|
Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
424767059
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$101.15 |
| Max. Negotiated Rate |
$115.43 |
| Rate for Payer: Cash Price |
$77.35
|
| Rate for Payer: Cash Price |
$83.85
|
| Rate for Payer: Health Management Network Commercial |
$109.65
|
| Rate for Payer: Health Management Network Commercial |
$101.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$116.10
|
| Rate for Payer: MDX Hawaii PPO |
$115.43
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
|
|
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC
|
Facility
|
IP
|
$71,911.87
|
|
|
Service Code
|
MSDRG 278
|
| Min. Negotiated Rate |
$71,911.87 |
| Max. Negotiated Rate |
$71,911.87 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$71,911.87
|
|
|
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC
|
Facility
|
IP
|
$71,911.87
|
|
|
Service Code
|
MSDRG 279
|
| Min. Negotiated Rate |
$71,911.87 |
| Max. Negotiated Rate |
$71,911.87 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$71,911.87
|
|
|
Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
424766419
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$242.25 |
| Max. Negotiated Rate |
$276.45 |
| Rate for Payer: Cash Price |
$185.25
|
| Rate for Payer: Cash Price |
$196.30
|
| Rate for Payer: Health Management Network Commercial |
$256.70
|
| Rate for Payer: Health Management Network Commercial |
$242.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$256.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$271.80
|
| Rate for Payer: MDX Hawaii PPO |
$276.45
|
| Rate for Payer: MDX Hawaii PPO |
$292.94
|
|
|
Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
424764109
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$34.94 |
| Max. Negotiated Rate |
$223.66 |
| Rate for Payer: AlohaCare Medicaid |
$75.00
|
| Rate for Payer: AlohaCare Medicaid |
$79.50
|
| Rate for Payer: AlohaCare Medicare |
$66.78
|
| Rate for Payer: AlohaCare Medicare |
$63.00
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cash Price |
$103.35
|
| Rate for Payer: Cash Price |
$103.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$146.28
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$138.00
|
| Rate for Payer: Devoted Health Medicare |
$63.00
|
| Rate for Payer: Devoted Health Medicare |
$66.78
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$34.94
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$34.94
|
| 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 |
$63.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.78
|
| 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 |
$135.15
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Humana Medicare |
$63.00
|
| Rate for Payer: Humana Medicare |
$66.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$143.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$76.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$81.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.00
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
| Rate for Payer: MDX Hawaii PPO |
$154.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$67.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$67.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.00
|
| Rate for Payer: University Health Alliance Commercial |
$223.66
|
| Rate for Payer: University Health Alliance Commercial |
$223.66
|
|
|
Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete
|
Facility
|
OP
|
$302.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
424766419
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$34.94 |
| Max. Negotiated Rate |
$292.94 |
| Rate for Payer: AlohaCare Medicaid |
$151.00
|
| Rate for Payer: AlohaCare Medicaid |
$142.50
|
| Rate for Payer: AlohaCare Medicare |
$126.84
|
| Rate for Payer: AlohaCare Medicare |
$119.70
|
| Rate for Payer: Cash Price |
$196.30
|
| Rate for Payer: Cash Price |
$185.25
|
| Rate for Payer: Cash Price |
$185.25
|
| Rate for Payer: Cash Price |
$196.30
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$277.84
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$262.20
|
| Rate for Payer: Devoted Health Medicare |
$119.70
|
| Rate for Payer: Devoted Health Medicare |
$126.84
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$34.94
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$34.94
|
| 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 |
$119.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$126.84
|
| 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 |
$242.25
|
| Rate for Payer: Health Management Network Commercial |
$256.70
|
| Rate for Payer: Humana Medicare |
$126.84
|
| Rate for Payer: Humana Medicare |
$119.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$256.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$271.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$154.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$145.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$126.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$119.70
|
| Rate for Payer: MDX Hawaii PPO |
$292.94
|
| Rate for Payer: MDX Hawaii PPO |
$276.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$126.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$119.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$119.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$126.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$67.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$67.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$119.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$126.84
|
| Rate for Payer: University Health Alliance Commercial |
$223.66
|
| Rate for Payer: University Health Alliance Commercial |
$223.66
|
|
|
Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
424764109
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$135.15 |
| Max. Negotiated Rate |
$154.23 |
| Rate for Payer: Cash Price |
