|
UC PROF RMV FB SHOULDER Charge
|
Facility
|
OP
|
$3,272.00
|
|
|
Service Code
|
HCPCS 23330
|
| Hospital Charge Code |
440233300
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$4,035.20 |
| Rate for Payer: AlohaCare Medicaid |
$1,636.00
|
| Rate for Payer: AlohaCare Medicare |
$1,374.24
|
| Rate for Payer: Cash Price |
$2,126.80
|
| Rate for Payer: Cash Price |
$2,126.80
|
| Rate for Payer: Cash Price |
$2,126.80
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$3,010.24
|
| Rate for Payer: Devoted Health Medicare |
$1,374.24
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,374.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,108.40
|
| Rate for Payer: Health Management Network Commercial |
$2,781.20
|
| Rate for Payer: Humana Medicare |
$1,374.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,944.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,374.24
|
| Rate for Payer: MDX Hawaii PPO |
$3,173.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,374.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,374.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,374.24
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
UC PROF RMV FB SHOULDER Charge
|
Facility
|
IP
|
$3,272.00
|
|
|
Service Code
|
HCPCS 23330
|
| Hospital Charge Code |
440233300
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,781.20 |
| Max. Negotiated Rate |
$3,173.84 |
| Rate for Payer: Cash Price |
$2,126.80
|
| Rate for Payer: Health Management Network Commercial |
$2,781.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,944.80
|
| Rate for Payer: MDX Hawaii PPO |
$3,173.84
|
|
|
UC PRO I&D TONSIL ABSCESS Charge
|
Facility
|
IP
|
$1,335.00
|
|
|
Service Code
|
HCPCS 42700
|
| Hospital Charge Code |
440427000
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,134.75 |
| Max. Negotiated Rate |
$1,294.95 |
| Rate for Payer: Cash Price |
$867.75
|
| Rate for Payer: Health Management Network Commercial |
$1,134.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,201.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,294.95
|
|
|
UC PRO I&D TONSIL ABSCESS Charge
|
Facility
|
OP
|
$1,335.00
|
|
|
Service Code
|
HCPCS 42700
|
| Hospital Charge Code |
440427000
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$667.50
|
| Rate for Payer: AlohaCare Medicare |
$560.70
|
| Rate for Payer: Cash Price |
$867.75
|
| Rate for Payer: Cash Price |
$867.75
|
| Rate for Payer: Cash Price |
$867.75
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,228.20
|
| Rate for Payer: Devoted Health Medicare |
$560.70
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$560.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,268.25
|
| Rate for Payer: Health Management Network Commercial |
$1,134.75
|
| Rate for Payer: Humana Medicare |
$560.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,201.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$560.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,294.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$560.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$560.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$560.70
|
| Rate for Payer: University Health Alliance Commercial |
$973.08
|
|
|
UC REMOVE FB, FOOT Charge
|
Facility
|
IP
|
$3,272.00
|
|
|
Service Code
|
HCPCS 28190
|
| Hospital Charge Code |
440281900
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,781.20 |
| Max. Negotiated Rate |
$3,173.84 |
| Rate for Payer: Cash Price |
$2,126.80
|
| Rate for Payer: Health Management Network Commercial |
$2,781.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,944.80
|
| Rate for Payer: MDX Hawaii PPO |
$3,173.84
|
|
|
UC REMOVE FB, FOOT Charge
|
Facility
|
OP
|
$3,272.00
|
|
|
Service Code
|
HCPCS 28190
|
| Hospital Charge Code |
440281900
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$4,035.20 |
| Rate for Payer: AlohaCare Medicaid |
$1,636.00
|
| Rate for Payer: AlohaCare Medicare |
$1,374.24
|
| Rate for Payer: Cash Price |
$2,126.80
|
| Rate for Payer: Cash Price |
$2,126.80
|
| Rate for Payer: Cash Price |
$2,126.80
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$3,010.24
|
| Rate for Payer: Devoted Health Medicare |
$1,374.24
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,374.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,108.40
|
| Rate for Payer: Health Management Network Commercial |
$2,781.20
|
| Rate for Payer: Humana Medicare |
$1,374.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,944.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,374.24
|
| Rate for Payer: MDX Hawaii PPO |
$3,173.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,374.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,374.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,374.24
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
UC STRAPPING TOES Charge
|
Facility
|
IP
|
$286.00
|
|
|
Service Code
|
HCPCS 29550
|
| Hospital Charge Code |
440295500
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$243.10 |
| Max. Negotiated Rate |
$277.42 |
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Health Management Network Commercial |
$243.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$257.40
|
| Rate for Payer: MDX Hawaii PPO |
$277.42
|
|
|
UC STRAPPING TOES Charge
|
Facility
|
OP
|
$286.00
|
|
|
Service Code
|
HCPCS 29550
|
| Hospital Charge Code |
440295500
