Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

LUTONIX 035 DCB OTW 8X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,315.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: MDX Hawaii PPO	$3,783.00

LUTONIX 035 DCB OTW 8X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,950.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: AlohaCare Medicaid	$1,950.00
Rate for Payer: AlohaCare Medicare	$2,964.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Devoted Health Medicare	$3,276.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,964.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,705.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Humana Medicare	$2,964.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: Kaiser Permanente Medicaid	$1,989.00
Rate for Payer: Kaiser Permanente Medicare	$2,964.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: Ohana Health Plan Medicaid	$2,964.00
Rate for Payer: Ohana Health Plan Medicare	$2,964.00
Rate for Payer: UnitedHealthcare Medicare	$2,964.00
Rate for Payer: University Health Alliance Commercial	$2,842.71

LUTONIX 035 DCB OTW 9X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,950.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: AlohaCare Medicaid	$1,950.00
Rate for Payer: AlohaCare Medicare	$2,964.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Devoted Health Medicare	$3,276.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,964.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,705.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Humana Medicare	$2,964.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: Kaiser Permanente Medicaid	$1,989.00
Rate for Payer: Kaiser Permanente Medicare	$2,964.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: Ohana Health Plan Medicaid	$2,964.00
Rate for Payer: Ohana Health Plan Medicare	$2,964.00
Rate for Payer: UnitedHealthcare Medicare	$2,964.00
Rate for Payer: University Health Alliance Commercial	$2,842.71

LUTONIX 035 DCB OTW 9X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,315.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: MDX Hawaii PPO	$3,783.00

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC

Facility

$76,510.06

Service Code	MSDRG 821
Min. Negotiated Rate	$76,510.06
Max. Negotiated Rate	$76,510.06
Rate for Payer: Hawaii Medical Service Association Commercial	$76,510.06

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$76,510.06

Service Code	MSDRG 820
Min. Negotiated Rate	$76,510.06
Max. Negotiated Rate	$76,510.06
Rate for Payer: Hawaii Medical Service Association Commercial	$76,510.06

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$30,646.69

Service Code	MSDRG 822
Min. Negotiated Rate	$30,646.69
Max. Negotiated Rate	$30,646.69
Rate for Payer: Hawaii Medical Service Association Commercial	$30,646.69

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC

Facility

$77,718.86

Service Code	MSDRG 841
Min. Negotiated Rate	$77,718.86
Max. Negotiated Rate	$77,718.86
Rate for Payer: Hawaii Medical Service Association Commercial	$77,718.86

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC

Facility

$82,293.34

Service Code	MSDRG 840
Min. Negotiated Rate	$82,293.34
Max. Negotiated Rate	$82,293.34
Rate for Payer: Hawaii Medical Service Association Commercial	$82,293.34

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC

Facility

$92,532.61

Service Code	MSDRG 824
Min. Negotiated Rate	$92,532.61
Max. Negotiated Rate	$92,532.61
Rate for Payer: Hawaii Medical Service Association Commercial	$92,532.61

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC

Facility

$92,532.61

Service Code	MSDRG 823
Min. Negotiated Rate	$92,532.61
Max. Negotiated Rate	$92,532.61
Rate for Payer: Hawaii Medical Service Association Commercial	$92,532.61

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC

Facility

$25,053.01

Service Code	MSDRG 825
Min. Negotiated Rate	$25,053.01
Max. Negotiated Rate	$25,053.01
Rate for Payer: Hawaii Medical Service Association Commercial	$25,053.01

LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC

Facility

$51,030.41

Service Code	MSDRG 842
Min. Negotiated Rate	$51,030.41
Max. Negotiated Rate	$51,030.41
Rate for Payer: Hawaii Medical Service Association Commercial	$51,030.41

MAG HYDROX/AL HYDROX/SIMETH/LIDO SUSPENSION (GI COCKTAIL) (35E [4080001]

