Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

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

Facility

IP

$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: MDX Hawaii PPO	$0.97

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

Facility

IP

$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: MDX Hawaii PPO	$1.94

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

Facility

OP

$2.00

Service Code	NDC 42019000000
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

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

Facility

OP

$1.00

Service Code	NDC 80010000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.63
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: University Health Alliance Commercial	$0.73

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

Facility

OP

$2.00

Service Code	NDC 42001000000
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: University Health Alliance Commercial	$1.46

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

Facility

IP

$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: MDX Hawaii PPO	$1.94

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

Facility

OP

$27.00

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$16.20
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	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$17.01
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: UnitedHealthcare Medicaid	$16.20
Rate for Payer: University Health Alliance Commercial	$19.68

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

Facility

IP

$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: MDX Hawaii PPO	$26.19

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

Facility

IP

$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: MDX Hawaii PPO	$26.19

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

Facility

OP

$27.00

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$16.20
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	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$17.01
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: UnitedHealthcare Medicaid	$16.20
Rate for Payer: University Health Alliance Commercial	$19.68

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

Facility

IP

$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: MDX Hawaii PPO	$29.10

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

Facility

OP

$30.00

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$18.00
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	$28.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: UnitedHealthcare Medicaid	$18.00
Rate for Payer: University Health Alliance Commercial	$21.87

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

Facility

IP

$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: MDX Hawaii PPO	$32.98

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

Facility

OP

$34.00

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$20.40
Rate for Payer: Cash Price	$20.40
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	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$21.42
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: University Health Alliance Commercial	$24.78

MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129651]

Facility

OP

$54.00

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cash Price	$32.40
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	$51.30
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$34.02
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: UnitedHealthcare Medicaid	$32.40
Rate for Payer: University Health Alliance Commercial	$39.36

MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129651]

Facility

IP

$54.00

Service Code	HCPCS J3475
Hospital Revenue Code	250
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$32.40
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$52.38

MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129652]

Facility

IP

$39.00

Service Code	HCPCS J3475
Hospital Revenue Code	250
Min. Negotiated Rate	$33.15
Max. Negotiated Rate	$37.83
Rate for Payer: Cash Price	$23.40
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: MDX Hawaii PPO	$37.83

MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [129652]

Facility

OP

$39.00

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$37.83
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$23.40
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	$37.05
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Kaiser Permanente Commercial	$24.57
Rate for Payer: Kaiser Permanente Medicaid	$19.89
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: UnitedHealthcare Medicaid	$23.40
Rate for Payer: University Health Alliance Commercial	$28.43

MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION [4720]

Facility

IP

$3.00

Service Code	HCPCS J3475
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: MDX Hawaii PPO	$37.83

MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION [4720]

Facility

OP

$3.00

Service Code	HCPCS J3475
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$3.00
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 ABD	$0.50
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 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 Medical Service Association Non-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 Medical Service Association Non-ABD	$0.50
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$37.05
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Commercial	$24.57
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Commercial	$3.15
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Commercial	$7.56
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicaid	$19.89
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: UnitedHealthcare Medicaid	$23.40
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicaid	$6.00
Rate for Payer: UnitedHealthcare Medicaid	$7.20
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: UnitedHealthcare Medicaid	$3.00
Rate for Payer: University Health Alliance Commercial	$4.37
Rate for Payer: University Health Alliance Commercial	$28.43
Rate for Payer: University Health Alliance Commercial	$2.19
Rate for Payer: University Health Alliance Commercial	$7.29
Rate for Payer: University Health Alliance Commercial	$3.64
Rate for Payer: University Health Alliance Commercial	$8.75

MAJOR ABDOMINAL VASCULAR PROCEDURES

Facility

IP

$10,394.69

Service Code	APR-DRG 1691
Min. Negotiated Rate	$10,394.69
Max. Negotiated Rate	$10,394.69
Rate for Payer: AlohaCare Medicaid	$10,394.69
Rate for Payer: Hawaii Medical Service Association ABD	$10,394.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,394.69
Rate for Payer: Kaiser Permanente Medicaid	$10,394.69
Rate for Payer: Ohana Health Plan Medicaid	$10,394.69
Rate for Payer: UnitedHealthcare Medicaid	$10,394.69

MAJOR ABDOMINAL VASCULAR PROCEDURES

Facility

IP

$32,791.27

Service Code	APR-DRG 1694
Min. Negotiated Rate	$32,791.27
Max. Negotiated Rate	$32,791.27
Rate for Payer: AlohaCare Medicaid	$32,791.27
Rate for Payer: Hawaii Medical Service Association ABD	$32,791.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$32,791.27
Rate for Payer: Kaiser Permanente Medicaid	$32,791.27
Rate for Payer: Ohana Health Plan Medicaid	$32,791.27
Rate for Payer: UnitedHealthcare Medicaid	$32,791.27

MAJOR ABDOMINAL VASCULAR PROCEDURES

Facility

IP

$13,106.85

Service Code	APR-DRG 1692
Min. Negotiated Rate	$13,106.85
Max. Negotiated Rate	$13,106.85
Rate for Payer: AlohaCare Medicaid	$13,106.85
Rate for Payer: Hawaii Medical Service Association ABD	$13,106.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,106.85
Rate for Payer: Kaiser Permanente Medicaid	$13,106.85
Rate for Payer: Ohana Health Plan Medicaid	$13,106.85
Rate for Payer: UnitedHealthcare Medicaid	$13,106.85

MAJOR ABDOMINAL VASCULAR PROCEDURES

Facility

IP

$19,982.51

Service Code	APR-DRG 1693
Min. Negotiated Rate	$19,982.51
Max. Negotiated Rate	$19,982.51
Rate for Payer: AlohaCare Medicaid	$19,982.51
Rate for Payer: Hawaii Medical Service Association ABD	$19,982.51
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19,982.51
Rate for Payer: Kaiser Permanente Medicaid	$19,982.51
Rate for Payer: Ohana Health Plan Medicaid	$19,982.51
Rate for Payer: UnitedHealthcare Medicaid	$19,982.51

MAJOR BILIARY TRACT PROCEDURES

Facility

IP

$10,291.63

Service Code	APR-DRG 2612
Min. Negotiated Rate	$10,291.63
Max. Negotiated Rate	$10,291.63
Rate for Payer: AlohaCare Medicaid	$10,291.63
Rate for Payer: Hawaii Medical Service Association ABD	$10,291.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,291.63
Rate for Payer: Kaiser Permanente Medicaid	$10,291.63
Rate for Payer: Ohana Health Plan Medicaid	$10,291.63
Rate for Payer: UnitedHealthcare Medicaid	$10,291.63

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