|
Magnesium FSI
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
HCPCS 83735
|
| Hospital Charge Code |
8117989
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$91.18 |
| Rate for Payer: AlohaCare Medicaid |
$47.00
|
| Rate for Payer: AlohaCare Medicare |
$47.00
|
| Rate for Payer: Cash Price |
$61.10
|
| Rate for Payer: Cash Price |
$61.10
|
| Rate for Payer: Devoted Health Medicare |
$51.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.70
|
| Rate for Payer: Health Management Network Commercial |
$79.90
|
| Rate for Payer: Humana Medicare |
$47.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.00
|
| Rate for Payer: MDX Hawaii PPO |
$91.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.00
|
| Rate for Payer: University Health Alliance Commercial |
$17.32
|
|
|
magnesium hydroxide 2400mg/ 30ml cup [HHSC]
|
Facility
|
OP
|
$14.65
|
|
|
Service Code
|
NDC 66689005399
|
| Hospital Charge Code |
2500507
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.33 |
| Max. Negotiated Rate |
$14.21 |
| Rate for Payer: AlohaCare Medicaid |
$7.33
|
| Rate for Payer: AlohaCare Medicare |
$7.33
|
| Rate for Payer: Cash Price |
$9.52
|
| Rate for Payer: Devoted Health Medicare |
$8.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.92
|
| Rate for Payer: Health Management Network Commercial |
$12.45
|
| Rate for Payer: Humana Medicare |
$7.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.33
|
| Rate for Payer: MDX Hawaii PPO |
$14.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.33
|
| Rate for Payer: University Health Alliance Commercial |
$10.68
|
|
|
magnesium hydroxide 2400mg/ 30ml cup [HHSC]
|
Facility
|
OP
|
$13.02
|
|
|
Service Code
|
NDC 00121043130
|
| Hospital Charge Code |
2500507
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$12.63 |
| Rate for Payer: AlohaCare Medicaid |
$6.51
|
| Rate for Payer: AlohaCare Medicare |
$6.51
|
| Rate for Payer: Cash Price |
$8.46
|
| Rate for Payer: Devoted Health Medicare |
$7.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.37
|
| Rate for Payer: Health Management Network Commercial |
$11.07
|
| Rate for Payer: Humana Medicare |
$6.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.51
|
| Rate for Payer: MDX Hawaii PPO |
$12.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.51
|
| Rate for Payer: University Health Alliance Commercial |
$9.49
|
|
|
magnesium hydroxide 2400mg/ 30ml cup [HHSC]
|
Facility
|
IP
|
$13.02
|
|
|
Service Code
|
NDC 00121043130
|
| Hospital Charge Code |
2500507
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.07 |
| Max. Negotiated Rate |
$12.63 |
| Rate for Payer: Cash Price |
$8.46
|
| Rate for Payer: Health Management Network Commercial |
$11.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.72
|
| Rate for Payer: MDX Hawaii PPO |
$12.63
|
|
|
magnesium hydroxide 2400mg/ 30ml cup [HHSC]
|
Facility
|
IP
|
$14.65
|
|
|
Service Code
|
NDC 66689005399
|
| Hospital Charge Code |
2500507
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$14.21 |
| Rate for Payer: Cash Price |
$9.52
|
| Rate for Payer: Health Management Network Commercial |
$12.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.19
|
| Rate for Payer: MDX Hawaii PPO |
$14.21
|
|
|
magnesium oxide 400 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 10006073038
|
| Hospital Charge Code |
2500508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
magnesium oxide 400 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 63739035410
|
| Hospital Charge Code |
2500508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
magnesium oxide 400 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 64980033901
|
| Hospital Charge Code |
2500508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
magnesium oxide 400 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60258017101
|
| Hospital Charge Code |
2500508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
magnesium oxide 400 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 64980033901
|
| Hospital Charge Code |
2500508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
magnesium oxide 400 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68585000641
|
| Hospital Charge Code |
2500508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
magnesium oxide 400 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 63739035410
|
| Hospital Charge Code |
2500508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
magnesium oxide 400 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60258017101
|
| Hospital Charge Code |
2500508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