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$120.12 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$143.00
|
| Rate for Payer: AlohaCare Medicare |
$120.12
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$263.12
|
| Rate for Payer: Devoted Health Medicare |
$120.12
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$120.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$271.70
|
| Rate for Payer: Health Management Network Commercial |
$243.10
|
| Rate for Payer: Humana Medicare |
$120.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$257.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$120.12
|
| Rate for Payer: MDX Hawaii PPO |
$277.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$120.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$120.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$120.12
|
| Rate for Payer: University Health Alliance Commercial |
$208.47
|
|
|
UDS 9
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
HCPCS 80305
|
| Hospital Charge Code |
422829470
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.98 |
| Max. Negotiated Rate |
$256.08 |
| Rate for Payer: AlohaCare Medicaid |
$132.00
|
| Rate for Payer: AlohaCare Medicare |
$110.88
|
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$242.88
|
| Rate for Payer: Devoted Health Medicare |
$110.88
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$19.03
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$15.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$110.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.60
|
| Rate for Payer: Health Management Network Commercial |
$224.40
|
| Rate for Payer: Humana Medicare |
$110.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$134.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$110.88
|
| Rate for Payer: MDX Hawaii PPO |
$256.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$110.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$110.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$110.88
|
| Rate for Payer: University Health Alliance Commercial |
$27.68
|
|
|
UDS 9
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
HCPCS 80305
|
| Hospital Charge Code |
422829470
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$224.40 |
| Max. Negotiated Rate |
$256.08 |
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Health Management Network Commercial |
$224.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.60
|
| Rate for Payer: MDX Hawaii PPO |
$256.08
|
|
|
Ultrasonic guidance for amniocentesis, imaging supervision and interpretation
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
HCPCS 76946
|
| Hospital Charge Code |
424769469
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$36.12 |
| Max. Negotiated Rate |
$113.53 |
| Rate for Payer: AlohaCare Medicaid |
$43.00
|
| Rate for Payer: AlohaCare Medicaid |
$40.00
|
| Rate for Payer: AlohaCare Medicare |
$36.12
|
| Rate for Payer: AlohaCare Medicare |
$33.60
|
| Rate for Payer: Cash Price |
$55.90
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$55.90
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$73.60
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$79.12
|
| Rate for Payer: Devoted Health Medicare |
$36.12
|
| Rate for Payer: Devoted Health Medicare |
$33.60
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$50.35
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$50.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$81.70
|
| Rate for Payer: Health Management Network Commercial |
$73.10
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Humana Medicare |
$33.60
|
| Rate for Payer: Humana Medicare |
$36.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$77.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$43.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$33.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.12
|
| Rate for Payer: MDX Hawaii PPO |
$83.42
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$36.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.12
|
| Rate for Payer: University Health Alliance Commercial |
$113.53
|
| Rate for Payer: University Health Alliance Commercial |
$113.53
|
|
|
Ultrasonic guidance for amniocentesis, imaging supervision and interpretation
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
HCPCS 76946
|
| Hospital Charge Code |
424769469
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$73.10 |
| Max. Negotiated Rate |
$83.42 |
| Rate for Payer: Cash Price |
$55.90
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Health Management Network Commercial |
$73.10
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$77.40
|
| Rate for Payer: MDX Hawaii PPO |
$83.42
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
|
|
Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation
|
Facility
|
OP
|
$203.00
|
|
|
Service Code
|
HCPCS 76948
|
| Hospital Charge Code |
424769489
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$50.35 |
| Max. Negotiated Rate |
$196.91 |
| Rate for Payer: AlohaCare Medicaid |
$101.50
|
| Rate for Payer: AlohaCare Medicaid |
$96.00
|
| Rate for Payer: AlohaCare Medicare |
$85.26
|
| Rate for Payer: AlohaCare Medicare |
$80.64
|
| Rate for Payer: Cash Price |
$131.95
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cash Price |
$131.95
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$176.64
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$186.76
