|
QUEtiapine 200 mg ER Tab [KMC]
|
Facility
|
IP
|
$70.11
|
|
|
Service Code
|
NDC 50228038260
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.59 |
| Max. Negotiated Rate |
$68.01 |
| Rate for Payer: Cash Price |
$45.57
|
| Rate for Payer: Health Management Network Commercial |
$59.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.10
|
| Rate for Payer: MDX Hawaii PPO |
$68.01
|
|
|
QUEtiapine 25 mg Tab [KMC]
|
Facility
|
IP
|
$15.98
|
|
|
Service Code
|
NDC 29300014701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.58 |
| Max. Negotiated Rate |
$15.50 |
| Rate for Payer: Cash Price |
$10.39
|
| Rate for Payer: Health Management Network Commercial |
$13.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.38
|
| Rate for Payer: MDX Hawaii PPO |
$15.50
|
|
|
QUEtiapine 25 mg Tab [KMC]
|
Facility
|
OP
|
$15.98
|
|
|
Service Code
|
NDC 29300014701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$15.50 |
| Rate for Payer: AlohaCare Medicaid |
$7.99
|
| Rate for Payer: AlohaCare Medicare |
$6.71
|
| Rate for Payer: Cash Price |
$10.39
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$14.70
|
| Rate for Payer: Devoted Health Medicare |
$6.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.71
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.18
|
| Rate for Payer: Health Management Network Commercial |
$13.58
|
| Rate for Payer: Humana Medicare |
$6.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.71
|
| Rate for Payer: MDX Hawaii PPO |
$15.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.71
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.71
|
| Rate for Payer: University Health Alliance Commercial |
$11.65
|
|
|
QUEtiapine 400 mg Tab [KMC]
|
Facility
|
IP
|
$79.47
|
|
|
Service Code
|
NDC 16714038001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.55 |
| Max. Negotiated Rate |
$77.09 |
| Rate for Payer: Cash Price |
$51.66
|
| Rate for Payer: Health Management Network Commercial |
$67.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.52
|
| Rate for Payer: MDX Hawaii PPO |
$77.09
|
|
|
QUEtiapine 400 mg Tab [KMC]
|
Facility
|
OP
|
$79.47
|
|
|
Service Code
|
NDC 16714038001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.38 |
| Max. Negotiated Rate |
$77.09 |
| Rate for Payer: AlohaCare Medicaid |
$39.73
|
| Rate for Payer: AlohaCare Medicare |
$33.38
|
| Rate for Payer: Cash Price |
$51.66
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$73.11
|
| Rate for Payer: Devoted Health Medicare |
$33.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$75.50
|
| Rate for Payer: Health Management Network Commercial |
$67.55
|
| Rate for Payer: Humana Medicare |
$33.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$33.38
|
| Rate for Payer: MDX Hawaii PPO |
$77.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.38
|
| Rate for Payer: University Health Alliance Commercial |
$57.93
|
|
|
QUEtiapine 50 mg Tab [KMC]
|
Facility
|
IP
|
$26.27
|
|
|
Service Code
|
NDC 65862049001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.33 |
| Max. Negotiated Rate |
$25.48 |
| Rate for Payer: Cash Price |
$17.08
|
| Rate for Payer: Health Management Network Commercial |
$22.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.64
|
| Rate for Payer: MDX Hawaii PPO |
$25.48
|
|
|
QUEtiapine 50 mg Tab [KMC]
|
Facility
|
OP
|
$26.27
|
|
|
Service Code
|
NDC 65862049001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.03 |
| Max. Negotiated Rate |
$25.48 |
| Rate for Payer: AlohaCare Medicaid |
$13.13
|
| Rate for Payer: AlohaCare Medicare |
$11.03
|
| Rate for Payer: Cash Price |
$17.08
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$24.17
|
| Rate for Payer: Devoted Health Medicare |
$11.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.96
|
| Rate for Payer: Health Management Network Commercial |
$22.33
|
| Rate for Payer: Humana Medicare |
$11.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.03
|
| Rate for Payer: MDX Hawaii PPO |
$25.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.03
|
| Rate for Payer: University Health Alliance Commercial |
$19.15
|
|
|
racepinephrine 2.25% / 0.5 mL Neb Soln [KMC]
|
Facility
|
IP
|
$7.50
|
|
|
Service Code
|
NDC 00487590199
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.38 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Cash Price |
$4.88
|
| Rate for Payer: Health Management Network Commercial |
$6.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.75
|
| Rate for Payer: MDX Hawaii PPO |
$7.28
|
|
|
racepinephrine 2.25% / 0.5 mL Neb Soln [KMC]
|
Facility
|
OP
|
$7.50
|
|
|
Service Code
|
NDC 00487590199
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: AlohaCare Medicaid |
$3.75
|
| Rate for Payer: AlohaCare Medicare |
$3.15
|
