare Medicare	$21,712.30
Rate for Payer: Devoted Health Medicare	$23,883.53
Rate for Payer: Hawaii Medical Service Association Commercial	$44,770.77
Rate for Payer: Hawaii Medical Service Association Medicare	$21,712.30
Rate for Payer: Humana Medicare	$21,712.30
Rate for Payer: Kaiser Permanente Commercial	$32,928.53
Rate for Payer: Kaiser Permanente Medicare	$21,712.30
Rate for Payer: Ohana Health Plan Medicare	$21,712.30
Rate for Payer: UnitedHealthcare Medicare	$21,712.30

SPLINT #10-1500-10NKL

Facility

OP

$157.00

Hospital Revenue Code	272
Min. Negotiated Rate	$80.07
Max. Negotiated Rate	$152.29
Rate for Payer: Cash Price	$94.20
Rate for Payer: Hawaii Western Management Group Commercial	$149.15
Rate for Payer: Health Management Network Commercial	$133.45
Rate for Payer: Kaiser Permanente Commercial	$98.91
Rate for Payer: Kaiser Permanente Medicaid	$80.07
Rate for Payer: MDX Hawaii PPO	$152.29
Rate for Payer: University Health Alliance Commercial	$114.44

SPLINT #10-1500-10NKL

Facility

IP

$157.00

Hospital Revenue Code	272
Min. Negotiated Rate	$133.45
Max. Negotiated Rate	$152.29
Rate for Payer: Cash Price	$94.20
Rate for Payer: Health Management Network Commercial	$133.45
Rate for Payer: MDX Hawaii PPO	$152.29

SPLINT DENVER SM 10-1500-05KS

Facility

OP

$260.00

Hospital Revenue Code	272
Min. Negotiated Rate	$132.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$247.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$163.80
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$189.51

SPLINT DENVER SM 10-1500-05KS

Facility

IP

$260.00

Hospital Revenue Code	272
Min. Negotiated Rate	$221.00
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: MDX Hawaii PPO	$252.20

SPLINT EXTERNAL NASAL

Facility

IP

$246.00

Hospital Revenue Code	272
Min. Negotiated Rate	$209.10
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$147.60
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: MDX Hawaii PPO	$238.62

SPLINT EXTERNAL NASAL

Facility

OP

$246.00

Hospital Revenue Code	272
Min. Negotiated Rate	$125.46
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$147.60
Rate for Payer: Hawaii Western Management Group Commercial	$233.70
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Kaiser Permanente Commercial	$154.98
Rate for Payer: Kaiser Permanente Medicaid	$125.46
Rate for Payer: MDX Hawaii PPO	$238.62
Rate for Payer: University Health Alliance Commercial	$179.31

SPLINT INTRANASAL

Facility

OP

$340.00

Hospital Revenue Code	272
Min. Negotiated Rate	$173.40
Max. Negotiated Rate	$329.80
Rate for Payer: Cash Price	$204.00
Rate for Payer: Hawaii Western Management Group Commercial	$323.00
Rate for Payer: Health Management Network Commercial	$289.00
Rate for Payer: Kaiser Permanente Commercial	$214.20
Rate for Payer: Kaiser Permanente Medicaid	$173.40
Rate for Payer: MDX Hawaii PPO	$329.80
Rate for Payer: University Health Alliance Commercial	$247.83

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