Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

PSA, Total, Medicare Screening FSI

Facility

OP

$145.00

Service Code	HCPCS G0103
Hospital Charge Code	8118029
Hospital Revenue Code	300
Min. Negotiated Rate	$24.14
Max. Negotiated Rate	$140.65
Rate for Payer: AlohaCare Medicaid	$72.50
Rate for Payer: AlohaCare Medicare	$72.50
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$79.75
Rate for Payer: Hawaii Medical Service Association Commercial	$24.14
Rate for Payer: Hawaii Medical Service Association Medicare	$72.50
Rate for Payer: Hawaii Western Management Group Commercial	$137.75
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Humana Medicare	$72.50
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: Kaiser Permanente Medicare	$72.50
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: Ohana Health Plan Medicaid	$72.50
Rate for Payer: Ohana Health Plan Medicare	$72.50
Rate for Payer: UnitedHealthcare Medicaid	$25.42
Rate for Payer: UnitedHealthcare Medicare	$72.50
Rate for Payer: University Health Alliance Commercial	$81.20

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

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

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 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 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

PSYCHOSES

Facility

IP

$15,761.83

Service Code	MSDRG 885
Min. Negotiated Rate	$15,761.83
Max. Negotiated Rate	$15,761.83
Rate for Payer: Hawaii Medical Service Association Commercial	$15,761.83

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	$123.20

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	$62.72

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

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	$112.00

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 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 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	$112.00

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	$154.00

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 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

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	$154.00

PT Gait Training Assistant Units

Facility

IP

$238.00

Service Code	HCPCS 97116 GP,CQ
Hospital Charge Code	8720438
Hospital Revenue Code	420
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$230.86
Rate for Payer: Cash Price	$154.70
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Kaiser Permanente Commercial	$214.20
Rate for Payer: MDX Hawaii PPO	$230.86

PT Gait Training Assistant Units

Facility

OP

$238.00

Service Code	HCPCS 97116 GP,CQ
Hospital Charge Code	8720438
Hospital Revenue Code	420
Min. Negotiated Rate	$16.70
Max. Negotiated Rate	$230.86
Rate for Payer: AlohaCare Medicaid	$119.00
Rate for Payer: AlohaCare Medicare	$119.00
Rate for Payer: Cash Price	$154.70
Rate for Payer: Cash Price	$154.70
Rate for Payer: Devoted Health Medicare	$130.90
Rate for Payer: Hawaii Medical Service Association Medicare	$119.00
Rate for Payer: Hawaii Western Management Group Commercial	$226.10
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Humana Medicare	$119.00
Rate for Payer: Kaiser Permanente Commercial	$214.20
Rate for Payer: Kaiser Permanente Medicaid	$121.38
Rate for Payer: Kaiser Permanente Medicare	$119.00
Rate for Payer: MDX Hawaii PPO	$230.86
Rate for Payer: Ohana Health Plan Medicaid	$119.00
Rate for Payer: Ohana Health Plan Medicare	$119.00
Rate for Payer: UnitedHealthcare Medicaid	$16.70
Rate for Payer: UnitedHealthcare Medicare	$119.00
Rate for Payer: University Health Alliance Commercial	$133.28

PT Group Therapy Assitant Units

Facility

OP

$132.00

Service Code	HCPCS 97150 GP,CQ
Hospital Charge Code	8720418
Hospital Revenue Code	420
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$128.04
Rate for Payer: AlohaCare Medicaid	$66.00
Rate for Payer: AlohaCare Medicare	$66.00
Rate for Payer: Cash Price	$85.80
Rate for Payer: Cash Price	$85.80
Rate for Payer: Devoted Health Medicare	$72.60
Rate for Payer: Hawaii Medical Service Association Medicare	$66.00
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Humana Medicare	$66.00
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: Kaiser Permanente Medicare	$66.00
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: Ohana Health Plan Medicaid	$66.00
Rate for Payer: Ohana Health Plan Medicare	$66.00
Rate for Payer: UnitedHealthcare Medicaid	$14.78
Rate for Payer: UnitedHealthcare Medicare	$66.00
Rate for Payer: University Health Alliance Commercial	$73.92

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