Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

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

lysine 500 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 50268051915
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

lysine 500 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 50268051915
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

macitentan 10 mg Tab [KMC]

Facility

$1,030.56

Service Code	NDC 66215050130
Hospital Revenue Code	250
Min. Negotiated Rate	$432.84
Max. Negotiated Rate	$999.64
Rate for Payer: AlohaCare Medicaid	$515.28
Rate for Payer: AlohaCare Medicare	$432.84
Rate for Payer: Cash Price	$669.86
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$948.12
Rate for Payer: Devoted Health Medicare	$432.84
Rate for Payer: Hawaii Medical Service Association Medicare	$432.84
Rate for Payer: Hawaii Western Management Group Commercial	$979.03
Rate for Payer: Health Management Network Commercial	$875.98
Rate for Payer: Humana Medicare	$432.84
Rate for Payer: Kaiser Permanente Commercial	$927.50
Rate for Payer: Kaiser Permanente Medicaid	$525.59
Rate for Payer: Kaiser Permanente Medicare	$432.84
Rate for Payer: MDX Hawaii PPO	$999.64
Rate for Payer: Ohana Health Plan Medicaid	$432.84
Rate for Payer: Ohana Health Plan Medicare	$432.84
Rate for Payer: UnitedHealthcare Medicaid	$618.34
Rate for Payer: UnitedHealthcare Medicare	$432.84
Rate for Payer: University Health Alliance Commercial	$751.18

macitentan 10 mg Tab [KMC]

Facility

$1,030.56

Service Code	NDC 66215050130
Hospital Revenue Code	250
Min. Negotiated Rate	$875.98
Max. Negotiated Rate	$999.64
Rate for Payer: Cash Price	$669.86
Rate for Payer: Health Management Network Commercial	$875.98
Rate for Payer: Kaiser Permanente Commercial	$927.50
Rate for Payer: MDX Hawaii PPO	$999.64

magnesium citrate 8.85% Oral Liq 296 mL [KMC]

Facility

$0.02

Service Code	NDC 70677005101
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: AlohaCare Medicaid	$0.01
Rate for Payer: AlohaCare Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.02
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Hawaii Medical Service Association Medicare	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$0.02
Rate for Payer: Health Management Network Commercial	$0.02
Rate for Payer: Humana Medicare	$0.01
Rate for Payer: Kaiser Permanente Commercial	$0.02
Rate for Payer: Kaiser Permanente Medicaid	$0.01
Rate for Payer: Kaiser Permanente Medicare	$0.01
Rate for Payer: MDX Hawaii PPO	$0.02
Rate for Payer: Ohana Health Plan Medicaid	$0.01
Rate for Payer: Ohana Health Plan Medicare	$0.01
Rate for Payer: UnitedHealthcare Medicaid	$0.01
Rate for Payer: UnitedHealthcare Medicare	$0.01
Rate for Payer: University Health Alliance Commercial	$0.01

magnesium citrate 8.85% Oral Liq 296 mL [KMC]

Facility

$0.02

Service Code	NDC 70677005101
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.02
Rate for Payer: Kaiser Permanente Commercial	$0.02
Rate for Payer: MDX Hawaii PPO	$0.02

Magnesium DLS

Facility

$124.00

Service Code	HCPCS 83735
Hospital Charge Code	422837355
Hospital Revenue Code	301
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$120.28
Rate for Payer: AlohaCare Medicaid	$62.00
Rate for Payer: AlohaCare Medicare	$52.08
Rate for Payer: Cash Price	$80.60
Rate for Payer: Cash Price	$80.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$114.08
Rate for Payer: Devoted Health Medicare	$52.08
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$9.26
Rate for Payer: Hawaii Medical Service Association Commercial	$8.38
Rate for Payer: Hawaii Medical Service Association Medicare	$52.08
Rate for Payer: Hawaii Western Management Group Commercial	$6.70
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Humana Medicare	$52.08
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: Kaiser Permanente Medicaid	$63.24
Rate for Payer: Kaiser Permanente Medicare	$52.08
Rate for Payer: MDX Hawaii PPO	$120.28
Rate for Payer: Ohana Health Plan Medicaid	$52.08
Rate for Payer: Ohana Health Plan Medicare	$52.08
Rate for Payer: UnitedHealthcare Medicaid	$9.26
Rate for Payer: UnitedHealthcare Medicare	$52.08
Rate for Payer: University Health Alliance Commercial	$17.32

Magnesium DLS

Facility

$124.00

Service Code	HCPCS 83735
Hospital Charge Code	422837355
Hospital Revenue Code	301
Min. Negotiated Rate	$105.40
Max. Negotiated Rate	$120.28
Rate for Payer: Cash Price	$80.60
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: MDX Hawaii PPO	$120.28

magnesium hydroxide 2400mg / 30mL Susp [KMC]

Facility

$0.31

Service Code	NDC 63739019610
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.20
Rate for Payer: Health Management Network Commercial	$0.26
Rate for Payer: Kaiser Permanente Commercial	$0.28
Rate for Payer: MDX Hawaii PPO	$0.30

magnesium hydroxide 2400mg / 30mL Susp [KMC]

