Kohala Hospital

All Charges

Charge

Type

Setting

Price

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

MAGNESIUM CITRATE PO SOLN

Facility

$17.98

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$8.99
Max. Negotiated Rate	$17.80
Rate for Payer: AlohaCare Medicaid	$8.99
Rate for Payer: AlohaCare Medicaid	$4.08
Rate for Payer: AlohaCare Medicare	$7.35
Rate for Payer: AlohaCare Medicare	$16.18
Rate for Payer: Cash Price	$11.69
Rate for Payer: Cash Price	$5.31
Rate for Payer: Devoted Health Medicare	$8.09
Rate for Payer: Devoted Health Medicare	$17.80
Rate for Payer: Hawaii Medical Service Association Medicare	$7.35
Rate for Payer: Hawaii Medical Service Association Medicare	$16.18
Rate for Payer: Hawaii Western Management Group Commercial	$7.76
Rate for Payer: Hawaii Western Management Group Commercial	$17.08
Rate for Payer: Health Management Network Commercial	$15.28
Rate for Payer: Health Management Network Commercial	$6.94
Rate for Payer: Humana Medicare	$7.35
Rate for Payer: Humana Medicare	$16.18
Rate for Payer: Kaiser Permanente Commercial	$16.18
Rate for Payer: Kaiser Permanente Commercial	$7.35
Rate for Payer: Kaiser Permanente Medicaid	$4.17
Rate for Payer: Kaiser Permanente Medicaid	$9.17
Rate for Payer: Kaiser Permanente Medicare	$16.18
Rate for Payer: Kaiser Permanente Medicare	$7.35
Rate for Payer: MDX Hawaii PPO	$17.44
Rate for Payer: MDX Hawaii PPO	$7.92
Rate for Payer: Ohana Health Plan Medicaid	$16.18
Rate for Payer: Ohana Health Plan Medicaid	$7.35
Rate for Payer: Ohana Health Plan Medicare	$16.18
Rate for Payer: Ohana Health Plan Medicare	$7.35
Rate for Payer: UnitedHealthcare Medicare	$16.18
Rate for Payer: UnitedHealthcare Medicare	$7.35
Rate for Payer: University Health Alliance Commercial	$13.11
Rate for Payer: University Health Alliance Commercial	$5.96

MAGNESIUM CITRATE PO SOLN

Facility

$17.98

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$15.28
Max. Negotiated Rate	$17.44
Rate for Payer: Cash Price	$11.69
Rate for Payer: Cash Price	$5.31
Rate for Payer: Health Management Network Commercial	$6.94
Rate for Payer: Health Management Network Commercial	$15.28
Rate for Payer: Kaiser Permanente Commercial	$7.35
Rate for Payer: Kaiser Permanente Commercial	$16.18
Rate for Payer: MDX Hawaii PPO	$17.44
Rate for Payer: MDX Hawaii PPO	$7.92

MAGNESIUM HYDROXIDE 400 MG/5 ML PO SUSP

Facility

$12.92

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.98
Max. Negotiated Rate	$12.53
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$10.98
Rate for Payer: Kaiser Permanente Commercial	$11.63
Rate for Payer: MDX Hawaii PPO	$12.53

MAGNESIUM HYDROXIDE 400 MG/5 ML PO SUSP

Facility

$12.92

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$6.46
Max. Negotiated Rate	$12.79
Rate for Payer: AlohaCare Medicaid	$6.46
Rate for Payer: AlohaCare Medicare	$11.63
Rate for Payer: Cash Price	$8.40
Rate for Payer: Devoted Health Medicare	$12.79
Rate for Payer: Hawaii Medical Service Association Medicare	$11.63
Rate for Payer: Hawaii Western Management Group Commercial	$12.27
Rate for Payer: Health Management Network Commercial	$10.98
Rate for Payer: Humana Medicare	$11.63
Rate for Payer: Kaiser Permanente Commercial	$11.63
Rate for Payer: Kaiser Permanente Medicaid	$6.59
Rate for Payer: Kaiser Permanente Medicare	$11.63
Rate for Payer: MDX Hawaii PPO	$12.53
Rate for Payer: Ohana Health Plan Medicaid	$11.63
Rate for Payer: Ohana Health Plan Medicare	$11.63
Rate for Payer: UnitedHealthcare Medicare	$11.63
Rate for Payer: University Health Alliance Commercial	$9.42