$103.35
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Health Management Network Commercial |
$135.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$143.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
| Rate for Payer: MDX Hawaii PPO |
$154.23
|
|
|
Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
424766429
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$34.94 |
| Max. Negotiated Rate |
$182.63 |
| Rate for Payer: AlohaCare Medicaid |
$69.50
|
| Rate for Payer: AlohaCare Medicaid |
$73.00
|
| Rate for Payer: AlohaCare Medicaid |
$151.00
|
| Rate for Payer: AlohaCare Medicare |
$61.32
|
| Rate for Payer: AlohaCare Medicare |
$126.84
|
| Rate for Payer: AlohaCare Medicare |
$58.38
|
| Rate for Payer: Cash Price |
$94.90
|
| Rate for Payer: Cash Price |
$90.35
|
| Rate for Payer: Cash Price |
$196.30
|
| Rate for Payer: Cash Price |
$196.30
|
| Rate for Payer: Cash Price |
$94.90
|
| Rate for Payer: Cash Price |
$90.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$134.32
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$127.88
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$277.84
|
| Rate for Payer: Devoted Health Medicare |
$126.84
|
| Rate for Payer: Devoted Health Medicare |
$61.32
|
| Rate for Payer: Devoted Health Medicare |
$58.38
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$34.94
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$34.94
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$34.94
|
| 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 |
$58.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$126.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$61.32
|
| 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 |
$124.10
|
| Rate for Payer: Health Management Network Commercial |
$256.70
|
| Rate for Payer: Health Management Network Commercial |
$118.15
|
| Rate for Payer: Humana Medicare |
$61.32
|
| Rate for Payer: Humana Medicare |
$58.38
|
| Rate for Payer: Humana Medicare |
$126.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$125.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$131.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$271.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$74.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$154.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$61.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$126.84
|
| Rate for Payer: MDX Hawaii PPO |
$141.62
|
| Rate for Payer: MDX Hawaii PPO |
$134.83
|
| Rate for Payer: MDX Hawaii PPO |
$292.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$58.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$61.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$126.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$126.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$61.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$55.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$55.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$55.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$126.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$61.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$58.38
|
| Rate for Payer: University Health Alliance Commercial |
$182.63
|
| Rate for Payer: University Health Alliance Commercial |
$182.63
|
| Rate for Payer: University Health Alliance Commercial |
$182.63
|
|
|
Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
424766429
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$118.15 |
| Max. Negotiated Rate |
$134.83 |
| Rate for Payer: Cash Price |
$90.35
|
| Rate for Payer: Cash Price |
$196.30
|
| Rate for Payer: Cash Price |
$94.90
|
| Rate for Payer: Health Management Network Commercial |
$118.15
|
| Rate for Payer: Health Management Network Commercial |
$256.70
|
| Rate for Payer: Health Management Network Commercial |
$124.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$125.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$131.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$271.80
|
| Rate for Payer: MDX Hawaii PPO |
$134.83
|
| Rate for Payer: MDX Hawaii PPO |
$292.94
|
| Rate for Payer: MDX Hawaii PPO |
$141.62
|
|
|
Ultrasound Charges
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 97035 GO
|
| Hospital Charge Code |
426970350
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$9.52 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: AlohaCare Medicaid |
$89.50
|
| Rate for Payer: AlohaCare Medicare |
$75.18
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$164.68
|
| Rate for Payer: Devoted Health Medicare |
$75.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$75.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$170.05
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Humana Medicare |
$75.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$75.18
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$75.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$75.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$75.18
|
| Rate for Payer: University Health Alliance Commercial |
$130.47
|
|
|
Ultrasound Charges
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 97035 GO
|
| Hospital Charge Code |
426970350
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
|
|
Ultrasound, chest (includes mediastinum), real time with image documentation
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
HCPCS 76604
|
| Hospital Charge Code |
424766049
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$42.98 |
| Max. Negotiated Rate |
$171.44 |
| Rate for Payer: AlohaCare Medicaid |
$58.50
|
| Rate for Payer: AlohaCare Medicaid |
$56.00
|
| Rate for Payer: AlohaCare Medicare |
$49.14
|
| Rate for Payer: AlohaCare Medicare |
$47.04
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Cash Price |
$72.80
|
| Rate for Payer: Cash Price |
$72.80
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$107.64