|
| Rate for Payer: Devoted Health Medicare |
$85.26
|
| Rate for Payer: Devoted Health Medicare |
$80.64
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$50.35
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$50.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$80.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$85.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$182.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$192.85
|
| Rate for Payer: Health Management Network Commercial |
$172.55
|
| Rate for Payer: Health Management Network Commercial |
$163.20
|
| Rate for Payer: Humana Medicare |
$80.64
|
| Rate for Payer: Humana Medicare |
$85.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$182.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$172.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$97.92
|
| Rate for Payer: Kaiser Permanente Medicaid |
$103.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$80.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$85.26
|
| Rate for Payer: MDX Hawaii PPO |
$196.91
|
| Rate for Payer: MDX Hawaii PPO |
$186.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$85.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$80.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$80.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$85.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$80.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$85.26
|
| Rate for Payer: University Health Alliance Commercial |
$112.74
|
| Rate for Payer: University Health Alliance Commercial |
$112.74
|
|
|
Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation
|
Facility
|
IP
|
$203.00
|
|
|
Service Code
|
HCPCS 76948
|
| Hospital Charge Code |
424769489
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$172.55 |
| Max. Negotiated Rate |
$196.91 |
| Rate for Payer: Cash Price |
$131.95
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Health Management Network Commercial |
$172.55
|
| Rate for Payer: Health Management Network Commercial |
$163.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$172.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$182.70
|
| Rate for Payer: MDX Hawaii PPO |
$196.91
|
| Rate for Payer: MDX Hawaii PPO |
$186.24
|
|
|
Ultrasonic guidance for endomyocardial biopsy, imaging supervision and interpretation
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
HCPCS 76932
|
| Hospital Charge Code |
424769329
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$153.00 |
| Max. Negotiated Rate |
$174.60 |
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$110.50
|
| Rate for Payer: Health Management Network Commercial |
$153.00
|
| Rate for Payer: Health Management Network Commercial |
$144.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$153.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$162.00
|
| Rate for Payer: MDX Hawaii PPO |
$174.60
|
| Rate for Payer: MDX Hawaii PPO |
$164.90
|
|
|
Ultrasonic guidance for endomyocardial biopsy, imaging supervision and interpretation
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
HCPCS 76932
|
| Hospital Charge Code |
424769329
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$50.35 |
| Max. Negotiated Rate |
$174.60 |
| Rate for Payer: AlohaCare Medicaid |
$90.00
|
| Rate for Payer: AlohaCare Medicaid |
$85.00
|
| Rate for Payer: AlohaCare Medicare |
$75.60
|
| Rate for Payer: AlohaCare Medicare |
$71.40
|
| Rate for Payer: Cash Price |
$110.50
|
| Rate for Payer: Cash Price |
$110.50
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$165.60
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$156.40
|
| Rate for Payer: Devoted Health Medicare |
$75.60
|
| Rate for Payer: Devoted Health Medicare |
$71.40
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$50.35
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$50.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$71.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$75.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$171.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$161.50
|
| Rate for Payer: Health Management Network Commercial |
$153.00
|
| Rate for Payer: Health Management Network Commercial |
$144.50
|
| Rate for Payer: Humana Medicare |
$71.40
|
| Rate for Payer: Humana Medicare |
$75.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$153.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$162.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$86.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$75.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$71.40
|
| Rate for Payer: MDX Hawaii PPO |
$164.90
|
| Rate for Payer: MDX Hawaii PPO |
$174.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$71.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$75.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$71.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$75.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$71.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$75.60
|
| Rate for Payer: University Health Alliance Commercial |
$123.91
|
| Rate for Payer: University Health Alliance Commercial |
$131.20
|
|
|
Ultrasonic guidance for pericardiocentesis, imaging supervision and interpretation
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
HCPCS 76930
|
| Hospital Charge Code |
424769309
