|
magic mouthwash 4 oz [HHSC]
|
Facility
|
IP
|
$467.72
|
|
|
Service Code
|
NDC 65628005004
|
| Hospital Charge Code |
2500037
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$397.56 |
| Max. Negotiated Rate |
$453.69 |
| Rate for Payer: Cash Price |
$304.02
|
| Rate for Payer: Health Management Network Commercial |
$397.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$420.95
|
| Rate for Payer: MDX Hawaii PPO |
$453.69
|
|
|
magic mouthwash 4 oz [HHSC]
|
Facility
|
OP
|
$467.72
|
|
|
Service Code
|
NDC 65628005004
|
| Hospital Charge Code |
2500037
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$233.86 |
| Max. Negotiated Rate |
$453.69 |
| Rate for Payer: AlohaCare Medicaid |
$233.86
|
| Rate for Payer: AlohaCare Medicare |
$233.86
|
| Rate for Payer: Cash Price |
$304.02
|
| Rate for Payer: Devoted Health Medicare |
$257.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$233.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$444.33
|
| Rate for Payer: Health Management Network Commercial |
$397.56
|
| Rate for Payer: Humana Medicare |
$233.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$420.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$238.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$233.86
|
| Rate for Payer: MDX Hawaii PPO |
$453.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$233.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$233.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$280.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$233.86
|
| Rate for Payer: University Health Alliance Commercial |
$340.92
|
|
|
magnesium citrate 296ml soln [HHSC]
|
Facility
|
IP
|
$10.10
|
|
|
Service Code
|
NDC 87701040244
|
| Hospital Charge Code |
2500506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.59 |
| Max. Negotiated Rate |
$9.80 |
| Rate for Payer: Cash Price |
$6.56
|
| Rate for Payer: Health Management Network Commercial |
$8.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.09
|
| Rate for Payer: MDX Hawaii PPO |
$9.80
|
|
|
magnesium citrate 296ml soln [HHSC]
|
Facility
|
IP
|
$6.85
|
|
|
Service Code
|
NDC 00869068638
|
| Hospital Charge Code |
2500506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.82 |
| Max. Negotiated Rate |
$6.64 |
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Health Management Network Commercial |
$5.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.17
|
| Rate for Payer: MDX Hawaii PPO |
$6.64
|
|
|
magnesium citrate 296ml soln [HHSC]
|
Facility
|
OP
|
$9.87
|
|
|
Service Code
|
NDC 69452038998
|
| Hospital Charge Code |
2500506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.93 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: AlohaCare Medicaid |
$4.93
|
| Rate for Payer: AlohaCare Medicare |
$4.93
|
| Rate for Payer: Cash Price |
$6.42
|
| Rate for Payer: Devoted Health Medicare |
$5.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.38
|
| Rate for Payer: Health Management Network Commercial |
$8.39
|
| Rate for Payer: Humana Medicare |
$4.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.93
|
| Rate for Payer: MDX Hawaii PPO |
$9.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.93
|
| Rate for Payer: University Health Alliance Commercial |
$7.19
|
|
|
magnesium citrate 296ml soln [HHSC]
|
Facility
|
IP
|
$9.87
|
|
|
Service Code
|
NDC 69452038998
|
| Hospital Charge Code |
2500506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.39 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Cash Price |
$6.42
|
| Rate for Payer: Health Management Network Commercial |
$8.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.88
|
| Rate for Payer: MDX Hawaii PPO |
$9.57
|
|
|
magnesium citrate 296ml soln [HHSC]
|
Facility
|
OP
|
$7.84
|
|
|
Service Code
|
NDC 24385067510
|
| Hospital Charge Code |
2500506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: AlohaCare Medicaid |
$3.92
|
| Rate for Payer: AlohaCare Medicare |
$3.92
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Devoted Health Medicare |
$4.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.45
|
