Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

pseudoephedrine 60 mg tablet [HHSC]

Facility

OP

$3.00

Service Code	NDC 00904690706
Hospital Charge Code	2500711
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

pseudoephedrine 60 mg tablet [HHSC]

Facility

IP

$3.00

Service Code	NDC 00904690706
Hospital Charge Code	2500711
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

pseudoephedrine 60 mg tablet [HHSC]

Facility

IP

$3.00

Service Code	NDC 00904672846
Hospital Charge Code	2500711
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

pseudoephedrine 60 mg tablet [HHSC]

Facility

OP

$3.00

Service Code	NDC 00904512559
Hospital Charge Code	2500711
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

pseudoephedrine 60 mg tablet [HHSC]

Facility

IP

$3.00

Service Code	NDC 00904512559
Hospital Charge Code	2500711
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

pseudoephedrine 60 mg tablet [HHSC]

Facility

IP

$3.00

Service Code	NDC 00904672852
Hospital Charge Code	2500711
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

pseudoephedrine 60 mg tablet [HHSC]

Facility

OP

$3.00

Service Code	NDC 00904672852
Hospital Charge Code	2500711
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

pseudoephedrine 60 mg tablet [HHSC]

Facility

OP

$3.00

Service Code	NDC 00904672846
Hospital Charge Code	2500711
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

PSYCHOSES

Facility

IP

$16,954.84

Service Code	MSDRG 885
Min. Negotiated Rate	$16,954.84
Max. Negotiated Rate	$16,954.84
Rate for Payer: Hawaii Medical Service Association Commercial	$16,954.84

psyllium 5.8 g powder packet [HHSC]

Facility

IP

$3.00

Service Code	NDC 37000002444
Hospital Charge Code	2500712
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

psyllium 5.8 g powder packet [HHSC]

Facility

IP

$3.04

Service Code	NDC 37000002404
Hospital Charge Code	2500712
Hospital Revenue Code	250
Min. Negotiated Rate	$2.58
Max. Negotiated Rate	$2.95
Rate for Payer: Cash Price	$1.98
Rate for Payer: Health Management Network Commercial	$2.58
Rate for Payer: Kaiser Permanente Commercial	$2.74
Rate for Payer: MDX Hawaii PPO	$2.95

psyllium 5.8 g powder packet [HHSC]

Facility

OP

$3.00

Service Code	NDC 37000002444
Hospital Charge Code	2500712
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

psyllium 5.8 g powder packet [HHSC]

Facility

OP

$3.04

Service Code	NDC 37000002404
Hospital Charge Code	2500712
Hospital Revenue Code	250
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$2.95
Rate for Payer: AlohaCare Medicaid	$1.52
Rate for Payer: AlohaCare Medicare	$1.52
Rate for Payer: Cash Price	$1.98
Rate for Payer: Devoted Health Medicare	$1.67
Rate for Payer: Hawaii Medical Service Association Medicare	$1.52
Rate for Payer: Hawaii Western Management Group Commercial	$2.89
Rate for Payer: Health Management Network Commercial	$2.58
Rate for Payer: Humana Medicare	$1.52
Rate for Payer: Kaiser Permanente Commercial	$2.74
Rate for Payer: Kaiser Permanente Medicaid	$1.55
Rate for Payer: Kaiser Permanente Medicare	$1.52
Rate for Payer: MDX Hawaii PPO	$2.95
Rate for Payer: Ohana Health Plan Medicaid	$1.52
Rate for Payer: Ohana Health Plan Medicare	$1.52
Rate for Payer: UnitedHealthcare Medicaid	$1.82
Rate for Payer: UnitedHealthcare Medicare	$1.52
Rate for Payer: University Health Alliance Commercial	$2.22

PT ADL Training Assitant Units

Facility

IP

$220.00

Service Code	HCPCS 97535 GP,CQ
Hospital Charge Code	8735281
Hospital Revenue Code	420
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

PT ADL Training Assitant Units

Facility

OP

$220.00

Service Code	HCPCS 97535 GP,CQ
Hospital Charge Code	8735281
Hospital Revenue Code	420
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicaid	$19.20
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

PT Attended E-Stim Assistant Units

Facility

OP

$112.00

Service Code	HCPCS 97032 GP,CQ
Hospital Charge Code	8720422
Hospital Revenue Code	420
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$108.64
Rate for Payer: AlohaCare Medicaid	$56.00
Rate for Payer: AlohaCare Medicare	$56.00
Rate for Payer: Cash Price	$72.80
Rate for Payer: Cash Price	$72.80
Rate for Payer: Devoted Health Medicare	$61.60
Rate for Payer: Hawaii Medical Service Association Medicare	$56.00
Rate for Payer: Hawaii Western Management Group Commercial	$106.40
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Humana Medicare	$56.00
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Medicaid	$57.12
Rate for Payer: Kaiser Permanente Medicare	$56.00
Rate for Payer: MDX Hawaii PPO	$108.64
Rate for Payer: Ohana Health Plan Medicaid	$56.00
Rate for Payer: Ohana Health Plan Medicare	$56.00
Rate for Payer: UnitedHealthcare Medicaid	$13.64
Rate for Payer: UnitedHealthcare Medicare	$56.00
Rate for Payer: University Health Alliance Commercial	$81.64

PT Attended E-Stim Assistant Units

Facility

IP

$112.00

Service Code	HCPCS 97032 GP,CQ
Hospital Charge Code	8720422
Hospital Revenue Code	420
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$108.64
Rate for Payer: Cash Price	$72.80
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: MDX Hawaii PPO	$108.64

PT Canalith Repositioning Assist Units

Facility

IP

$200.00

Service Code	HCPCS 95992 GP,CQ
Hospital Charge Code	8720420
Hospital Revenue Code	420
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: MDX Hawaii PPO	$194.00