| Rate for Payer: Cash Price |
$4.88
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$6.90
|
| Rate for Payer: Devoted Health Medicare |
$3.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.12
|
| Rate for Payer: Health Management Network Commercial |
$6.38
|
| Rate for Payer: Humana Medicare |
$3.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.15
|
| Rate for Payer: MDX Hawaii PPO |
$7.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.15
|
| Rate for Payer: University Health Alliance Commercial |
$5.47
|
|
|
RADEX SHOULDER COMPLETE MINIMUM 2 VIEWS
|
Professional
|
Both
|
$369.00
|
|
|
Service Code
|
HCPCS 73030
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$23.33 |
| Max. Negotiated Rate |
$313.65 |
| Rate for Payer: AlohaCare Medicaid |
$23.33
|
| Rate for Payer: AlohaCare Medicare |
$39.44
|
| Rate for Payer: Cash Price |
$239.85
|
| Rate for Payer: Cash Price |
$239.85
|
| Rate for Payer: Devoted Health Medicare |
$39.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$35.09
|
| Rate for Payer: Health Management Network Commercial |
$313.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.33
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.44
|
|
|
Radiologic examination, abdomen; 1 view
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
HCPCS 74018
|
| Hospital Charge Code |
424740189
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$43.35 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$33.15
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
|
|
Radiologic examination, abdomen; 1 view
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
HCPCS 74018
|
| Hospital Charge Code |
424740189
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$18.74 |
| Max. Negotiated Rate |
$128.51 |
| Rate for Payer: AlohaCare Medicaid |
$25.50
|
| Rate for Payer: AlohaCare Medicare |
$21.42
|
| Rate for Payer: Cash Price |
$33.15
|
| Rate for Payer: Cash Price |
$33.15
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$46.92
|
| Rate for Payer: Devoted Health Medicare |
$21.42
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$18.74
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Humana Medicare |
$21.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.42
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.42
|
| Rate for Payer: University Health Alliance Commercial |
$56.31
|
|
|
Radiologic examination, ankle; 2 views
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
HCPCS 73600
|
| Hospital Charge Code |
424736009
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$15.96 |
| Max. Negotiated Rate |
$128.51 |
| Rate for Payer: AlohaCare Medicaid |
$19.00
|
| Rate for Payer: AlohaCare Medicaid |
$18.00
|
| Rate for Payer: AlohaCare Medicare |
$15.96
|
| Rate for Payer: AlohaCare Medicare |
$15.12
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$34.96
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$33.12
|
| Rate for Payer: Devoted Health Medicare |
$15.12
|
| Rate for Payer: Devoted Health Medicare |
$15.96
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$16.41
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$16.41
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Health Management Network Commercial |
$30.60
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Humana Medicare |
$15.96
|
| Rate for Payer: Humana Medicare |
$15.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.12
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
| Rate for Payer: MDX Hawaii PPO |
$34.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.96
|
| Rate for Payer: University Health Alliance Commercial |
$55.46
|
| Rate for Payer: University Health Alliance Commercial |
$55.46
|
|
|
Radiologic examination, ankle; 2 views
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS 73600
|
| Hospital Charge Code |
424736009
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$30.60 |
| Max. Negotiated Rate |
$34.92 |
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Health Management Network Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: MDX Hawaii PPO |
$34.92
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
|
|
Radiologic examination, ankle; complete, minimum of 3 views
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
HCPCS 73610
|
| Hospital Charge Code |
424736109
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$32.30 |
| Max. Negotiated Rate |
$36.86 |
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
|
|
Radiologic examination, ankle; complete, minimum of 3 views
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
HCPCS 73610
|
| Hospital Charge Code |
424736109
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$15.96 |
| Max. Negotiated Rate |
$128.51 |