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$59.22 |
| Max. Negotiated Rate |
$201.58 |
| Rate for Payer: AlohaCare Medicaid |
$70.50
|
| Rate for Payer: AlohaCare Medicaid |
$67.50
|
| Rate for Payer: AlohaCare Medicare |
$56.70
|
| Rate for Payer: AlohaCare Medicare |
$59.22
|
| Rate for Payer: Cash Price |
$91.65
|
| Rate for Payer: Cash Price |
$87.75
|
| Rate for Payer: Cash Price |
$87.75
|
| Rate for Payer: Cash Price |
$91.65
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$124.20
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$129.72
|
| Rate for Payer: Devoted Health Medicare |
$59.22
|
| Rate for Payer: Devoted Health Medicare |
$56.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$59.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$128.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$133.95
|
| Rate for Payer: Health Management Network Commercial |
$114.75
|
| Rate for Payer: Health Management Network Commercial |
$119.85
|
| Rate for Payer: Humana Medicare |
$59.22
|
| Rate for Payer: Humana Medicare |
$56.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$68.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$56.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$59.22
|
| Rate for Payer: MDX Hawaii PPO |
$130.95
|
| Rate for Payer: MDX Hawaii PPO |
$136.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$59.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$56.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$59.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$59.22
|
| Rate for Payer: University Health Alliance Commercial |
$201.58
|
| Rate for Payer: University Health Alliance Commercial |
$201.58
|
|
|
Ultrasonic guidance for pericardiocentesis, imaging supervision and interpretation
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
HCPCS 76930
|
| Hospital Charge Code |
424769309
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$119.85 |
| Max. Negotiated Rate |
$136.77 |
| Rate for Payer: Cash Price |
$91.65
|
| Rate for Payer: Cash Price |
$87.75
|
| Rate for Payer: Health Management Network Commercial |
$114.75
|
| Rate for Payer: Health Management Network Commercial |
$119.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.90
|
| Rate for Payer: MDX Hawaii PPO |
$136.77
|
| Rate for Payer: MDX Hawaii PPO |
$130.95
|
|
|
Ultrasonic guidance, intraoperative
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
HCPCS 76998
|
| Hospital Charge Code |
424769989
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$93.99 |
| Max. Negotiated Rate |
$256.08 |
| Rate for Payer: AlohaCare Medicaid |
$132.00
|
| Rate for Payer: AlohaCare Medicaid |
$125.00
|
| Rate for Payer: AlohaCare Medicare |
$105.00
|
| Rate for Payer: AlohaCare Medicare |
$110.88
|
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$242.88
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$230.00
|
| Rate for Payer: Devoted Health Medicare |
$105.00
|
| Rate for Payer: Devoted Health Medicare |
$110.88
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$93.99
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$93.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$110.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$105.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$250.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$237.50
|
| Rate for Payer: Health Management Network Commercial |
$212.50
|
| Rate for Payer: Health Management Network Commercial |
$224.40
|
| Rate for Payer: Humana Medicare |
$105.00
|
| Rate for Payer: Humana Medicare |
$110.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$225.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$134.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$127.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$110.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$105.00
|
| Rate for Payer: MDX Hawaii PPO |
$256.08
|
| Rate for Payer: MDX Hawaii PPO |
$242.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$105.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$110.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$110.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$105.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$105.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$110.88
|
| Rate for Payer: University Health Alliance Commercial |
$182.22
|
| Rate for Payer: University Health Alliance Commercial |
$192.43
|
|
|
Ultrasonic guidance, intraoperative
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
HCPCS 76998
|
| Hospital Charge Code |
424769989
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$224.40 |
| Max. Negotiated Rate |
$256.08 |
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Health Management Network Commercial |
$212.50
|
| Rate for Payer: Health Management Network Commercial |
$224.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$225.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.60
|
| Rate for Payer: MDX Hawaii PPO |
$256.08
|
| Rate for Payer: MDX Hawaii PPO |
$242.50
|
|
|
ULTRASOUND ABDOM B SCAN
|
Facility
|
OP
|
$689.00
|
|
|
Service Code
|
HCPCS 76700
|
| Hospital Charge Code |
424767000
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$64.94 |
| Max. Negotiated Rate |
$668.33 |
| Rate for Payer: AlohaCare Medicaid |
$344.50
|
| Rate for Payer: AlohaCare Medicare |
$289.38
|
| Rate for Payer: Cash Price |