| Rate for Payer: Health Management Network Commercial |
$6.66
|
| Rate for Payer: Humana Medicare |
$3.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.92
|
| Rate for Payer: MDX Hawaii PPO |
$7.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.92
|
| Rate for Payer: University Health Alliance Commercial |
$5.71
|
|
|
magnesium citrate 296ml soln [HHSC]
|
Facility
|
IP
|
$19.73
|
|
|
Service Code
|
NDC 71399788901
|
| Hospital Charge Code |
2500506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.77 |
| Max. Negotiated Rate |
$19.14 |
| Rate for Payer: Cash Price |
$12.82
|
| Rate for Payer: Health Management Network Commercial |
$16.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.76
|
| Rate for Payer: MDX Hawaii PPO |
$19.14
|
|
|
magnesium citrate 296ml soln [HHSC]
|
Facility
|
OP
|
$10.10
|
|
|
Service Code
|
NDC 87701040244
|
| Hospital Charge Code |
2500506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.05 |
| Max. Negotiated Rate |
$9.80 |
| Rate for Payer: AlohaCare Medicaid |
$5.05
|
| Rate for Payer: AlohaCare Medicare |
$5.05
|
| Rate for Payer: Cash Price |
$6.56
|
| Rate for Payer: Devoted Health Medicare |
$5.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$8.59
|
| Rate for Payer: Humana Medicare |
$5.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.05
|
| Rate for Payer: MDX Hawaii PPO |
$9.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.05
|
| Rate for Payer: University Health Alliance Commercial |
$7.36
|
|
|
magnesium citrate 296ml soln [HHSC]
|
Facility
|
OP
|
$19.73
|
|
|
Service Code
|
NDC 71399788901
|
| Hospital Charge Code |
2500506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.87 |
| Max. Negotiated Rate |
$19.14 |
| Rate for Payer: AlohaCare Medicaid |
$9.87
|
| Rate for Payer: AlohaCare Medicare |
$9.87
|
| Rate for Payer: Cash Price |
$12.82
|
| Rate for Payer: Devoted Health Medicare |
$10.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.74
|
| Rate for Payer: Health Management Network Commercial |
$16.77
|
| Rate for Payer: Humana Medicare |
$9.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.87
|
| Rate for Payer: MDX Hawaii PPO |
$19.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.87
|
| Rate for Payer: University Health Alliance Commercial |
$14.38
|
|
|
magnesium citrate 296ml soln [HHSC]
|
Facility
|
OP
|
$6.85
|
|
|
Service Code
|
NDC 00869068638
|
| Hospital Charge Code |
2500506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.42 |
| Max. Negotiated Rate |
$6.64 |
| Rate for Payer: AlohaCare Medicaid |
$3.42
|
| Rate for Payer: AlohaCare Medicare |
$3.42
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Devoted Health Medicare |
$3.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.51
|
| Rate for Payer: Health Management Network Commercial |
$5.82
|
| Rate for Payer: Humana Medicare |
$3.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.42
|
| Rate for Payer: MDX Hawaii PPO |
$6.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.42
|
| Rate for Payer: University Health Alliance Commercial |
$4.99
|
|
|
magnesium citrate 296ml soln [HHSC]
|
Facility
|
IP
|
$7.84
|
|
|
Service Code
|
NDC 24385067510
|
| Hospital Charge Code |
2500506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.66 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Health Management Network Commercial |
$6.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.06
|
| Rate for Payer: MDX Hawaii PPO |
$7.60
|
|
|
magnesium citrate 296ml soln [HHSC]
|
Facility
|
IP
|
$11.67
|
|
|
Service Code
|
NDC 00904678744
|
| Hospital Charge Code |
2500506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.92 |
| Max. Negotiated Rate |
$11.32 |
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Health Management Network Commercial |
$9.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.50
|
| Rate for Payer: MDX Hawaii PPO |
$11.32
|
|
|
magnesium citrate 296ml soln [HHSC]
|
Facility
|
OP
|
$11.67
|
|
|
Service Code
|
NDC 00904678744
|
| Hospital Charge Code |
2500506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$11.32 |