Facility

$0.31

Service Code	NDC 63739019610
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.30
Rate for Payer: AlohaCare Medicaid	$0.16
Rate for Payer: AlohaCare Medicare	$0.13
Rate for Payer: Cash Price	$0.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.29
Rate for Payer: Devoted Health Medicare	$0.13
Rate for Payer: Hawaii Medical Service Association Medicare	$0.13
Rate for Payer: Hawaii Western Management Group Commercial	$0.29
Rate for Payer: Health Management Network Commercial	$0.26
Rate for Payer: Humana Medicare	$0.13
Rate for Payer: Kaiser Permanente Commercial	$0.28
Rate for Payer: Kaiser Permanente Medicaid	$0.16
Rate for Payer: Kaiser Permanente Medicare	$0.13
Rate for Payer: MDX Hawaii PPO	$0.30
Rate for Payer: Ohana Health Plan Medicaid	$0.13
Rate for Payer: Ohana Health Plan Medicare	$0.13
Rate for Payer: UnitedHealthcare Medicaid	$0.19
Rate for Payer: UnitedHealthcare Medicare	$0.13
Rate for Payer: University Health Alliance Commercial	$0.23

magnesium lactate 84 mg ER tab [KMC]

Facility

$3.00

Service Code	NDC 71321080060
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

magnesium lactate 84 mg ER tab [KMC]

Facility

$3.00

Service Code	NDC 71321080060
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

Magnesium Level

Facility

$124.00

Service Code	HCPCS 83735
Hospital Charge Code	422837350
Hospital Revenue Code	301
Min. Negotiated Rate	$105.40
Max. Negotiated Rate	$120.28
Rate for Payer: Cash Price	$80.60
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: MDX Hawaii PPO	$120.28

Magnesium Level

Facility

$124.00

Service Code	HCPCS 83735
Hospital Charge Code	422837350
Hospital Revenue Code	301
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$120.28
Rate for Payer: AlohaCare Medicaid	$62.00
Rate for Payer: AlohaCare Medicare	$52.08
Rate for Payer: Cash Price	$80.60
Rate for Payer: Cash Price	$80.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$114.08
Rate for Payer: Devoted Health Medicare	$52.08
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$9.26
Rate for Payer: Hawaii Medical Service Association Commercial	$8.38
Rate for Payer: Hawaii Medical Service Association Medicare	$52.08
Rate for Payer: Hawaii Western Management Group Commercial	$6.70
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Humana Medicare	$52.08
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: Kaiser Permanente Medicaid	$63.24
Rate for Payer: Kaiser Permanente Medicare	$52.08
Rate for Payer: MDX Hawaii PPO	$120.28
Rate for Payer: Ohana Health Plan Medicaid	$52.08
Rate for Payer: Ohana Health Plan Medicare	$52.08
Rate for Payer: UnitedHealthcare Medicaid	$9.26
Rate for Payer: UnitedHealthcare Medicare	$52.08
Rate for Payer: University Health Alliance Commercial	$17.32

magnesium oxide 400 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00603020922
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

magnesium oxide 400 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00603020922
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

magnesium sulfate 1 g / 2 mL Inj Sol [KMC]

Facility

$2.88

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$2.45
Max. Negotiated Rate	$2.79
Rate for Payer: Cash Price	$1.87
Rate for Payer: Health Management Network Commercial	$2.45
Rate for Payer: Kaiser Permanente Commercial	$2.59
Rate for Payer: MDX Hawaii PPO	$2.79

magnesium sulfate 1 g / 2 mL Inj Sol [KMC]

Facility

$2.88

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$2.79
Rate for Payer: AlohaCare Medicaid	$1.44
Rate for Payer: AlohaCare Medicare	$1.21
Rate for Payer: Cash Price	$1.87
Rate for Payer: Cash Price	$1.87
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.65
Rate for Payer: Devoted Health Medicare	$1.21
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1.21
Rate for Payer: Hawaii Western Management Group Commercial	$2.74
Rate for Payer: Health Management Network Commercial	$2.45
Rate for Payer: Humana Medicare	$1.21
Rate for Payer: Kaiser Permanente Commercial	$2.59
Rate for Payer: Kaiser Permanente Medicaid	$1.47
Rate for Payer: Kaiser Permanente Medicare	$1.21
Rate for Payer: MDX Hawaii PPO	$2.79
Rate for Payer: Ohana Health Plan Medicaid	$1.21
Rate for Payer: Ohana Health Plan Medicare	$1.21
Rate for Payer: UnitedHealthcare Medicaid	$1.73
Rate for Payer: UnitedHealthcare Medicare	$1.21
Rate for Payer: University Health Alliance Commercial	$2.10

MAJOR BLADDER PROCEDURES WITH CC

Facility

$45,792.26

Service Code	MSDRG 654
Min. Negotiated Rate	$45,792.26
Max. Negotiated Rate	$45,792.26
Rate for Payer: Hawaii Medical Service Association Commercial	$45,792.26

Know your out-of-pocket cost for care.

All Charges