Kona Community Hospital

All Charges

Charge

Type

Setting

Price

M001PCB7020500 Balloon Peripheral Cutting 7.0mmX2.0cmX50cm [3641974]

Facility

$3,878.00

Service Code	HCPCS C1725
Hospital Charge Code	3641974
Hospital Revenue Code	272
Min. Negotiated Rate	$1,977.78
Max. Negotiated Rate	$3,761.66
Rate for Payer: Cash Price	$2,520.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,684.10
Rate for Payer: Health Management Network Commercial	$3,296.30
Rate for Payer: Kaiser Permanente Commercial	$2,443.14
Rate for Payer: Kaiser Permanente Medicaid	$1,977.78
Rate for Payer: MDX Hawaii PPO	$3,761.66
Rate for Payer: University Health Alliance Commercial	$2,826.67

M001PCB7020500 Balloon Peripheral Cutting 7.0mmX2.0cmX50cm [3641974]

Facility

$3,878.00

Service Code	HCPCS C1725
Hospital Charge Code	3641974
Hospital Revenue Code	272
Min. Negotiated Rate	$3,296.30
Max. Negotiated Rate	$3,761.66
Rate for Payer: Cash Price	$2,520.70
Rate for Payer: Health Management Network Commercial	$3,296.30
Rate for Payer: MDX Hawaii PPO	$3,761.66

M0067301251 Urovac Bladder Evacuator [3601731]

Facility

$163.20

Hospital Charge Code	3601731
Hospital Revenue Code	272
Min. Negotiated Rate	$83.23
Max. Negotiated Rate	$158.30
Rate for Payer: Cash Price	$106.08
Rate for Payer: Hawaii Western Management Group Commercial	$155.04
Rate for Payer: Health Management Network Commercial	$138.72
Rate for Payer: Kaiser Permanente Commercial	$102.82
Rate for Payer: Kaiser Permanente Medicaid	$83.23
Rate for Payer: MDX Hawaii PPO	$158.30
Rate for Payer: University Health Alliance Commercial	$118.96

M0067301251 Urovac Bladder Evacuator [3601731]

Facility

$163.20

Hospital Charge Code	3601731
Hospital Revenue Code	272
Min. Negotiated Rate	$138.72
Max. Negotiated Rate	$158.30
Rate for Payer: Cash Price	$106.08
Rate for Payer: Health Management Network Commercial	$138.72
Rate for Payer: MDX Hawaii PPO	$158.30

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: MDX Hawaii PPO	$7.92
Rate for Payer: MDX Hawaii PPO	$17.44

MAGNESIUM CITRATE PO SOLN

Facility

$17.98

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$9.17
Max. Negotiated Rate	$17.44
Rate for Payer: Cash Price	$11.69
Rate for Payer: Cash Price	$5.31
Rate for Payer: Hawaii Western Management Group Commercial	$17.08
Rate for Payer: Hawaii Western Management Group Commercial	$7.76
Rate for Payer: Health Management Network Commercial	$6.94
Rate for Payer: Health Management Network Commercial	$15.28
Rate for Payer: Kaiser Permanente Commercial	$11.33
Rate for Payer: Kaiser Permanente Commercial	$5.15
Rate for Payer: Kaiser Permanente Medicaid	$4.17
Rate for Payer: Kaiser Permanente Medicaid	$9.17
Rate for Payer: MDX Hawaii PPO	$7.92
Rate for Payer: MDX Hawaii PPO	$17.44
Rate for Payer: UnitedHealthcare Medicaid	$10.79
Rate for Payer: UnitedHealthcare Medicaid	$4.90
Rate for Payer: University Health Alliance Commercial	$5.96
Rate for Payer: University Health Alliance Commercial	$13.11

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: MDX Hawaii PPO	$12.53

MAGNESIUM HYDROXIDE 400 MG/5 ML PO SUSP

Facility

$12.92

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$6.59
Max. Negotiated Rate	$12.53
Rate for Payer: Cash Price	$8.40
Rate for Payer: Hawaii Western Management Group Commercial	$12.27
Rate for Payer: Health Management Network Commercial	$10.98
Rate for Payer: Kaiser Permanente Commercial	$8.14
Rate for Payer: Kaiser Permanente Medicaid	$6.59
Rate for Payer: MDX Hawaii PPO	$12.53
Rate for Payer: UnitedHealthcare Medicaid	$7.75
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	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: MDX Hawaii PPO	$1.16

