|
HC MRI, CERV SPINE CONTRAST - MRI CERVICAL SPINE W CONTRAST
|
Facility
|
IP
|
$1,776.00
|
|
|
Service Code
|
HCPCS 72142
|
| Hospital Charge Code |
6127214201
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$1,509.60 |
| Max. Negotiated Rate |
$1,722.72 |
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Health Management Network Commercial |
$1,509.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,722.72
|
|
|
HC MRI, CERV SPINE - MRI CERVICAL SPINE WO CONTRAST
|
Facility
|
OP
|
$1,203.00
|
|
|
Service Code
|
HCPCS 72141
|
| Hospital Charge Code |
6127214102
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$281.87 |
| Max. Negotiated Rate |
$1,166.91 |
| Rate for Payer: AlohaCare Medicaid |
$281.87
|
| Rate for Payer: AlohaCare Medicare |
$281.87
|
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Devoted Health Medicare |
$310.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$396.10
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$352.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$281.87
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$415.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$281.87
|
| Rate for Payer: Health Management Network Commercial |
$1,022.55
|
| Rate for Payer: Humana Medicare |
$281.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$757.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$613.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$281.87
|
| Rate for Payer: MDX Hawaii PPO |
$1,166.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$310.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$281.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$396.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$281.87
|
| Rate for Payer: University Health Alliance Commercial |
$856.18
|
|
|
HC MRI, CERV SPINE - MRI CERVICAL SPINE WO CONTRAST
|
Facility
|
IP
|
$1,203.00
|
|
|
Service Code
|
HCPCS 72141
|
| Hospital Charge Code |
6127214102
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$1,022.55 |
| Max. Negotiated Rate |
$1,166.91 |
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Health Management Network Commercial |
$1,022.55
|
| Rate for Payer: MDX Hawaii PPO |
$1,166.91
|
|
|
HC MRI, CHEST, COMBO - MRI CHEST W WO CONTRAST
|
Facility
|
OP
|
$1,776.00
|
|
|
Service Code
|
HCPCS 71552
|
| Hospital Charge Code |
6107155202
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$412.14 |
| Max. Negotiated Rate |
$1,722.72 |
| Rate for Payer: AlohaCare Medicaid |
$412.14
|
| Rate for Payer: AlohaCare Medicare |
$412.14
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Devoted Health Medicare |
$453.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$704.71
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$515.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$412.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$877.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.14
|
| Rate for Payer: Health Management Network Commercial |
$1,509.60
|
| Rate for Payer: Humana Medicare |
$412.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,118.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$905.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$412.14
|
| Rate for Payer: MDX Hawaii PPO |
$1,722.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$453.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$412.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$704.71
|
| Rate for Payer: UnitedHealthcare Medicare |
$412.14
|
| Rate for Payer: University Health Alliance Commercial |
$1,300.64
|
|
|
HC MRI, CHEST, COMBO - MRI CHEST W WO CONTRAST
|
Facility
|
IP
|
$1,776.00
|
|
|
Service Code
|
HCPCS 71552
|
| Hospital Charge Code |
6107155202
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,509.60 |
| Max. Negotiated Rate |
$1,722.72 |
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Health Management Network Commercial |
$1,509.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,722.72
|
|
|
HC MRI, CHEST - MRI CHEST WO CONTRAST
|
Facility
|
OP
|
$1,203.00
|
|
|
Service Code
|
HCPCS 71550
|
| Hospital Charge Code |
6107155001
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$281.87 |
| Max. Negotiated Rate |
$1,166.91 |
| Rate for Payer: AlohaCare Medicaid |
$281.87
|
| Rate for Payer: AlohaCare Medicare |
$281.87
|
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Devoted Health Medicare |
$310.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$369.93
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$352.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$281.87
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$395.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$281.87
|
| Rate for Payer: Health Management Network Commercial |
$1,022.55
|
| Rate for Payer: Humana Medicare |
$281.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$757.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$613.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$281.87
|
| Rate for Payer: MDX Hawaii PPO |
$1,166.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$310.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$281.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$369.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$281.87
|
| Rate for Payer: University Health Alliance Commercial |
$847.54
|
|
|
HC MRI, CHEST - MRI CHEST WO CONTRAST
|
Facility
|
IP
|
$1,203.00
|
|
|
Service Code
|
HCPCS 71550
|
| Hospital Charge Code |
6107155001