magnesium oxide 400 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 10006070028
|
| Hospital Charge Code |
2500508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
magnesium oxide 400 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68585000641
|
| Hospital Charge Code |
2500508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
magnesium oxide 400 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 10006073038
|
| Hospital Charge Code |
2500508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
magnesium oxide 400 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 10006070028
|
| Hospital Charge Code |
2500508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
magnesium sulf 4% 40 gm/1000 ml [HHSC]
|
Facility
|
IP
|
$58.48
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
2500511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.71 |
| Max. Negotiated Rate |
$56.73 |
| Rate for Payer: Cash Price |
$38.01
|
| Rate for Payer: Cash Price |
$40.99
|
| Rate for Payer: Health Management Network Commercial |
$49.71
|
| Rate for Payer: Health Management Network Commercial |
$53.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.75
|
| Rate for Payer: MDX Hawaii PPO |
$61.17
|
| Rate for Payer: MDX Hawaii PPO |
$56.73
|
|
|
magnesium sulf 4% 40 gm/1000 ml [HHSC]
|
Facility
|
OP
|
$58.48
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
2500511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$56.73 |
| Rate for Payer: AlohaCare Medicaid |
$29.24
|
| Rate for Payer: AlohaCare Medicaid |
$31.53
|
| Rate for Payer: AlohaCare Medicare |
$31.53
|
| Rate for Payer: AlohaCare Medicare |
$29.24
|
| Rate for Payer: Cash Price |
$40.99
|
| Rate for Payer: Cash Price |
$38.01
|
| Rate for Payer: Cash Price |
$38.01
|
| Rate for Payer: Cash Price |
$40.99
|
| Rate for Payer: Devoted Health Medicare |
$32.16
|
| Rate for Payer: Devoted Health Medicare |
$34.68
|
| 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 |
$31.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.24
|
| 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 |
$55.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$59.91
|
| Rate for Payer: Health Management Network Commercial |
$53.60
|
| Rate for Payer: Health Management Network Commercial |
$49.71
|
| Rate for Payer: Humana Medicare |
$29.24
|
| Rate for Payer: Humana Medicare |
$31.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$32.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.53
|
| Rate for Payer: MDX Hawaii PPO |
$56.73
|
| Rate for Payer: MDX Hawaii PPO |
$61.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$31.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.53
|
| Rate for Payer: University Health Alliance Commercial |
$42.63
|
| Rate for Payer: University Health Alliance Commercial |
$45.96
|
|
|
magnesium sulfate 1gm/2 ml vial [HHSC]
|
Facility
|
OP
|
$10.54
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
2500512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$10.22 |
| Rate for Payer: AlohaCare Medicaid |
$5.27
|
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$5.27
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Cash Price |
$6.85
|
| Rate for Payer: Cash Price |
$6.85
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Devoted Health Medicare |
$5.80
|
| Rate for Payer: Devoted Health Medicare |
$4.41
|
| 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 |
$4.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.27
|
| 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 |
$10.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.61
|
| Rate for Payer: Health Management Network Commercial |
$6.81
|
| Rate for Payer: Health Management Network Commercial |
$8.96
|
| Rate for Payer: Humana Medicare |
$5.27
|
| Rate for Payer: Humana Medicare |
$4.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.00
|
| Rate for Payer: MDX Hawaii PPO |
$10.22
|
| Rate for Payer: MDX Hawaii PPO |
$7.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.00
|
| Rate for Payer: University Health Alliance Commercial |
$7.68
|
| Rate for Payer: University Health Alliance Commercial |
$5.84
|
|
|
magnesium sulfate 1gm/2 ml vial [HHSC]
|
Facility
|
IP
|
$10.54
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
2500512
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.96 |
| Max. Negotiated Rate |
$10.22 |
| Rate for Payer: Cash Price |
$6.85
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Health Management Network Commercial |
$8.96
|
| Rate for Payer: Health Management Network Commercial |
$6.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.21
|