| Rate for Payer: AlohaCare Medicaid |
$19.00
|
| Rate for Payer: AlohaCare Medicaid |
$20.00
|
| Rate for Payer: AlohaCare Medicaid |
$21.00
|
| Rate for Payer: AlohaCare Medicare |
$16.80
|
| Rate for Payer: AlohaCare Medicare |
$17.64
|
| Rate for Payer: AlohaCare Medicare |
$15.96
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$36.80
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$34.96
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$38.64
|
| Rate for Payer: Devoted Health Medicare |
$17.64
|
| Rate for Payer: Devoted Health Medicare |
$16.80
|
| Rate for Payer: Devoted Health Medicare |
$15.96
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$17.34
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$17.34
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$17.34
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$17.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Humana Medicare |
$16.80
|
| Rate for Payer: Humana Medicare |
$15.96
|
| Rate for Payer: Humana Medicare |
$17.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$17.64
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$17.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$17.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$17.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.96
|
| Rate for Payer: University Health Alliance Commercial |
$62.59
|
| Rate for Payer: University Health Alliance Commercial |
$62.59
|
| Rate for Payer: University Health Alliance Commercial |
$62.59
|
|
|
Radiologic examination; calcaneus, minimum of 2 views
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
HCPCS 73650
|
| Hospital Charge Code |
424736509
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$15.54 |
| Max. Negotiated Rate |
$128.51 |
| Rate for Payer: AlohaCare Medicaid |
$18.50
|
| Rate for Payer: AlohaCare Medicaid |
$17.00
|
| Rate for Payer: AlohaCare Medicare |
$15.54
|
| Rate for Payer: AlohaCare Medicare |
$14.28
|
| Rate for Payer: Cash Price |
$24.05
|
| Rate for Payer: Cash Price |
$22.10
|
| Rate for Payer: Cash Price |
$22.10
|
| Rate for Payer: Cash Price |
$24.05
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$34.04
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$31.28
|
| Rate for Payer: Devoted Health Medicare |
$14.28
|
| Rate for Payer: Devoted Health Medicare |
$15.54
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$17.03
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$17.03
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Health Management Network Commercial |
$28.90
|
| Rate for Payer: Health Management Network Commercial |
$31.45
|
| Rate for Payer: Humana Medicare |
$15.54
|
| Rate for Payer: Humana Medicare |
$14.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.28
|
| Rate for Payer: MDX Hawaii PPO |
$35.89
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.54
|
| Rate for Payer: University Health Alliance Commercial |
$53.87
|
| Rate for Payer: University Health Alliance Commercial |
$53.87
|
|
|
Radiologic examination; calcaneus, minimum of 2 views
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
HCPCS 73650
|
| Hospital Charge Code |
424736509
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$28.90 |
| Max. Negotiated Rate |
$32.98 |
| Rate for Payer: Cash Price |
$22.10
|
| Rate for Payer: Cash Price |
$24.05
|
| Rate for Payer: Health Management Network Commercial |
$31.45
|
| Rate for Payer: Health Management Network Commercial |
$28.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.30
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
| Rate for Payer: MDX Hawaii PPO |
$35.89
|
|
|
Radiologic examination, foot; 2 views
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
HCPCS 73620
|
| Hospital Charge Code |
424736209
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$27.20 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: Cash Price |
$20.80
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Health Management Network Commercial |
$30.60
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.40
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
| Rate for Payer: MDX Hawaii PPO |
$34.92
|
|
|
Radiologic examination, foot; 2 views
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS 73620
|
| Hospital Charge Code |
424736209
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$128.51 |
| Rate for Payer: AlohaCare Medicaid |
$18.00
|
| Rate for Payer: AlohaCare Medicaid |
$16.00
|
| Rate for Payer: AlohaCare Medicare |
$15.12
|
| Rate for Payer: AlohaCare Medicare |
$13.44
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$20.80
|
| Rate for Payer: Cash Price |
$20.80
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$33.12