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,022.55 |
| Max. Negotiated Rate |
$1,166.91 |
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Health Management Network Commercial |
$1,022.55
|
| Rate for Payer: MDX Hawaii PPO |
$1,166.91
|
|
|
HC MRI, DORSAL SPINE COMBO - MRI THORACIC SPINE W WO CONTRAST
|
Facility
|
IP
|
$1,776.00
|
|
|
Service Code
|
HCPCS 72157
|
| Hospital Charge Code |
6127215701
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$1,509.60 |
| Max. Negotiated Rate |
$1,722.72 |
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Health Management Network Commercial |
$1,509.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,722.72
|
|
|
HC MRI, DORSAL SPINE COMBO - MRI THORACIC SPINE W WO CONTRAST
|
Facility
|
OP
|
$1,776.00
|
|
|
Service Code
|
HCPCS 72157
|
| Hospital Charge Code |
6127215701
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$412.14 |
| Max. Negotiated Rate |
$1,722.72 |
| Rate for Payer: AlohaCare Medicaid |
$412.14
|
| Rate for Payer: AlohaCare Medicare |
$412.14
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Devoted Health Medicare |
$453.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$819.66
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$515.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$412.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$882.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.14
|
| Rate for Payer: Health Management Network Commercial |
$1,509.60
|
| Rate for Payer: Humana Medicare |
$412.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,118.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$905.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$412.14
|
| Rate for Payer: MDX Hawaii PPO |
$1,722.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$453.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$412.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$819.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$412.14
|
| Rate for Payer: University Health Alliance Commercial |
$1,315.18
|
|
|
HC MRI, DORSAL SPINE CONTRAST - MRI THORACIC SPINE W CONTRAST
|
Facility
|
OP
|
$1,776.00
|
|
|
Service Code
|
HCPCS 72147
|
| Hospital Charge Code |
6127214701
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$412.14 |
| Max. Negotiated Rate |
$1,722.72 |
| Rate for Payer: AlohaCare Medicaid |
$412.14
|
| Rate for Payer: AlohaCare Medicare |
$412.14
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Devoted Health Medicare |
$453.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$442.34
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$515.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$412.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$480.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.14
|
| Rate for Payer: Health Management Network Commercial |
$1,509.60
|
| Rate for Payer: Humana Medicare |
$412.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,118.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$905.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$412.14
|
| Rate for Payer: MDX Hawaii PPO |
$1,722.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$453.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$412.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$442.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$412.14
|
| Rate for Payer: University Health Alliance Commercial |
$996.11
|
|
|
HC MRI, DORSAL SPINE CONTRAST - MRI THORACIC SPINE W CONTRAST
|
Facility
|
IP
|
$1,776.00
|
|
|
Service Code
|
HCPCS 72147
|
| Hospital Charge Code |
6127214701
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$1,509.60 |
| Max. Negotiated Rate |
$1,722.72 |
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Health Management Network Commercial |
$1,509.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,722.72
|
|
|
HC MRI, DORSAL SPINE - MRI THORACIC SPINE WO CONTRAST
|
Facility
|
IP
|
$1,203.00
|
|
|
Service Code
|
HCPCS 72146
|
| Hospital Charge Code |
6127214602
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$1,022.55 |
| Max. Negotiated Rate |
$1,166.91 |
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Health Management Network Commercial |
$1,022.55
|
| Rate for Payer: MDX Hawaii PPO |
$1,166.91
|
|
|
HC MRI, DORSAL SPINE - MRI THORACIC SPINE WO CONTRAST
|
Facility
|
OP
|
$1,203.00
|
|
|
Service Code
|
HCPCS 72146
|
| Hospital Charge Code |
6127214602
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$281.87 |
| Max. Negotiated Rate |
$1,166.91 |
| Rate for Payer: AlohaCare Medicaid |
$281.87
|
| Rate for Payer: AlohaCare Medicare |
$281.87
|
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Devoted Health Medicare |
$310.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$409.59
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$352.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$281.87
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$445.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$281.87
|
| Rate for Payer: Health Management Network Commercial |
$1,022.55
|
| Rate for Payer: Humana Medicare |
$281.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$757.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$613.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$281.87
|
| Rate for Payer: MDX Hawaii PPO |
$1,166.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$310.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$281.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$409.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$281.87