$447.85
|
| Rate for Payer: Cash Price |
$447.85
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$633.88
|
| Rate for Payer: Devoted Health Medicare |
$289.38
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$64.94
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$289.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$585.65
|
| Rate for Payer: Humana Medicare |
$289.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$620.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$351.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$289.38
|
| Rate for Payer: MDX Hawaii PPO |
$668.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$289.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$289.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$289.38
|
| Rate for Payer: University Health Alliance Commercial |
$268.45
|
|
|
ULTRASOUND ABDOM B SCAN
|
Facility
|
IP
|
$689.00
|
|
|
Service Code
|
HCPCS 76700
|
| Hospital Charge Code |
424767000
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$585.65 |
| Max. Negotiated Rate |
$668.33 |
| Rate for Payer: Cash Price |
$447.85
|
| Rate for Payer: Health Management Network Commercial |
$585.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$620.10
|
| Rate for Payer: MDX Hawaii PPO |
$668.33
|
|
|
Ultrasound, abdominal, real time with image documentation; complete
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
HCPCS 76700
|
| Hospital Charge Code |
424767009
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$138.55 |
| Max. Negotiated Rate |
$158.11 |
| Rate for Payer: Cash Price |
$105.95
|
| Rate for Payer: Cash Price |
$113.75
|
| Rate for Payer: Health Management Network Commercial |
$148.75
|
| Rate for Payer: Health Management Network Commercial |
$138.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$146.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$157.50
|
| Rate for Payer: MDX Hawaii PPO |
$158.11
|
| Rate for Payer: MDX Hawaii PPO |
$169.75
|
|
|
Ultrasound, abdominal, real time with image documentation; complete
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS 76700
|
| Hospital Charge Code |
424767009
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$64.94 |
| Max. Negotiated Rate |
$268.45 |
| Rate for Payer: AlohaCare Medicaid |
$87.50
|
| Rate for Payer: AlohaCare Medicaid |
$81.50
|
| Rate for Payer: AlohaCare Medicare |
$73.50
|
| Rate for Payer: AlohaCare Medicare |
$68.46
|
| Rate for Payer: Cash Price |
$113.75
|
| Rate for Payer: Cash Price |
$105.95
|
| Rate for Payer: Cash Price |
$105.95
|
| Rate for Payer: Cash Price |
$113.75
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$161.00
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$149.96
|
| Rate for Payer: Devoted Health Medicare |
$68.46
|
| Rate for Payer: Devoted Health Medicare |
$73.50
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$64.94
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$64.94
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$73.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$138.55
|
| Rate for Payer: Health Management Network Commercial |
$148.75
|
| Rate for Payer: Humana Medicare |
$73.50
|
| Rate for Payer: Humana Medicare |
$68.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$146.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$157.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$89.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$73.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$68.46
|
| Rate for Payer: MDX Hawaii PPO |
$169.75
|
| Rate for Payer: MDX Hawaii PPO |
$158.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$73.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$73.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$73.50
|
| Rate for Payer: University Health Alliance Commercial |
$268.45
|
| Rate for Payer: University Health Alliance Commercial |
$268.45
|
|
|
Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
424767059
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$46.98 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: AlohaCare Medicaid |
$64.50
|
| Rate for Payer: AlohaCare Medicaid |
$59.50
|
| Rate for Payer: AlohaCare Medicare |
$54.18
|
| Rate for Payer: AlohaCare Medicare |
$49.98
|
| Rate for Payer: Cash Price |
$83.85
|
| Rate for Payer: Cash Price |
$77.35
|
| Rate for Payer: Cash Price |
$77.35
|
| Rate for Payer: Cash Price |
$83.85
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$118.68
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$109.48
|
| Rate for Payer: Devoted Health Medicare |
$49.98
|
| Rate for Payer: Devoted Health Medicare |
$54.18
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$46.98
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$46.98
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$101.15
|
| Rate for Payer: Health Management Network Commercial |
$109.65
|
| Rate for Payer: Humana Medicare |
$54.18
|
| Rate for Payer: Humana Medicare |
$49.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$116.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.98
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
| Rate for Payer: MDX Hawaii PPO |
$115.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.18
|
| Rate for Payer: University Health Alliance Commercial |
$200.93
|
| Rate for Payer: University Health Alliance Commercial |
$200.93
|
|