MAGNESIUM OXIDE 400 MG PO TABLET

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1.19
Rate for Payer: AlohaCare Medicaid	$0.60
Rate for Payer: AlohaCare Medicare	$1.08
Rate for Payer: Cash Price	$0.78
Rate for Payer: Devoted Health Medicare	$1.19
Rate for Payer: Hawaii Medical Service Association Medicare	$1.08
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Humana Medicare	$1.08
Rate for Payer: Kaiser Permanente Commercial	$1.08
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: Kaiser Permanente Medicare	$1.08
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: Ohana Health Plan Medicaid	$1.08
Rate for Payer: Ohana Health Plan Medicare	$1.08
Rate for Payer: UnitedHealthcare Medicare	$1.08
Rate for Payer: University Health Alliance Commercial	$0.87

MAGNESIUM OXIDE 400 MG PO TABLET

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$1.08
Rate for Payer: MDX Hawaii PPO	$1.16

MAGNESIUM SULFATE 4 MEQ/ML (50%) INJ (COMPONENT FOR MIXTURES)

Facility

$12.54

Service Code	HCPCS J3475
Hospital Revenue Code	250
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$12.16
Rate for Payer: Cash Price	$8.15
Rate for Payer: Health Management Network Commercial	$10.66
Rate for Payer: Kaiser Permanente Commercial	$11.29
Rate for Payer: MDX Hawaii PPO	$12.16

MAGNESIUM SULFATE 4 MEQ/ML (50%) INJ (COMPONENT FOR MIXTURES)

Facility

$12.54

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$12.41
Rate for Payer: AlohaCare Medicaid	$6.27
Rate for Payer: AlohaCare Medicare	$11.29
Rate for Payer: Cash Price	$8.15
Rate for Payer: Cash Price	$8.15
Rate for Payer: Devoted Health Medicare	$12.41
Rate for Payer: Hawaii Medical Service Association ABD	$0.50
Rate for Payer: Hawaii Medical Service Association Medicare	$11.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.50
Rate for Payer: Hawaii Western Management Group Commercial	$11.91
Rate for Payer: Health Management Network Commercial	$10.66
Rate for Payer: Humana Medicare	$11.29
Rate for Payer: Kaiser Permanente Commercial	$11.29
Rate for Payer: Kaiser Permanente Medicaid	$6.40
Rate for Payer: Kaiser Permanente Medicare	$11.29
Rate for Payer: MDX Hawaii PPO	$12.16
Rate for Payer: Ohana Health Plan Medicaid	$11.29
Rate for Payer: Ohana Health Plan Medicare	$11.29
Rate for Payer: UnitedHealthcare Medicaid	$7.52
Rate for Payer: UnitedHealthcare Medicare	$11.29
Rate for Payer: University Health Alliance Commercial	$9.14

MAGNESIUM SULFATE IN D5W 1 G IV IVPB

Facility

$54.58

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$54.03
Rate for Payer: AlohaCare Medicaid	$27.29
Rate for Payer: AlohaCare Medicaid	$10.49
Rate for Payer: AlohaCare Medicare	$18.88
Rate for Payer: AlohaCare Medicare	$49.12
Rate for Payer: Cash Price	$13.64
Rate for Payer: Cash Price	$13.64
Rate for Payer: Cash Price	$35.48
Rate for Payer: Cash Price	$35.48
Rate for Payer: Devoted Health Medicare	$20.77
Rate for Payer: Devoted Health Medicare	$54.03
Rate for Payer: Hawaii Medical Service Association ABD	$0.50
Rate for Payer: Hawaii Medical Service Association ABD	$0.50
Rate for Payer: Hawaii Medical Service Association Medicare	$18.88
Rate for Payer: Hawaii Medical Service Association Medicare	$49.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.50
Rate for Payer: Hawaii Western Management Group Commercial	$19.93
Rate for Payer: Hawaii Western Management Group Commercial	$51.85
Rate for Payer: Health Management Network Commercial	$17.83
Rate for Payer: Health Management Network Commercial	$46.39
Rate for Payer: Humana Medicare	$18.88
Rate for Payer: Humana Medicare	$49.12
Rate for Payer: Kaiser Permanente Commercial	$49.12
Rate for Payer: Kaiser Permanente Commercial	$18.88
Rate for Payer: Kaiser Permanente Medicaid	$10.70
Rate for Payer: Kaiser Permanente Medicaid	$27.84
Rate for Payer: Kaiser Permanente Medicare	$18.88
Rate for Payer: Kaiser Permanente Medicare	$49.12
Rate for Payer: MDX Hawaii PPO	$20.35
Rate for Payer: MDX Hawaii PPO	$52.94
Rate for Payer: Ohana Health Plan Medicaid	$49.12
Rate for Payer: Ohana Health Plan Medicaid	$18.88
Rate for Payer: Ohana Health Plan Medicare	$18.88
Rate for Payer: Ohana Health Plan Medicare	$49.12
Rate for Payer: UnitedHealthcare Medicaid	$12.59
Rate for Payer: UnitedHealthcare Medicaid	$32.75
Rate for Payer: UnitedHealthcare Medicare	$49.12
Rate for Payer: UnitedHealthcare Medicare	$18.88
Rate for Payer: University Health Alliance Commercial	$15.29
Rate for Payer: University Health Alliance Commercial	$39.78