|
| Rate for Payer: University Health Alliance Commercial |
$855.88
|
|
|
HC MRI, FACE, NECK, COMBO - MR ORBIT FACE NECK W AND WO IV CONTRAST
|
Facility
|
OP
|
$1,776.00
|
|
|
Service Code
|
HCPCS 70543
|
| Hospital Charge Code |
6107054302
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$412.14 |
| Max. Negotiated Rate |
$1,722.72 |
| Rate for Payer: AlohaCare Medicaid |
$412.14
|
| Rate for Payer: AlohaCare Medicare |
$412.14
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Devoted Health Medicare |
$453.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$983.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$515.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$412.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$952.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.14
|
| Rate for Payer: Health Management Network Commercial |
$1,509.60
|
| Rate for Payer: Humana Medicare |
$412.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,118.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$905.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$412.14
|
| Rate for Payer: MDX Hawaii PPO |
$1,722.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$453.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$412.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$983.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$412.14
|
| Rate for Payer: University Health Alliance Commercial |
$1,285.82
|
|
|
HC MRI, FACE, NECK, COMBO - MR ORBIT FACE NECK W AND WO IV CONTRAST
|
Facility
|
IP
|
$1,776.00
|
|
|
Service Code
|
HCPCS 70543
|
| Hospital Charge Code |
6107054302
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,509.60 |
| Max. Negotiated Rate |
$1,722.72 |
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Health Management Network Commercial |
$1,509.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,722.72
|
|
|
HC MRI, FACE, NECK - MR ORBIT FACE NECK WO IV CONTRAST
|
Facility
|
OP
|
$1,203.00
|
|
|
Service Code
|
HCPCS 70540
|
| Hospital Charge Code |
6107054002
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$281.87 |
| Max. Negotiated Rate |
$1,166.91 |
| Rate for Payer: AlohaCare Medicaid |
$281.87
|
| Rate for Payer: AlohaCare Medicare |
$281.87
|
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Devoted Health Medicare |
$310.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$369.03
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$352.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$281.87
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$393.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$281.87
|
| Rate for Payer: Health Management Network Commercial |
$1,022.55
|
| Rate for Payer: Humana Medicare |
$281.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$757.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$613.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$281.87
|
| Rate for Payer: MDX Hawaii PPO |
$1,166.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$310.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$281.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$369.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$281.87
|
| Rate for Payer: University Health Alliance Commercial |
$837.87
|
|
|
HC MRI, FACE, NECK - MR ORBIT FACE NECK WO IV CONTRAST
|
Facility
|
IP
|
$1,203.00
|
|
|
Service Code
|
HCPCS 70540
|
| Hospital Charge Code |
6107054002
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,022.55 |
| Max. Negotiated Rate |
$1,166.91 |
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Health Management Network Commercial |
$1,022.55
|
| Rate for Payer: MDX Hawaii PPO |
$1,166.91
|
|
|
HC MRI, FACE, NECK W/CONTRAST - MRI NECK SOFT TISSUE W CONTRAST
|
Facility
|
OP
|
$1,392.00
|
|
|
Service Code
|
HCPCS 70542
|
| Hospital Charge Code |
6147054201
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$382.28 |
| Max. Negotiated Rate |
$1,350.24 |
| Rate for Payer: AlohaCare Medicaid |
$412.14
|
| Rate for Payer: AlohaCare Medicare |
$412.14
|
| Rate for Payer: Cash Price |
$835.20
|
| Rate for Payer: Cash Price |
$835.20
|
| Rate for Payer: Devoted Health Medicare |
$453.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$382.28
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$515.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$412.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$475.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.14
|
| Rate for Payer: Health Management Network Commercial |
$1,183.20
|
| Rate for Payer: Humana Medicare |
$412.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$876.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$709.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$412.14
|
| Rate for Payer: MDX Hawaii PPO |
$1,350.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$453.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$412.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$382.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$412.14
|
| Rate for Payer: University Health Alliance Commercial |
$974.25
|
|
|
HC MRI, FACE, NECK W/CONTRAST - MRI NECK SOFT TISSUE W CONTRAST
|
Facility
|
IP
|
$1,392.00
|
|
|
Service Code
|
HCPCS 70542
|
| Hospital Charge Code |
6147054201
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,183.20 |
| Max. Negotiated Rate |
$1,350.24 |
| Rate for Payer: Cash Price |
$835.20