PT Canalith Repositioning Assist Units

Facility

OP

$200.00

Service Code	HCPCS 95992 GP,CQ
Hospital Charge Code	8720420
Hospital Revenue Code	420
Min. Negotiated Rate	$25.72
Max. Negotiated Rate	$194.00
Rate for Payer: AlohaCare Medicaid	$100.00
Rate for Payer: AlohaCare Medicare	$100.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Devoted Health Medicare	$110.00
Rate for Payer: Hawaii Medical Service Association Medicare	$100.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Humana Medicare	$100.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: Kaiser Permanente Medicare	$100.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: Ohana Health Plan Medicaid	$100.00
Rate for Payer: Ohana Health Plan Medicare	$100.00
Rate for Payer: UnitedHealthcare Medicaid	$25.72
Rate for Payer: UnitedHealthcare Medicare	$100.00
Rate for Payer: University Health Alliance Commercial	$145.78

PT Canalith Repositioning Charge

Facility

OP

$200.00

Service Code	HCPCS 95992 GP,CQ
Hospital Charge Code	8111752
Hospital Revenue Code	420
Min. Negotiated Rate	$25.72
Max. Negotiated Rate	$194.00
Rate for Payer: AlohaCare Medicaid	$100.00
Rate for Payer: AlohaCare Medicare	$100.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Devoted Health Medicare	$110.00
Rate for Payer: Hawaii Medical Service Association Medicare	$100.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Humana Medicare	$100.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: Kaiser Permanente Medicare	$100.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: Ohana Health Plan Medicaid	$100.00
Rate for Payer: Ohana Health Plan Medicare	$100.00
Rate for Payer: UnitedHealthcare Medicaid	$25.72
Rate for Payer: UnitedHealthcare Medicare	$100.00
Rate for Payer: University Health Alliance Commercial	$145.78

PT Canalith Repositioning Charge

Facility

IP

$200.00

Service Code	HCPCS 95992 GP,CQ
Hospital Charge Code	8111752
Hospital Revenue Code	420
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: MDX Hawaii PPO	$194.00

PT Functional Capacity Assist Units

Facility

IP

$275.00

Service Code	HCPCS 97750 GP,CQ
Hospital Charge Code	8736071
Hospital Revenue Code	420
Min. Negotiated Rate	$233.75
Max. Negotiated Rate	$266.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Health Management Network Commercial	$233.75
Rate for Payer: Kaiser Permanente Commercial	$247.50
Rate for Payer: MDX Hawaii PPO	$266.75

PT Functional Capacity Assist Units

Facility

OP

$275.00

Service Code	HCPCS 97750 GP,CQ
Hospital Charge Code	8736071
Hospital Revenue Code	420
Min. Negotiated Rate	$19.83
Max. Negotiated Rate	$266.75
Rate for Payer: AlohaCare Medicaid	$137.50
Rate for Payer: AlohaCare Medicare	$137.50
Rate for Payer: Cash Price	$178.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Devoted Health Medicare	$151.25
Rate for Payer: Hawaii Medical Service Association Medicare	$137.50
Rate for Payer: Hawaii Western Management Group Commercial	$261.25
Rate for Payer: Health Management Network Commercial	$233.75
Rate for Payer: Humana Medicare	$137.50
Rate for Payer: Kaiser Permanente Commercial	$247.50
Rate for Payer: Kaiser Permanente Medicaid	$140.25
Rate for Payer: Kaiser Permanente Medicare	$137.50
Rate for Payer: MDX Hawaii PPO	$266.75
Rate for Payer: Ohana Health Plan Medicaid	$137.50
Rate for Payer: Ohana Health Plan Medicare	$137.50
Rate for Payer: UnitedHealthcare Medicaid	$19.83
Rate for Payer: UnitedHealthcare Medicare	$137.50
Rate for Payer: University Health Alliance Commercial	$200.45

PT Functional Measure Testing Charge

Facility

OP

$275.00

Service Code	HCPCS 97750 GP,CQ
Hospital Charge Code	8111818
Hospital Revenue Code	420
Min. Negotiated Rate	$19.83
Max. Negotiated Rate	$266.75
Rate for Payer: AlohaCare Medicaid	$137.50
Rate for Payer: AlohaCare Medicare	$137.50
Rate for Payer: Cash Price	$178.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Devoted Health Medicare	$151.25
Rate for Payer: Hawaii Medical Service Association Medicare	$137.50
Rate for Payer: Hawaii Western Management Group Commercial	$261.25
Rate for Payer: Health Management Network Commercial	$233.75
Rate for Payer: Humana Medicare	$137.50
Rate for Payer: Kaiser Permanente Commercial	$247.50
Rate for Payer: Kaiser Permanente Medicaid	$140.25
Rate for Payer: Kaiser Permanente Medicare	$137.50
Rate for Payer: MDX Hawaii PPO	$266.75
Rate for Payer: Ohana Health Plan Medicaid	$137.50
Rate for Payer: Ohana Health Plan Medicare	$137.50
Rate for Payer: UnitedHealthcare Medicaid	$19.83
Rate for Payer: UnitedHealthcare Medicare	$137.50
Rate for Payer: University Health Alliance Commercial	$200.45

PT Functional Measure Testing Charge

Facility

IP

$275.00

Service Code	HCPCS 97750 GP,CQ
Hospital Charge Code	8111818
Hospital Revenue Code	420
Min. Negotiated Rate	$233.75
Max. Negotiated Rate	$266.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Health Management Network Commercial	$233.75
Rate for Payer: Kaiser Permanente Commercial	$247.50
Rate for Payer: MDX Hawaii PPO	$266.75

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