Kau Hospital

All Charges

Charge

Type

Setting

Price

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	$7.13
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$7.13
Rate for Payer: Cash Price	$13.80
Rate for Payer: Devoted Health Medicare	$7.82
Rate for Payer: Hawaii Medical Service Association Medicare	$7.13
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$7.13
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$7.13
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$7.13
Rate for Payer: Ohana Health Plan Medicare	$7.13
Rate for Payer: UnitedHealthcare Medicare	$7.13
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	637
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$12.61
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$4.03
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$4.42
Rate for Payer: Hawaii Medical Service Association Medicare	$4.03
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Humana Medicare	$4.03
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicare	$4.03
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: Ohana Health Plan Medicaid	$4.03
Rate for Payer: Ohana Health Plan Medicare	$4.03
Rate for Payer: UnitedHealthcare Medicare	$4.03
Rate for Payer: University Health Alliance Commercial	$9.48

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 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 60687042976
Hospital Revenue Code	637
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$2.79
Rate for Payer: Cash Price	$5.40
Rate for Payer: Devoted Health Medicare	$3.06
Rate for Payer: Hawaii Medical Service Association Medicare	$2.79
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$2.79
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$2.79
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$2.79
Rate for Payer: Ohana Health Plan Medicare	$2.79
Rate for Payer: UnitedHealthcare Medicare	$2.79
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	637
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$2.79
Rate for Payer: Cash Price	$5.40
Rate for Payer: Devoted Health Medicare	$3.06
Rate for Payer: Hawaii Medical Service Association Medicare	$2.79
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$2.79
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$2.79
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$2.79
Rate for Payer: Ohana Health Plan Medicare	$2.79
Rate for Payer: UnitedHealthcare Medicare	$2.79
Rate for Payer: University Health Alliance Commercial	$6.56

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

Facility

$1.00

Service Code	NDC 80010000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.31
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.34
Rate for Payer: Hawaii Medical Service Association Medicare	$0.31
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.31
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.31
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.31
Rate for Payer: Ohana Health Plan Medicare	$0.31
Rate for Payer: UnitedHealthcare Medicare	$0.31
Rate for Payer: University Health Alliance Commercial	$0.73

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

Facility

$2.00

Service Code	NDC 42001000000
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

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

Facility

$2.00

Service Code	NDC 42001000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
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 42019000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

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

Facility

$2.00

Service Code	NDC 42019000000
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [137043]

Facility

$27.00

Service Code	HCPCS J3475
Hospital Revenue Code	250
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [137043]

Facility

$27.00

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$26.19
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$8.37
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$16.20
Rate for Payer: Devoted Health Medicare	$9.18
Rate for Payer: Hawaii Medical Service Association ABD	$0.50
Rate for Payer: Hawaii Medical Service Association Medicare	$8.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.50
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Humana Medicare	$8.37
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicare	$8.37
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$8.37
Rate for Payer: Ohana Health Plan Medicare	$8.37
Rate for Payer: UnitedHealthcare Medicaid	$16.20
Rate for Payer: UnitedHealthcare Medicare	$8.37
Rate for Payer: University Health Alliance Commercial	$19.68

MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION [129653]

Facility

$27.00

Service Code	HCPCS J3475
Hospital Revenue Code	250
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION [129653]

Facility

$27.00

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$26.19
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$8.37
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$16.20
Rate for Payer: Devoted Health Medicare	$9.18
Rate for Payer: Hawaii Medical Service Association ABD	$0.50
Rate for Payer: Hawaii Medical Service Association Medicare	$8.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.50
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Humana Medicare	$8.37
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicare	$8.37
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$8.37
Rate for Payer: Ohana Health Plan Medicare	$8.37
Rate for Payer: UnitedHealthcare Medicaid	$16.20
Rate for Payer: UnitedHealthcare Medicare	$8.37
Rate for Payer: University Health Alliance Commercial	$19.68

MAGNESIUM SULFATE 2 GM IN 1 L NS (SIMPLE) [4080270]

Facility

$30.00

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$29.10
Rate for Payer: AlohaCare Medicaid	$15.00
Rate for Payer: AlohaCare Medicare	$9.30
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Devoted Health Medicare	$10.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.50
Rate for Payer: Hawaii Medical Service Association Medicare	$9.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.50
Rate for Payer: Hawaii Western Management Group Commercial	$28.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Humana Medicare	$9.30
Rate for Payer: Kaiser Permanente Commercial	$27.00
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: Kaiser Permanente Medicare	$9.30
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: Ohana Health Plan Medicaid	$9.30
Rate for Payer: Ohana Health Plan Medicare	$9.30
Rate for Payer: UnitedHealthcare Medicaid	$18.00
Rate for Payer: UnitedHealthcare Medicare	$9.30
Rate for Payer: University Health Alliance Commercial	$21.87

MAGNESIUM SULFATE 2 GM IN 1 L NS (SIMPLE) [4080270]

Facility

$30.00

Service Code	HCPCS J3475
Hospital Revenue Code	250
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$27.00
Rate for Payer: MDX Hawaii PPO	$29.10

MAGNESIUM SULFATE 2 GM IN 500 ML NS (SIMPLE) [4080271]

Facility

$34.00

Service Code	HCPCS J3475
Hospital Revenue Code	250
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$20.40
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98

Know your out-of-pocket cost for care.

All Charges