|
| Rate for Payer: Health Management Network Commercial |
$1,183.20
|
| Rate for Payer: MDX Hawaii PPO |
$1,350.24
|
|
|
HC MRI JNT OF LWR EXTRE W/O DYE
|
Facility
|
OP
|
$1,203.00
|
|
|
Service Code
|
HCPCS 73721
|
| Hospital Charge Code |
6167372101
|
|
Hospital Revenue Code
|
616
|
| Min. Negotiated Rate |
$281.87 |
| Max. Negotiated Rate |
$1,166.91 |
| Rate for Payer: AlohaCare Medicaid |
$281.87
|
| Rate for Payer: AlohaCare Medicare |
$281.87
|
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Devoted Health Medicare |
$310.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$396.10
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$352.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$281.87
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$415.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$281.87
|
| Rate for Payer: Health Management Network Commercial |
$1,022.55
|
| Rate for Payer: Humana Medicare |
$281.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$757.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$613.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$281.87
|
| Rate for Payer: MDX Hawaii PPO |
$1,166.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$310.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$281.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$396.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$281.87
|
| Rate for Payer: University Health Alliance Commercial |
$837.57
|
|
|
HC MRI JNT OF LWR EXTRE W/O DYE
|
Facility
|
IP
|
$1,203.00
|
|
|
Service Code
|
HCPCS 73721
|
| Hospital Charge Code |
6167372101
|
|
Hospital Revenue Code
|
616
|
| Min. Negotiated Rate |
$1,022.55 |
| Max. Negotiated Rate |
$1,166.91 |
| Rate for Payer: Cash Price |
$721.80
|
| Rate for Payer: Health Management Network Commercial |
$1,022.55
|
| Rate for Payer: MDX Hawaii PPO |
$1,166.91
|
|
|
HC MRI, JOINT OF LEG. COMBO W AND WO IV CONTRAST
|
Facility
|
OP
|
$1,776.00
|
|
|
Service Code
|
HCPCS 73723
|
| Hospital Charge Code |
6107372301
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$412.14 |
| Max. Negotiated Rate |
$1,722.72 |
| Rate for Payer: AlohaCare Medicaid |
$412.14
|
| Rate for Payer: AlohaCare Medicare |
$412.14
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Devoted Health Medicare |
$453.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$707.76
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$515.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$412.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$880.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.14
|
| Rate for Payer: Health Management Network Commercial |
$1,509.60
|
| Rate for Payer: Humana Medicare |
$412.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,118.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$905.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$412.14
|
| Rate for Payer: MDX Hawaii PPO |
$1,722.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$453.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$412.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$707.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$412.14
|
| Rate for Payer: University Health Alliance Commercial |
$1,286.32
|
|
|
HC MRI, JOINT OF LEG. COMBO W AND WO IV CONTRAST
|
Facility
|
IP
|
$1,776.00
|
|
|
Service Code
|
HCPCS 73723
|
| Hospital Charge Code |
6107372301
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,509.60 |
| Max. Negotiated Rate |
$1,722.72 |
| Rate for Payer: Cash Price |
$1,065.60
|
| Rate for Payer: Health Management Network Commercial |
$1,509.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,722.72
|
|
|
HC MRI, JOINT OF LEG W/CONTRAST
|
Facility
|
OP
|
$3,930.00
|
|
|
Service Code
|
HCPCS 73722
|
| Hospital Charge Code |
6107372201
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$382.28 |
| Max. Negotiated Rate |
$3,812.10 |
| Rate for Payer: AlohaCare Medicaid |
$926.08
|
| Rate for Payer: AlohaCare Medicare |
$926.08
|
| Rate for Payer: Cash Price |
$2,358.00
|
| Rate for Payer: Cash Price |
$2,358.00
|
| Rate for Payer: Devoted Health Medicare |
$1,018.69
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$382.28
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,157.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$926.08
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$475.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$926.08
|
| Rate for Payer: Health Management Network Commercial |
$3,340.50
|
| Rate for Payer: Humana Medicare |
$926.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,475.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,004.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$926.08
|
| Rate for Payer: MDX Hawaii PPO |
$3,812.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,018.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$926.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$382.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$926.08
|
| Rate for Payer: University Health Alliance Commercial |
$973.95
|
|
|
HC MRI, JOINT OF LEG W/CONTRAST
|
Facility
|
IP
|
$3,930.00
|
|
|
Service Code
|
HCPCS 73722
|
| Hospital Charge Code |
6107372201
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,340.50 |
| Max. Negotiated Rate |
$3,812.10 |
| Rate for Payer: Cash Price |
$2,358.00
|
| Rate for Payer: Health Management Network Commercial |
$3,340.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,812.10
|
|
