Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION [174859]

Facility

OP

$5,286.00

Service Code	HCPCS J9309
Hospital Revenue Code	636
Min. Negotiated Rate	$136.23
Max. Negotiated Rate	$5,127.42
Rate for Payer: AlohaCare Medicaid	$137.23
Rate for Payer: AlohaCare Medicare	$137.23
Rate for Payer: Cash Price	$3,171.60
Rate for Payer: Cash Price	$3,171.60
Rate for Payer: Devoted Health Medicare	$150.95
Rate for Payer: Hawaii Medical Service Association ABD	$136.23
Rate for Payer: Hawaii Medical Service Association Commercial	$171.54
Rate for Payer: Hawaii Medical Service Association Medicare	$137.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136.23
Rate for Payer: Hawaii Western Management Group Commercial	$5,021.70
Rate for Payer: Health Management Network Commercial	$4,493.10
Rate for Payer: Humana Medicare	$137.23
Rate for Payer: Kaiser Permanente Commercial	$3,330.18
Rate for Payer: Kaiser Permanente Medicaid	$2,695.86
Rate for Payer: Kaiser Permanente Medicare	$137.23
Rate for Payer: MDX Hawaii PPO	$5,127.42
Rate for Payer: Ohana Health Plan Medicaid	$150.95
Rate for Payer: Ohana Health Plan Medicare	$137.23
Rate for Payer: UnitedHealthcare Medicaid	$3,171.60
Rate for Payer: UnitedHealthcare Medicare	$137.23
Rate for Payer: University Health Alliance Commercial	$3,852.97

POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION [174859]

Facility

IP

$5,286.00

Service Code	HCPCS J9309
Hospital Revenue Code	250
Min. Negotiated Rate	$4,493.10
Max. Negotiated Rate	$5,127.42
Rate for Payer: Cash Price	$3,171.60
Rate for Payer: Health Management Network Commercial	$4,493.10
Rate for Payer: MDX Hawaii PPO	$5,127.42

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

IP

$6.00

Service Code	NDC 00904693176
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

IP

$5.00

Service Code	NDC 00904693186
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

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

IP

$6.00

Service Code	NDC 62559015730
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

OP

$6.00

Service Code	NDC 00904693176
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

OP

$6.00

Service Code	NDC 62559015730
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

OP

$5.00

Service Code	NDC 00904693186
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

PORT ACCESS AIRSEAL 8X100MM

Facility

IP

$351.00

Hospital Revenue Code	272
Min. Negotiated Rate	$298.35
Max. Negotiated Rate	$340.47
Rate for Payer: Cash Price	$210.60
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: MDX Hawaii PPO	$340.47

PORT ACCESS AIRSEAL 8X100MM

Facility

OP

$351.00

Hospital Revenue Code	272
Min. Negotiated Rate	$179.01
Max. Negotiated Rate	$340.47
Rate for Payer: Cash Price	$210.60
Rate for Payer: Hawaii Western Management Group Commercial	$333.45
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Kaiser Permanente Commercial	$221.13
Rate for Payer: Kaiser Permanente Medicaid	$179.01
Rate for Payer: MDX Hawaii PPO	$340.47
Rate for Payer: University Health Alliance Commercial	$255.84

PORTAL SKID AR-4505

Facility

IP

$236.00

Hospital Revenue Code	272
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: MDX Hawaii PPO	$228.92

PORTAL SKID AR-4505

Facility

OP

$236.00

Hospital Revenue Code	272
Min. Negotiated Rate	$120.36
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$148.68
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: University Health Alliance Commercial	$172.02

PORT INTERGRATED ALLOX2-FH11SE

Facility

IP

$3,750.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$2,100.00
Max. Negotiated Rate	$3,637.50
Rate for Payer: Cash Price	$2,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,625.00
Rate for Payer: Health Management Network Commercial	$3,187.50
Rate for Payer: MDX Hawaii PPO	$3,637.50
Rate for Payer: University Health Alliance Commercial	$2,100.00

PORT INTERGRATED ALLOX2-FH11SE

Facility

OP

$3,750.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,912.50
Max. Negotiated Rate	$3,637.50
Rate for Payer: Cash Price	$2,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,625.00
Rate for Payer: Health Management Network Commercial	$3,187.50
Rate for Payer: Kaiser Permanente Commercial	$2,362.50
Rate for Payer: Kaiser Permanente Medicaid	$1,912.50
Rate for Payer: MDX Hawaii PPO	$3,637.50
Rate for Payer: University Health Alliance Commercial	$2,100.00

POSACONAZOLE 300 MG/16.7 ML INTRAVENOUS SOLUTION [125429]

Facility

OP

$1,592.00

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$811.92
Max. Negotiated Rate	$1,544.24
Rate for Payer: Cash Price	$955.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,512.40
Rate for Payer: Health Management Network Commercial	$1,353.20
Rate for Payer: Kaiser Permanente Commercial	$1,002.96
Rate for Payer: Kaiser Permanente Medicaid	$811.92
Rate for Payer: MDX Hawaii PPO	$1,544.24
Rate for Payer: UnitedHealthcare Medicaid	$955.20
Rate for Payer: University Health Alliance Commercial	$1,160.41