MAGNESIUM SULFATE IN D5W 1 G IV IVPB

Facility

$20.98

Service Code	HCPCS J3475
Hospital Revenue Code	250
Min. Negotiated Rate	$17.83
Max. Negotiated Rate	$20.35
Rate for Payer: Cash Price	$13.64
Rate for Payer: Cash Price	$35.48
Rate for Payer: Health Management Network Commercial	$46.39
Rate for Payer: Health Management Network Commercial	$17.83
Rate for Payer: Kaiser Permanente Commercial	$18.88
Rate for Payer: Kaiser Permanente Commercial	$49.12
Rate for Payer: MDX Hawaii PPO	$20.35
Rate for Payer: MDX Hawaii PPO	$52.94

MAGNESIUM SULFATE IN WATER 2 GRAM/50 ML (4 %) IV IVPB

Facility

$71.20

Service Code	HCPCS J3475
Hospital Revenue Code	250
Min. Negotiated Rate	$60.52
Max. Negotiated Rate	$69.06
Rate for Payer: Cash Price	$46.28
Rate for Payer: Health Management Network Commercial	$60.52
Rate for Payer: Kaiser Permanente Commercial	$64.08
Rate for Payer: MDX Hawaii PPO	$69.06

MAGNESIUM SULFATE IN WATER 2 GRAM/50 ML (4 %) IV IVPB

Facility

$71.20

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$70.49
Rate for Payer: AlohaCare Medicaid	$35.60
Rate for Payer: AlohaCare Medicare	$64.08
Rate for Payer: Cash Price	$46.28
Rate for Payer: Cash Price	$46.28
Rate for Payer: Devoted Health Medicare	$70.49
Rate for Payer: Hawaii Medical Service Association ABD	$0.50
Rate for Payer: Hawaii Medical Service Association Medicare	$64.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.50
Rate for Payer: Hawaii Western Management Group Commercial	$67.64
Rate for Payer: Health Management Network Commercial	$60.52
Rate for Payer: Humana Medicare	$64.08
Rate for Payer: Kaiser Permanente Commercial	$64.08
Rate for Payer: Kaiser Permanente Medicaid	$36.31
Rate for Payer: Kaiser Permanente Medicare	$64.08
Rate for Payer: MDX Hawaii PPO	$69.06
Rate for Payer: Ohana Health Plan Medicaid	$64.08
Rate for Payer: Ohana Health Plan Medicare	$64.08
Rate for Payer: UnitedHealthcare Medicaid	$42.72
Rate for Payer: UnitedHealthcare Medicare	$64.08
Rate for Payer: University Health Alliance Commercial	$51.90

MAGNESIUM SULFATE IN WATER 4 GRAM/100 ML (4 %) IV IVPB

Facility

$45.87

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$45.41
Rate for Payer: AlohaCare Medicaid	$22.93
Rate for Payer: AlohaCare Medicare	$41.28
Rate for Payer: Cash Price	$29.82
Rate for Payer: Cash Price	$29.82
Rate for Payer: Devoted Health Medicare	$45.41
Rate for Payer: Hawaii Medical Service Association ABD	$0.50
Rate for Payer: Hawaii Medical Service Association Medicare	$41.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.50
Rate for Payer: Hawaii Western Management Group Commercial	$43.58
Rate for Payer: Health Management Network Commercial	$38.99
Rate for Payer: Humana Medicare	$41.28
Rate for Payer: Kaiser Permanente Commercial	$41.28
Rate for Payer: Kaiser Permanente Medicaid	$23.39
Rate for Payer: Kaiser Permanente Medicare	$41.28
Rate for Payer: MDX Hawaii PPO	$44.49
Rate for Payer: Ohana Health Plan Medicaid	$41.28
Rate for Payer: Ohana Health Plan Medicare	$41.28
Rate for Payer: UnitedHealthcare Medicaid	$27.52
Rate for Payer: UnitedHealthcare Medicare	$41.28
Rate for Payer: University Health Alliance Commercial	$33.43