Facility

$23.00

Service Code	NDC 00004080001
Hospital Revenue Code	637
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$17.48
Rate for Payer: Cash Price	$13.80
Rate for Payer: Devoted Health Medicare	$19.32
Rate for Payer: Hawaii Medical Service Association Medicare	$17.48
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$17.48
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$17.48
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$17.48
Rate for Payer: Ohana Health Plan Medicare	$17.48
Rate for Payer: UnitedHealthcare Medicare	$17.48
Rate for Payer: University Health Alliance Commercial	$16.76

MAG HYDROX/AL HYDROX/SIMETH/LIDO SUSPENSION (GI COCKTAIL) (35E [4080001]

Facility

$23.00

Service Code	NDC 00004080001
Hospital Revenue Code	250
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

MAGNESIUM CITRATE ORAL SOLUTION [1701]

Facility

$13.00

Service Code	NDC 71399005101
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: MDX Hawaii PPO	$12.61

MAGNESIUM CITRATE ORAL SOLUTION [1701]

Facility

$13.00

Service Code	NDC 71399005101
Hospital Revenue Code	637
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$12.61
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$9.88
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$10.92
Rate for Payer: Hawaii Medical Service Association Medicare	$9.88
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Humana Medicare	$9.88
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicare	$9.88
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: Ohana Health Plan Medicaid	$9.88
Rate for Payer: Ohana Health Plan Medicare	$9.88
Rate for Payer: UnitedHealthcare Medicare	$9.88
Rate for Payer: University Health Alliance Commercial	$9.48

MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION [28836]

Facility

$9.00

Service Code	NDC 60687042976
Hospital Revenue Code	637
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$6.84
Rate for Payer: Cash Price	$5.40
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Hawaii Medical Service Association Medicare	$6.84
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$6.84
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$6.84
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$6.84
Rate for Payer: Ohana Health Plan Medicare	$6.84
Rate for Payer: UnitedHealthcare Medicare	$6.84
Rate for Payer: University Health Alliance Commercial	$6.56

MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION [28836]

Facility

$9.00

Service Code	NDC 00121043130
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION [28836]

Facility

$9.00

Service Code	NDC 60687042976
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION [28836]

Facility

$9.00

Service Code	NDC 00121043130
Hospital Revenue Code	637
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$6.84
Rate for Payer: Cash Price	$5.40
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Hawaii Medical Service Association Medicare	$6.84
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$6.84
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$6.84
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$6.84
Rate for Payer: Ohana Health Plan Medicare	$6.84
Rate for Payer: UnitedHealthcare Medicare	$6.84
Rate for Payer: University Health Alliance Commercial	$6.56

MAGNESIUM L-LACTATE ER 84 MG TABLET,EXTENDED RELEASE [4715]

Facility

$2.00

Service Code	NDC 42019000000
Hospital Revenue Code	637
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$1.52
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.52
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$1.52
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$1.52
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$1.52
Rate for Payer: Ohana Health Plan Medicare	$1.52
Rate for Payer: UnitedHealthcare Medicare	$1.52
Rate for Payer: University Health Alliance Commercial	$1.46

MAGNESIUM L-LACTATE ER 84 MG TABLET,EXTENDED RELEASE [4715]

Facility

$1.00

Service Code	NDC 80010000000
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

MAGNESIUM L-LACTATE ER 84 MG TABLET,EXTENDED RELEASE [4715]

Facility

$2.00

Service Code	NDC 42001000000
Hospital Revenue Code	637
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$1.52
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.52
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$1.52
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$1.52
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$1.52
Rate for Payer: Ohana Health Plan Medicare	$1.52
Rate for Payer: UnitedHealthcare Medicare	$1.52
Rate for Payer: University Health Alliance Commercial	$1.46

MAGNESIUM L-LACTATE ER 84 MG TABLET,EXTENDED RELEASE [4715]

Facility

$1.00

Service Code	NDC 80010000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.76
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.76
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.76
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.76
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.76
Rate for Payer: Ohana Health Plan Medicare	$0.76
Rate for Payer: UnitedHealthcare Medicare	$0.76
Rate for Payer: University Health Alliance Commercial	$0.73

Know your out-of-pocket cost for care.

All Charges