Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

OP

$48.00

Service Code	NDC 67877012425
Hospital Revenue Code	637
Min. Negotiated Rate	$14.88
Max. Negotiated Rate	$46.56
Rate for Payer: AlohaCare Medicaid	$24.00
Rate for Payer: AlohaCare Medicare	$14.88
Rate for Payer: Cash Price	$28.80
Rate for Payer: Devoted Health Medicare	$16.32
Rate for Payer: Hawaii Medical Service Association Medicare	$14.88
Rate for Payer: Hawaii Western Management Group Commercial	$45.60
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Humana Medicare	$14.88
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: Kaiser Permanente Medicare	$14.88
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: Ohana Health Plan Medicaid	$14.88
Rate for Payer: Ohana Health Plan Medicare	$14.88
Rate for Payer: UnitedHealthcare Medicare	$14.88
Rate for Payer: University Health Alliance Commercial	$34.99

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: Kaiser Permanente Commercial	$79.20
Rate for Payer: MDX Hawaii PPO	$85.36

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

IP

$102.00

Service Code	NDC 61570013185
Hospital Revenue Code	250
Min. Negotiated Rate	$86.70
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$61.20
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Kaiser Permanente Commercial	$91.80
Rate for Payer: MDX Hawaii PPO	$98.94

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: Kaiser Permanente Commercial	$43.20
Rate for Payer: MDX Hawaii PPO	$46.56

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

OP

$227.00

Service Code	NDC 59762013104
Hospital Revenue Code	637
Min. Negotiated Rate	$70.37
Max. Negotiated Rate	$220.19
Rate for Payer: AlohaCare Medicaid	$113.50
Rate for Payer: AlohaCare Medicare	$70.37
Rate for Payer: Cash Price	$136.20
Rate for Payer: Devoted Health Medicare	$77.18
Rate for Payer: Hawaii Medical Service Association Medicare	$70.37
Rate for Payer: Hawaii Western Management Group Commercial	$215.65
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Humana Medicare	$70.37
Rate for Payer: Kaiser Permanente Commercial	$204.30
Rate for Payer: Kaiser Permanente Medicaid	$115.77
Rate for Payer: Kaiser Permanente Medicare	$70.37
Rate for Payer: MDX Hawaii PPO	$220.19
Rate for Payer: Ohana Health Plan Medicaid	$70.37
Rate for Payer: Ohana Health Plan Medicare	$70.37
Rate for Payer: UnitedHealthcare Medicare	$70.37
Rate for Payer: University Health Alliance Commercial	$165.46

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: Kaiser Permanente Commercial	$262.80
Rate for Payer: MDX Hawaii PPO	$283.24

SILVER SULFADIAZINE 1 % TOPICAL CREAM [7224]

Facility

OP

$292.00

Service Code	NDC 67877012440
Hospital Revenue Code	637
Min. Negotiated Rate	$90.52
Max. Negotiated Rate	$283.24
Rate for Payer: AlohaCare Medicaid	$146.00
Rate for Payer: AlohaCare Medicare	$90.52
Rate for Payer: Cash Price	$175.20
Rate for Payer: Devoted Health Medicare	$99.28
Rate for Payer: Hawaii Medical Service Association Medicare	$90.52
Rate for Payer: Hawaii Western Management Group Commercial	$277.40
Rate for Payer: Health Management Network Commercial	$248.20
Rate for Payer: Humana Medicare	$90.52
Rate for Payer: Kaiser Permanente Commercial	$262.80
Rate for Payer: Kaiser Permanente Medicaid	$148.92
Rate for Payer: Kaiser Permanente Medicare	$90.52
Rate for Payer: MDX Hawaii PPO	$283.24
Rate for Payer: Ohana Health Plan Medicaid	$90.52
Rate for Payer: Ohana Health Plan Medicare	$90.52
Rate for Payer: UnitedHealthcare Medicare	$90.52
Rate for Payer: University Health Alliance Commercial	$212.84

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: Kaiser Permanente Commercial	$9.00
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: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

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	$3.10
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$3.10
Rate for Payer: Cash Price	$6.00
Rate for Payer: Devoted Health Medicare	$3.40
Rate for Payer: Hawaii Medical Service Association Medicare	$3.10
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$3.10
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$3.10
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$3.10
Rate for Payer: Ohana Health Plan Medicare	$3.10
Rate for Payer: UnitedHealthcare Medicare	$3.10
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	$3.10
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$3.10
Rate for Payer: Cash Price	$6.00
Rate for Payer: Devoted Health Medicare	$3.40
Rate for Payer: Hawaii Medical Service Association Medicare	$3.10
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$3.10
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$3.10
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$3.10
Rate for Payer: Ohana Health Plan Medicare	$3.10
Rate for Payer: UnitedHealthcare Medicare	$3.10
Rate for Payer: University Health Alliance Commercial	$7.29

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: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

OP

$1.00

Service Code	NDC 77333081210
Hospital Revenue Code	637
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.31
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.34
Rate for Payer: Hawaii Medical Service Association Medicare	$0.31
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.31
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.31
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.31
Rate for Payer: Ohana Health Plan Medicare	$0.31
Rate for Payer: UnitedHealthcare Medicare	$0.31
Rate for Payer: University Health Alliance Commercial	$0.73