MAGNESIUM SULFATE IN WATER 4 GRAM/100 ML (4 %) IV IVPB

Facility

$45.87

Service Code	HCPCS J3475
Hospital Revenue Code	250
Min. Negotiated Rate	$38.99
Max. Negotiated Rate	$44.49
Rate for Payer: Cash Price	$29.82
Rate for Payer: Health Management Network Commercial	$38.99
Rate for Payer: Kaiser Permanente Commercial	$41.28
Rate for Payer: MDX Hawaii PPO	$44.49

MAGNESIUM SULFATE (LAXATIVE) 495 MG/5 GRAM PO GRAN

Facility

$30.08

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$25.57
Max. Negotiated Rate	$29.18
Rate for Payer: Cash Price	$19.55
Rate for Payer: Health Management Network Commercial	$25.57
Rate for Payer: Kaiser Permanente Commercial	$27.07
Rate for Payer: MDX Hawaii PPO	$29.18

MAGNESIUM SULFATE (LAXATIVE) 495 MG/5 GRAM PO GRAN

Facility

$30.08

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$15.04
Max. Negotiated Rate	$29.78
Rate for Payer: AlohaCare Medicaid	$15.04
Rate for Payer: AlohaCare Medicare	$27.07
Rate for Payer: Cash Price	$19.55
Rate for Payer: Devoted Health Medicare	$29.78
Rate for Payer: Hawaii Medical Service Association Medicare	$27.07
Rate for Payer: Hawaii Western Management Group Commercial	$28.58
Rate for Payer: Health Management Network Commercial	$25.57
Rate for Payer: Humana Medicare	$27.07
Rate for Payer: Kaiser Permanente Commercial	$27.07
Rate for Payer: Kaiser Permanente Medicaid	$15.34
Rate for Payer: Kaiser Permanente Medicare	$27.07
Rate for Payer: MDX Hawaii PPO	$29.18
Rate for Payer: Ohana Health Plan Medicaid	$27.07
Rate for Payer: Ohana Health Plan Medicare	$27.07
Rate for Payer: UnitedHealthcare Medicare	$27.07
Rate for Payer: University Health Alliance Commercial	$21.93

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

MAJOR BLADDER PROCEDURES WITH MCC

Facility

$45,792.26

Service Code	MSDRG 653
Min. Negotiated Rate	$45,792.26
Max. Negotiated Rate	$45,792.26
Rate for Payer: Hawaii Medical Service Association Commercial	$45,792.26

MAJOR BLADDER PROCEDURES WITHOUT CC/MCC

Facility

$45,792.26

Service Code	MSDRG 655
Min. Negotiated Rate	$45,792.26
Max. Negotiated Rate	$45,792.26
Rate for Payer: Hawaii Medical Service Association Commercial	$45,792.26

MAJOR CHEST PROCEDURES WITH CC

Facility

$63,213.23

Service Code	MSDRG 164
Min. Negotiated Rate	$63,213.23
Max. Negotiated Rate	$63,213.23
Rate for Payer: Hawaii Medical Service Association Commercial	$63,213.23

MAJOR CHEST PROCEDURES WITH MCC

Facility

$63,450.25

Service Code	MSDRG 163
Min. Negotiated Rate	$63,450.25
Max. Negotiated Rate	$63,450.25
Rate for Payer: Hawaii Medical Service Association Commercial	$63,450.25

MAJOR CHEST PROCEDURES WITHOUT CC/MCC

Facility

$45,436.73

Service Code	MSDRG 165
Min. Negotiated Rate	$45,436.73
Max. Negotiated Rate	$45,436.73
Rate for Payer: Hawaii Medical Service Association Commercial	$45,436.73

MAJOR CHEST TRAUMA WITH CC

Facility

$19,767.47

Service Code	MSDRG 184
Min. Negotiated Rate	$19,767.47
Max. Negotiated Rate	$19,767.47
Rate for Payer: Hawaii Medical Service Association Commercial	$19,767.47

Know your out-of-pocket cost for care.

All Charges