POSACONAZOLE 300 MG/16.7 ML INTRAVENOUS SOLUTION [125429]

Facility

IP

$1,592.00

Service Code	HCPCS J3490
Hospital Revenue Code	250
Min. Negotiated Rate	$1,353.20
Max. Negotiated Rate	$1,544.24
Rate for Payer: Cash Price	$955.20
Rate for Payer: Health Management Network Commercial	$1,353.20
Rate for Payer: MDX Hawaii PPO	$1,544.24

POSITIONER SAFE-T

Facility

IP

$544.00

Hospital Revenue Code	272
Min. Negotiated Rate	$462.40
Max. Negotiated Rate	$527.68
Rate for Payer: Cash Price	$326.40
Rate for Payer: Health Management Network Commercial	$462.40
Rate for Payer: MDX Hawaii PPO	$527.68

POSITIONER SAFE-T

Facility

OP

$544.00

Hospital Revenue Code	272
Min. Negotiated Rate	$277.44
Max. Negotiated Rate	$527.68
Rate for Payer: Cash Price	$326.40
Rate for Payer: Hawaii Western Management Group Commercial	$516.80
Rate for Payer: Health Management Network Commercial	$462.40
Rate for Payer: Kaiser Permanente Commercial	$342.72
Rate for Payer: Kaiser Permanente Medicaid	$277.44
Rate for Payer: MDX Hawaii PPO	$527.68
Rate for Payer: University Health Alliance Commercial	$396.52

POSITIONING REVERSE KIT 40642

Facility

OP

$737.00

Hospital Revenue Code	272
Min. Negotiated Rate	$375.87
Max. Negotiated Rate	$714.89
Rate for Payer: Cash Price	$442.20
Rate for Payer: Hawaii Western Management Group Commercial	$700.15
Rate for Payer: Health Management Network Commercial	$626.45
Rate for Payer: Kaiser Permanente Commercial	$464.31
Rate for Payer: Kaiser Permanente Medicaid	$375.87
Rate for Payer: MDX Hawaii PPO	$714.89
Rate for Payer: University Health Alliance Commercial	$537.20

POSITIONING REVERSE KIT 40642

Facility

IP

$737.00

Hospital Revenue Code	272
Min. Negotiated Rate	$626.45
Max. Negotiated Rate	$714.89
Rate for Payer: Cash Price	$442.20
Rate for Payer: Health Management Network Commercial	$626.45
Rate for Payer: MDX Hawaii PPO	$714.89

POST 30D ANGLE 11MM 4922-2-140

Facility

IP

$488.00

Hospital Revenue Code	278
Min. Negotiated Rate	$273.28
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$292.80
Rate for Payer: Hawaii Western Management Group Commercial	$341.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: University Health Alliance Commercial	$273.28

POST 30D ANGLE 11MM 4922-2-140

Facility

OP

$488.00

Hospital Revenue Code	278
Min. Negotiated Rate	$248.88
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$292.80
Rate for Payer: Hawaii Western Management Group Commercial	$341.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Kaiser Permanente Commercial	$307.44
Rate for Payer: Kaiser Permanente Medicaid	$248.88
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: University Health Alliance Commercial	$273.28

POST 90 DEG 4922-2-160

Facility

OP

$901.00

Hospital Revenue Code	272
Min. Negotiated Rate	$459.51
Max. Negotiated Rate	$873.97
Rate for Payer: Cash Price	$540.60
Rate for Payer: Hawaii Western Management Group Commercial	$855.95
Rate for Payer: Health Management Network Commercial	$765.85
Rate for Payer: Kaiser Permanente Commercial	$567.63
Rate for Payer: Kaiser Permanente Medicaid	$459.51
Rate for Payer: MDX Hawaii PPO	$873.97
Rate for Payer: University Health Alliance Commercial	$656.74

POST 90 DEG 4922-2-160

Facility

IP

$901.00

Hospital Revenue Code	272
Min. Negotiated Rate	$765.85
Max. Negotiated Rate	$873.97
Rate for Payer: Cash Price	$540.60
Rate for Payer: Health Management Network Commercial	$765.85
Rate for Payer: MDX Hawaii PPO	$873.97

POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY

Facility

OP

$11,157.19

Service Code	CPT 57250
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$11,157.19
Rate for Payer: AlohaCare Medicaid	$5,909.62
Rate for Payer: AlohaCare Medicare	$5,909.62
Rate for Payer: Devoted Health Medicare	$6,500.58
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	$5,909.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$5,909.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$5,909.62
Rate for Payer: Ohana Health Plan Medicaid	$6,500.58
Rate for Payer: Ohana Health Plan Medicare	$5,909.62
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$5,909.62
Rate for Payer: University Health Alliance Commercial	$11,157.19

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