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: Kaiser Permanente Commercial	$0.90
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	$0.31
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.31
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.34
Rate for Payer: Hawaii Medical Service Association Medicare	$0.31
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.31
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.31
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.31
Rate for Payer: Ohana Health Plan Medicare	$0.31
Rate for Payer: UnitedHealthcare Medicare	$0.31
Rate for Payer: University Health Alliance Commercial	$0.73

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

IP

$23,796.81

Service Code	MSDRG 194
Min. Negotiated Rate	$23,796.81
Max. Negotiated Rate	$23,796.81
Rate for Payer: Hawaii Medical Service Association Commercial	$23,796.81

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

IP

$24,626.38

Service Code	MSDRG 193
Min. Negotiated Rate	$24,626.38
Max. Negotiated Rate	$24,626.38
Rate for Payer: Hawaii Medical Service Association Commercial	$24,626.38

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

IP

$18,937.90

Service Code	MSDRG 195
Min. Negotiated Rate	$18,937.90
Max. Negotiated Rate	$18,937.90
Rate for Payer: Hawaii Medical Service Association Commercial	$18,937.90

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: Kaiser Permanente Commercial	$777.60
Rate for Payer: MDX Hawaii PPO	$838.08
Rate for Payer: University Health Alliance Commercial	$483.84

SIMPLEX W/GENTAMICN 6195-1-010

Facility

OP

$864.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$267.84
Max. Negotiated Rate	$838.08
Rate for Payer: AlohaCare Medicaid	$432.00
Rate for Payer: AlohaCare Medicare	$267.84
Rate for Payer: Cash Price	$518.40
Rate for Payer: Devoted Health Medicare	$293.76
Rate for Payer: Hawaii Medical Service Association Medicare	$267.84
Rate for Payer: Hawaii Western Management Group Commercial	$604.80
Rate for Payer: Health Management Network Commercial	$734.40
Rate for Payer: Humana Medicare	$267.84
Rate for Payer: Kaiser Permanente Commercial	$777.60
Rate for Payer: Kaiser Permanente Medicaid	$440.64
Rate for Payer: Kaiser Permanente Medicare	$267.84
Rate for Payer: MDX Hawaii PPO	$838.08
Rate for Payer: Ohana Health Plan Medicaid	$267.84
Rate for Payer: Ohana Health Plan Medicare	$267.84
Rate for Payer: UnitedHealthcare Medicare	$267.84
Rate for Payer: University Health Alliance Commercial	$483.84

SIMPLICITI GUIDE PIN 9722908

Facility

OP

$600.00

Hospital Revenue Code	272
Min. Negotiated Rate	$186.00
Max. Negotiated Rate	$582.00
Rate for Payer: AlohaCare Medicaid	$300.00
Rate for Payer: AlohaCare Medicare	$186.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Devoted Health Medicare	$204.00
Rate for Payer: Hawaii Medical Service Association Medicare	$186.00
Rate for Payer: Hawaii Western Management Group Commercial	$570.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Humana Medicare	$186.00
Rate for Payer: Kaiser Permanente Commercial	$540.00
Rate for Payer: Kaiser Permanente Medicaid	$306.00
Rate for Payer: Kaiser Permanente Medicare	$186.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: Ohana Health Plan Medicaid	$186.00
Rate for Payer: Ohana Health Plan Medicare	$186.00
Rate for Payer: UnitedHealthcare Medicare	$186.00
Rate for Payer: University Health Alliance Commercial	$437.34

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: Kaiser Permanente Commercial	$540.00
Rate for Payer: MDX Hawaii PPO	$582.00

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: Kaiser Permanente Commercial	$7,422.30
Rate for Payer: MDX Hawaii PPO	$7,999.59
Rate for Payer: University Health Alliance Commercial	$4,618.32

SIMPLIDERM SD.090.1020ELP

Facility

OP

$8,247.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$2,556.57
Max. Negotiated Rate	$7,999.59
Rate for Payer: AlohaCare Medicaid	$4,123.50
Rate for Payer: AlohaCare Medicare	$2,556.57
Rate for Payer: Cash Price	$4,948.20
Rate for Payer: Devoted Health Medicare	$2,803.98
Rate for Payer: Hawaii Medical Service Association Medicare	$2,556.57
Rate for Payer: Hawaii Western Management Group Commercial	$5,772.90
Rate for Payer: Health Management Network Commercial	$7,009.95
Rate for Payer: Humana Medicare	$2,556.57
Rate for Payer: Kaiser Permanente Commercial	$7,422.30
Rate for Payer: Kaiser Permanente Medicaid	$4,205.97
Rate for Payer: Kaiser Permanente Medicare	$2,556.57
Rate for Payer: MDX Hawaii PPO	$7,999.59
Rate for Payer: Ohana Health Plan Medicaid	$2,556.57
Rate for Payer: Ohana Health Plan Medicare	$2,556.57
Rate for Payer: UnitedHealthcare Medicare	$2,556.57
Rate for Payer: University Health Alliance Commercial	$4,618.32

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT

Facility

IP

$696,862.50

Service Code	MSDRG 008
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$696,862.50
Rate for Payer: Hawaii Medical Service Association Commercial	$696,862.50
Rate for Payer: University Health Alliance Commercial	$10,400.00

<<
<
760
761
762
763
764
765
766
767
768
769
>
>>