| Rate for Payer: MDX Hawaii PPO |
$7.77
|
| Rate for Payer: MDX Hawaii PPO |
$10.22
|
|
|
magnesium sulfate 5 gm/10 mL vial [HHSC]
|
Facility
|
OP
|
$14.75
|
|
|
Service Code
|
NDC 63323006411
|
| Hospital Charge Code |
2501135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.38 |
| Max. Negotiated Rate |
$14.31 |
| Rate for Payer: AlohaCare Medicaid |
$7.38
|
| Rate for Payer: AlohaCare Medicare |
$7.38
|
| Rate for Payer: Cash Price |
$9.59
|
| Rate for Payer: Devoted Health Medicare |
$8.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.01
|
| Rate for Payer: Health Management Network Commercial |
$12.54
|
| Rate for Payer: Humana Medicare |
$7.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.38
|
| Rate for Payer: MDX Hawaii PPO |
$14.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.38
|
| Rate for Payer: University Health Alliance Commercial |
$10.75
|
|
|
magnesium sulfate 5 gm/10 mL vial [HHSC]
|
Facility
|
IP
|
$14.75
|
|
|
Service Code
|
NDC 63323006411
|
| Hospital Charge Code |
2501135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.54 |
| Max. Negotiated Rate |
$14.31 |
| Rate for Payer: Cash Price |
$9.59
|
| Rate for Payer: Health Management Network Commercial |
$12.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.28
|
| Rate for Payer: MDX Hawaii PPO |
$14.31
|
|
|
magnesium-swfi 2 gm/50 mL premix [HHSC]
|
Facility
|
IP
|
$98.61
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
2500510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$83.82 |
| Max. Negotiated Rate |
$95.65 |
| Rate for Payer: Cash Price |
$64.10
|
| Rate for Payer: Cash Price |
$59.33
|
| Rate for Payer: Cash Price |
$66.41
|
| Rate for Payer: Health Management Network Commercial |
$86.84
|
| Rate for Payer: Health Management Network Commercial |
$83.82
|
| Rate for Payer: Health Management Network Commercial |
$77.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$91.95
|
| Rate for Payer: MDX Hawaii PPO |
$88.54
|
| Rate for Payer: MDX Hawaii PPO |
$99.10
|
| Rate for Payer: MDX Hawaii PPO |
$95.65
|
|
|
magnesium-swfi 2 gm/50 mL premix [HHSC]
|
Facility
|
OP
|
$102.17
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
2500510
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$99.10 |
| Rate for Payer: AlohaCare Medicaid |
$51.09
|
| Rate for Payer: AlohaCare Medicaid |
$49.30
|
| Rate for Payer: AlohaCare Medicaid |
$45.64
|
| Rate for Payer: AlohaCare Medicare |
$45.64
|
| Rate for Payer: AlohaCare Medicare |
$51.09
|
| Rate for Payer: AlohaCare Medicare |
$49.30
|
| Rate for Payer: Cash Price |
$59.33
|
| Rate for Payer: Cash Price |
$64.10
|
| Rate for Payer: Cash Price |
$59.33
|
| Rate for Payer: Cash Price |
$66.41
|
| Rate for Payer: Cash Price |
$66.41
|
| Rate for Payer: Cash Price |
$64.10
|
| Rate for Payer: Devoted Health Medicare |
$56.19
|
| Rate for Payer: Devoted Health Medicare |
$54.24
|
| Rate for Payer: Devoted Health Medicare |
$50.20
|
| 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 |
$51.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45.64
|
| 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 |
$86.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$97.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$93.68
|
| Rate for Payer: Health Management Network Commercial |
$83.82
|
| Rate for Payer: Health Management Network Commercial |
$86.84
|
| Rate for Payer: Health Management Network Commercial |
$77.59
|
| Rate for Payer: Humana Medicare |
$51.09
|
| Rate for Payer: Humana Medicare |
$45.64
|
| Rate for Payer: Humana Medicare |
$49.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$91.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$52.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$51.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.30
|
| Rate for Payer: MDX Hawaii PPO |
$95.65
|
| Rate for Payer: MDX Hawaii PPO |
$88.54
|
| Rate for Payer: MDX Hawaii PPO |
$99.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$51.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$45.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$51.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$54.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$61.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$59.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$45.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$51.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.30
|
| Rate for Payer: University Health Alliance Commercial |
$74.47
|
| Rate for Payer: University Health Alliance Commercial |
$66.53
|
| Rate for Payer: University Health Alliance Commercial |
$71.88
|
|
