|
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: Kaiser Permanente Commercial |
$30.60
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
|
|
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: Kaiser Permanente Commercial |
$48.60
|
| Rate for Payer: MDX Hawaii PPO |
$52.38
|
|
|
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: AlohaCare Medicaid |
$27.00
|
| Rate for Payer: AlohaCare Medicare |
$16.74
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Devoted Health Medicare |
$18.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.74
|
| 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: Humana Medicare |
$16.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.74
|
| Rate for Payer: MDX Hawaii PPO |
$52.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.74
|
| Rate for Payer: University Health Alliance Commercial |
$39.36
|
|
|
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: AlohaCare Medicaid |
$19.50
|
| Rate for Payer: AlohaCare Medicare |
$12.09
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Devoted Health Medicare |
$13.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.09
|
| 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: Humana Medicare |
$12.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.09
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.09
|
| Rate for Payer: University Health Alliance Commercial |
$28.43
|
|
|
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: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
|
|
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION [4720]
|
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: AlohaCare Medicaid |
$19.50
|
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicaid |
$5.00
|
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$1.86
|
| Rate for Payer: AlohaCare Medicare |
$12.09
|
| Rate for Payer: AlohaCare Medicare |
$3.10
|
| Rate for Payer: AlohaCare Medicare |
$3.72
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: AlohaCare Medicare |
$1.55
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Devoted Health Medicare |
$1.70
|
| Rate for Payer: Devoted Health Medicare |
$13.26
|
| Rate for Payer: Devoted Health Medicare |
$3.40
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Devoted Health Medicare |
$4.08
|
| Rate for Payer: Devoted Health Medicare |
$2.04
|
| 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 Medicare |
$3.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.55
|
| 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 |
$2.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| 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 |
$33.15
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$3.72
|
| Rate for Payer: Humana Medicare |
$3.10
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Humana Medicare |
$1.55
|
| Rate for Payer: Humana Medicare |
$12.09
|
| Rate for Payer: Humana Medicare |
$1.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.72
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.09
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
| 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 |
$7.29
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION [4720]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
HCPCS J3475
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| 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 |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
MAJOR BLADDER PROCEDURES WITH CC
|
Facility
|
IP
|
$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
|
IP
|
$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
|
IP
|
$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
|
IP
|
$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
|
IP
|
$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
|
IP
|
$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
|
IP
|
$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
|
|
|
MAJOR CHEST TRAUMA WITH MCC
|
Facility
|
IP
|
$21,521.42
|
|
|
Service Code
|
MSDRG 183
|
| Min. Negotiated Rate |
$21,521.42 |
| Max. Negotiated Rate |
$21,521.42 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$21,521.42
|
|
|
MAJOR CHEST TRAUMA WITHOUT CC/MCC
|
Facility
|
IP
|
$18,890.49
|
|
|
Service Code
|
MSDRG 185
|
| Min. Negotiated Rate |
$18,890.49 |
| Max. Negotiated Rate |
$18,890.49 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$18,890.49
|
|
|
MAJOR ESOPHAGEAL DISORDERS WITH CC
|
Facility
|
IP
|
$19,340.83
|
|
|
Service Code
|
MSDRG 369
|
| Min. Negotiated Rate |
$19,340.83 |
| Max. Negotiated Rate |
$19,340.83 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,340.83
|
|
|
MAJOR ESOPHAGEAL DISORDERS WITH MCC
|
Facility
|
IP
|
$19,340.83
|
|
|
Service Code
|
MSDRG 368
|
| Min. Negotiated Rate |
$19,340.83 |
| Max. Negotiated Rate |
$19,340.83 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,340.83
|
|
|
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$19,340.83
|
|
|
Service Code
|
MSDRG 370
|
| Min. Negotiated Rate |
$19,340.83 |
| Max. Negotiated Rate |
$19,340.83 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,340.83
|
|
|
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC
|
Facility
|
IP
|
$21,995.46
|
|
|
Service Code
|
MSDRG 372
|
| Min. Negotiated Rate |
$21,995.46 |
| Max. Negotiated Rate |
$21,995.46 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$21,995.46
|
|
|
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC
|
Facility
|
IP
|
$21,995.46
|
|
|
Service Code
|
MSDRG 371
|
| Min. Negotiated Rate |
$21,995.46 |
| Max. Negotiated Rate |
$21,995.46 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$21,995.46
|
|
|
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC
|
Facility
|
IP
|
$21,995.46
|
|
|
Service Code
|
MSDRG 373
|
| Min. Negotiated Rate |
$21,995.46 |
| Max. Negotiated Rate |
$21,995.46 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$21,995.46
|
|
|
MAJOR HEAD AND NECK PROCEDURES WITH CC
|
Facility
|
IP
|
$50,390.45
|
|
|
Service Code
|
MSDRG 141
|
| Min. Negotiated Rate |
$50,390.45 |
| Max. Negotiated Rate |
$50,390.45 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$50,390.45
|
|
|
MAJOR HEAD AND NECK PROCEDURES WITH MCC
|
Facility
|
IP
|
$61,340.78
|
|
|
Service Code
|
MSDRG 140
|
| Min. Negotiated Rate |
$61,340.78 |
| Max. Negotiated Rate |
$61,340.78 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$61,340.78
|
|
|
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$28,086.87
|
|
|
Service Code
|
MSDRG 142
|
| Min. Negotiated Rate |
$28,086.87 |
| Max. Negotiated Rate |
$28,086.87 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$28,086.87
|
|