| Rate for Payer: AlohaCare Medicaid |
$5.83
|
| Rate for Payer: AlohaCare Medicare |
$5.83
|
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Devoted Health Medicare |
$6.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.09
|
| Rate for Payer: Health Management Network Commercial |
$9.92
|
| Rate for Payer: Humana Medicare |
$5.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.83
|
| Rate for Payer: MDX Hawaii PPO |
$11.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.83
|
| Rate for Payer: University Health Alliance Commercial |
$8.51
|
|
|
magnesium-d5w 1gm/ 100ml premix [HHSC]
|
Facility
|
OP
|
$47.02
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
2500509
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$45.61 |
| Rate for Payer: AlohaCare Medicaid |
$23.51
|
| Rate for Payer: AlohaCare Medicaid |
$28.59
|
| Rate for Payer: AlohaCare Medicaid |
$26.95
|
| Rate for Payer: AlohaCare Medicare |
$26.95
|
| Rate for Payer: AlohaCare Medicare |
$23.51
|
| Rate for Payer: AlohaCare Medicare |
$28.59
|
| Rate for Payer: Cash Price |
$35.04
|
| Rate for Payer: Cash Price |
$37.17
|
| Rate for Payer: Cash Price |
$35.04
|
| Rate for Payer: Cash Price |
$30.56
|
| Rate for Payer: Cash Price |
$30.56
|
| Rate for Payer: Cash Price |
$37.17
|
| Rate for Payer: Devoted Health Medicare |
$25.86
|
| Rate for Payer: Devoted Health Medicare |
$31.45
|
| Rate for Payer: Devoted Health Medicare |
$29.64
|
| 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 |
$23.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.95
|
| 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 |
$51.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$54.33
|
| Rate for Payer: Health Management Network Commercial |
$48.61
|
| Rate for Payer: Health Management Network Commercial |
$39.97
|
| Rate for Payer: Health Management Network Commercial |
$45.81
|
| Rate for Payer: Humana Medicare |
$23.51
|
| Rate for Payer: Humana Medicare |
$26.95
|
| Rate for Payer: Humana Medicare |
$28.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.47
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.59
|
| Rate for Payer: MDX Hawaii PPO |
$55.47
|
| Rate for Payer: MDX Hawaii PPO |
$52.28
|
| Rate for Payer: MDX Hawaii PPO |
$45.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.59
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.59
|
| Rate for Payer: University Health Alliance Commercial |
$34.27
|
| Rate for Payer: University Health Alliance Commercial |
$39.29
|
| Rate for Payer: University Health Alliance Commercial |
$41.69
|
|
|
magnesium-d5w 1gm/ 100ml premix [HHSC]
|
Facility
|
IP
|
$57.19
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
2500509
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.61 |
| Max. Negotiated Rate |
$55.47 |
| Rate for Payer: Cash Price |
$37.17
|
| Rate for Payer: Cash Price |
$35.04
|
| Rate for Payer: Cash Price |
$30.56
|
| Rate for Payer: Health Management Network Commercial |
$39.97
|
| Rate for Payer: Health Management Network Commercial |
$48.61
|
| Rate for Payer: Health Management Network Commercial |
$45.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.32
|
| Rate for Payer: MDX Hawaii PPO |
$52.28
|
| Rate for Payer: MDX Hawaii PPO |
$45.61
|
| Rate for Payer: MDX Hawaii PPO |
$55.47
|
|
|
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 FSI
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
HCPCS 83735
|
| Hospital Charge Code |
8117989
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$79.90 |
| Max. Negotiated Rate |
$91.18 |
| Rate for Payer: Cash Price |
$61.10
|
| Rate for Payer: Health Management Network Commercial |
$79.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.60
|
| Rate for Payer: MDX Hawaii PPO |
$91.18
|
|
|
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
|
$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 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
|
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 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-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
|
|