MAGNESIUM OXIDE 400 MG PO TABLET

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$0.76
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: UnitedHealthcare Medicaid	$0.72
Rate for Payer: University Health Alliance Commercial	$0.87

MAGNESIUM SULFATE 2 GRAM/50 ML IV IVPB (REPLACEMENT SCALE)

Facility

$49.02

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$47.55
Rate for Payer: Cash Price	$31.86
Rate for Payer: Cash Price	$31.86
Rate for Payer: Hawaii Medical Service Association ABD	$0.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.50
Rate for Payer: Hawaii Western Management Group Commercial	$46.57
Rate for Payer: Health Management Network Commercial	$41.67
Rate for Payer: Kaiser Permanente Commercial	$30.88
Rate for Payer: Kaiser Permanente Medicaid	$25.00
Rate for Payer: MDX Hawaii PPO	$47.55
Rate for Payer: UnitedHealthcare Medicaid	$29.41
Rate for Payer: University Health Alliance Commercial	$35.73

MAGNESIUM SULFATE 2 GRAM/50 ML IV IVPB (REPLACEMENT SCALE)

Facility

$49.02

Service Code	HCPCS J3475
Hospital Revenue Code	250
Min. Negotiated Rate	$41.67
Max. Negotiated Rate	$47.55
Rate for Payer: Cash Price	$31.86
Rate for Payer: Health Management Network Commercial	$41.67
Rate for Payer: MDX Hawaii PPO	$47.55

MAGNESIUM SULFATE 500 MG/ML (50 %) INJ SOLN

Facility

$53.42

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$51.82
Rate for Payer: Cash Price	$34.72
Rate for Payer: Cash Price	$8.15
Rate for Payer: Cash Price	$34.72
Rate for Payer: Cash Price	$8.15
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 Non-ABD	$0.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.50
Rate for Payer: Hawaii Western Management Group Commercial	$11.91
Rate for Payer: Hawaii Western Management Group Commercial	$50.75
Rate for Payer: Health Management Network Commercial	$45.41
Rate for Payer: Health Management Network Commercial	$10.66
Rate for Payer: Kaiser Permanente Commercial	$33.65
Rate for Payer: Kaiser Permanente Commercial	$7.90
Rate for Payer: Kaiser Permanente Medicaid	$27.24
Rate for Payer: Kaiser Permanente Medicaid	$6.40
Rate for Payer: MDX Hawaii PPO	$12.16
Rate for Payer: MDX Hawaii PPO	$51.82
Rate for Payer: UnitedHealthcare Medicaid	$7.52
Rate for Payer: UnitedHealthcare Medicaid	$32.05
Rate for Payer: University Health Alliance Commercial	$9.14
Rate for Payer: University Health Alliance Commercial	$38.94

MAGNESIUM SULFATE 500 MG/ML (50 %) INJ SOLN

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: Cash Price	$34.72
Rate for Payer: Health Management Network Commercial	$10.66
Rate for Payer: Health Management Network Commercial	$45.41
Rate for Payer: MDX Hawaii PPO	$12.16
Rate for Payer: MDX Hawaii PPO	$51.82

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	$52.94
Rate for Payer: Cash Price	$35.48
Rate for Payer: Cash Price	$13.64
Rate for Payer: Cash Price	$13.64
Rate for Payer: Cash Price	$35.48
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 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	$46.39
Rate for Payer: Health Management Network Commercial	$17.83
Rate for Payer: Kaiser Permanente Commercial	$34.39
Rate for Payer: Kaiser Permanente Commercial	$13.22
Rate for Payer: Kaiser Permanente Medicaid	$10.70
Rate for Payer: Kaiser Permanente Medicaid	$27.84
Rate for Payer: MDX Hawaii PPO	$20.35
Rate for Payer: MDX Hawaii PPO	$52.94
Rate for Payer: UnitedHealthcare Medicaid	$32.75
Rate for Payer: UnitedHealthcare Medicaid	$12.59
Rate for Payer: University Health Alliance Commercial	$39.78
Rate for Payer: University Health Alliance Commercial	$15.29