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$29.44
|
| Rate for Payer: Devoted Health Medicare |
$13.44
|
| Rate for Payer: Devoted Health Medicare |
$15.12
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$16.41
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$16.41
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Health Management Network Commercial |
$30.60
|
| Rate for Payer: Humana Medicare |
$15.12
|
| Rate for Payer: Humana Medicare |
$13.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.44
|
| Rate for Payer: MDX Hawaii PPO |
$34.92
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.12
|
| Rate for Payer: University Health Alliance Commercial |
$54.67
|
| Rate for Payer: University Health Alliance Commercial |
$54.67
|
|
|
Radiologic examination, foot; complete, minimum of 3 views
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
HCPCS 73630
|
| Hospital Charge Code |
424736309
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$15.96 |
| Max. Negotiated Rate |
$128.51 |
| Rate for Payer: AlohaCare Medicaid |
$19.00
|
| Rate for Payer: AlohaCare Medicaid |
$18.00
|
| Rate for Payer: AlohaCare Medicare |
$15.96
|
| Rate for Payer: AlohaCare Medicare |
$15.12
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$34.96
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$33.12
|
| Rate for Payer: Devoted Health Medicare |
$15.12
|
| Rate for Payer: Devoted Health Medicare |
$15.96
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$19.08
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$19.08
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Health Management Network Commercial |
$30.60
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Humana Medicare |
$15.96
|
| Rate for Payer: Humana Medicare |
$15.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.12
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
| Rate for Payer: MDX Hawaii PPO |
$34.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.96
|
| Rate for Payer: University Health Alliance Commercial |
$62.59
|
| Rate for Payer: University Health Alliance Commercial |
$62.59
|
|
|
Radiologic examination, foot; complete, minimum of 3 views
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS 73630
|
| Hospital Charge Code |
424736309
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$30.60 |
| Max. Negotiated Rate |
$34.92 |
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Health Management Network Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: MDX Hawaii PPO |
$34.92
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
|
|
Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS 73502
|
| Hospital Charge Code |
424735029
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$20.16 |
| Max. Negotiated Rate |
$128.51 |
| Rate for Payer: AlohaCare Medicaid |
$24.00
|
| Rate for Payer: AlohaCare Medicare |
$20.16
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$44.16
|
| Rate for Payer: Devoted Health Medicare |
$20.16
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$20.87
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Health Management Network Commercial |
$40.80
|
| Rate for Payer: Humana Medicare |
$20.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.16
|
| Rate for Payer: MDX Hawaii PPO |
$46.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.16
|
| Rate for Payer: University Health Alliance Commercial |
$86.21
|
|
|
Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS 73502
|
| Hospital Charge Code |
424735029
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$40.80 |
| Max. Negotiated Rate |
$46.56 |
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Health Management Network Commercial |
$40.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.20
|
| Rate for Payer: MDX Hawaii PPO |
$46.56
|
|
|
Radiologic examination, knee; 3 views
|
Facility
|
OP
|
$44.00
|
|
|
Service Code
|
HCPCS 73562
|
| Hospital Charge Code |
424735629
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$18.48 |
| Max. Negotiated Rate |
$128.51 |
| Rate for Payer: AlohaCare Medicaid |
$22.00
|
| Rate for Payer: AlohaCare Medicare |
$18.48
|
| Rate for Payer: Cash Price |
$28.60
|
| Rate for Payer: Cash Price |
$28.60
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$40.48
|
| Rate for Payer: Devoted Health Medicare |
$18.48
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$18.84
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Health Management Network Commercial |
$37.40
|
| Rate for Payer: Humana Medicare |
$18.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.48
|
| Rate for Payer: MDX Hawaii PPO |
$42.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.48
|
| Rate for Payer: University Health Alliance Commercial |
$68.32
|
|