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	$17.83
Rate for Payer: Health Management Network Commercial	$46.39
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	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$69.06
Rate for Payer: Cash Price	$46.28
Rate for Payer: Cash Price	$46.28
Rate for Payer: Hawaii Medical Service Association ABD	$0.50
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: Kaiser Permanente Commercial	$44.86
Rate for Payer: Kaiser Permanente Medicaid	$36.31
Rate for Payer: MDX Hawaii PPO	$69.06
Rate for Payer: UnitedHealthcare Medicaid	$42.72
Rate for Payer: University Health Alliance Commercial	$51.90

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: MDX Hawaii PPO	$69.06

MAGNESIUM SULFATE IN WATER 40 GRAM/1,000 ML (4 %) IV SOLP

Facility

$48.29

Service Code	HCPCS J3475
Hospital Revenue Code	250
Min. Negotiated Rate	$41.05
Max. Negotiated Rate	$46.84
Rate for Payer: Cash Price	$31.39
Rate for Payer: Cash Price	$34.53
Rate for Payer: Health Management Network Commercial	$41.05
Rate for Payer: Health Management Network Commercial	$45.16
Rate for Payer: MDX Hawaii PPO	$46.84
Rate for Payer: MDX Hawaii PPO	$51.54

MAGNESIUM SULFATE IN WATER 40 GRAM/1,000 ML (4 %) IV SOLP

Facility

$53.13

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$51.54
Rate for Payer: Cash Price	$34.53
Rate for Payer: Cash Price	$31.39
Rate for Payer: Cash Price	$31.39
Rate for Payer: Cash Price	$34.53
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 Non-ABD	$0.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.50
Rate for Payer: Hawaii Western Management Group Commercial	$45.88
Rate for Payer: Hawaii Western Management Group Commercial	$50.47
Rate for Payer: Health Management Network Commercial	$45.16
Rate for Payer: Health Management Network Commercial	$41.05
Rate for Payer: Kaiser Permanente Commercial	$33.47
Rate for Payer: Kaiser Permanente Commercial	$30.42
Rate for Payer: Kaiser Permanente Medicaid	$24.63
Rate for Payer: Kaiser Permanente Medicaid	$27.10
Rate for Payer: MDX Hawaii PPO	$46.84
Rate for Payer: MDX Hawaii PPO	$51.54
Rate for Payer: UnitedHealthcare Medicaid	$31.88
Rate for Payer: UnitedHealthcare Medicaid	$28.97
Rate for Payer: University Health Alliance Commercial	$38.73
Rate for Payer: University Health Alliance Commercial	$35.20

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: MDX Hawaii PPO	$44.49

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	$44.49
Rate for Payer: Cash Price	$29.82
Rate for Payer: Cash Price	$29.82
Rate for Payer: Hawaii Medical Service Association ABD	$0.50
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: Kaiser Permanente Commercial	$28.90
Rate for Payer: Kaiser Permanente Medicaid	$23.39
Rate for Payer: MDX Hawaii PPO	$44.49
Rate for Payer: UnitedHealthcare Medicaid	$27.52
Rate for Payer: University Health Alliance Commercial	$33.43

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: MDX Hawaii PPO	$29.18

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

Facility

$30.08

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$15.34
Max. Negotiated Rate	$29.18
Rate for Payer: Cash Price	$19.55
Rate for Payer: Hawaii Western Management Group Commercial	$28.58
Rate for Payer: Health Management Network Commercial	$25.57
Rate for Payer: Kaiser Permanente Commercial	$18.95
Rate for Payer: Kaiser Permanente Medicaid	$15.34
Rate for Payer: MDX Hawaii PPO	$29.18
Rate for Payer: UnitedHealthcare Medicaid	$18.05
Rate for Payer: University Health Alliance Commercial	$21.93

MAJOR ABDOMINAL VASCULAR PROCEDURES

Facility

$19,508.46

Service Code	APR-DRG 1693
Min. Negotiated Rate	$19,508.46
Max. Negotiated Rate	$19,508.46
Rate for Payer: AlohaCare Medicaid	$19,508.46
Rate for Payer: Hawaii Medical Service Association ABD	$19,508.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19,508.46
Rate for Payer: Kaiser Permanente Medicaid	$19,508.46
Rate for Payer: Ohana Health Plan Medicaid	$19,508.46
Rate for Payer: UnitedHealthcare Medicaid	$19,508.46

Know your out-of-pocket cost for care.

All Charges