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$103.04
|
| Rate for Payer: Devoted Health Medicare |
$47.04
|
| Rate for Payer: Devoted Health Medicare |
$49.14
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$42.98
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$42.98
|
| 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 |
$47.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.14
|
| 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 |
$95.20
|
| Rate for Payer: Health Management Network Commercial |
$99.45
|
| Rate for Payer: Humana Medicare |
$49.14
|
| Rate for Payer: Humana Medicare |
$47.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$100.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.04
|
| Rate for Payer: MDX Hawaii PPO |
$113.49
|
| Rate for Payer: MDX Hawaii PPO |
$108.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.14
|
| Rate for Payer: University Health Alliance Commercial |
$171.44
|
| Rate for Payer: University Health Alliance Commercial |
$171.44
|
|
|
Ultrasound, chest (includes mediastinum), real time with image documentation
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
HCPCS 76604
|
| Hospital Charge Code |
424766049
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$95.20 |
| Max. Negotiated Rate |
$108.64 |
| Rate for Payer: Cash Price |
$72.80
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Health Management Network Commercial |
$99.45
|
| Rate for Payer: Health Management Network Commercial |
$95.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$100.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.30
|
| Rate for Payer: MDX Hawaii PPO |
$108.64
|
| Rate for Payer: MDX Hawaii PPO |
$113.49
|
|
|
Ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures) real-time with image documentation
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
HCPCS 76881
|
| Hospital Charge Code |
424768819
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$246.33 |
| Rate for Payer: AlohaCare Medicaid |
$65.00
|
| Rate for Payer: AlohaCare Medicare |
$54.60
|
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$119.60
|
| Rate for Payer: Devoted Health Medicare |
$54.60
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$61.93
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$110.50
|
| Rate for Payer: Humana Medicare |
$54.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$66.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.60
|
| Rate for Payer: MDX Hawaii PPO |
$126.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$61.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.60
|
| Rate for Payer: University Health Alliance Commercial |
$246.33
|
|
|
Ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures) real-time with image documentation
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
HCPCS 76881
|
| Hospital Charge Code |
424768819
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$110.50 |
| Max. Negotiated Rate |
$126.10 |
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Health Management Network Commercial |
$110.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.00
|
| Rate for Payer: MDX Hawaii PPO |
$126.10
|
|
|
ULTRASOUND EACH 15 MIN Occupational
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 97035 GO
|
| Hospital Charge Code |
426970350
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$9.52 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: AlohaCare Medicaid |
$89.50
|
| Rate for Payer: AlohaCare Medicare |
$75.18
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$164.68
|
| Rate for Payer: Devoted Health Medicare |
$75.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$75.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$170.05
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Humana Medicare |
$75.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$75.18
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$75.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$75.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$75.18
|
| Rate for Payer: University Health Alliance Commercial |
$130.47
|
|
|
ULTRASOUND EACH 15 MIN Occupational
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 97035 GO
|
| Hospital Charge Code |
426970350
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
|
|
ULTRASOUND EACH 15 MIN Physical
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 97035 GP
|
| Hospital Charge Code |
432970350
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
|
|
ULTRASOUND EACH 15 MIN Physical
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 97035 GP
|
| Hospital Charge Code |
432970350
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$9.52 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: AlohaCare Medicaid |
$89.50
|
| Rate for Payer: AlohaCare Medicare |
$75.18
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$164.68
|
| Rate for Payer: Devoted Health Medicare |
$75.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$75.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$170.05
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Humana Medicare |
$75.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$75.18
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$75.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$75.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$75.18
|
| Rate for Payer: University Health Alliance Commercial |
$130.47
|
|
|
Ultrasound, extremity, nonvascular, real-time with image documentation; complete
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
HCPCS 76881
|
| Hospital Charge Code |
424768819
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$116.45 |
| Max. Negotiated Rate |
$132.89 |
| Rate for Payer: Cash Price |
$89.05
|
| Rate for Payer: Health Management Network Commercial |
$116.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$123.30
|
| Rate for Payer: MDX Hawaii PPO |
$132.89
|
|
|
Ultrasound, extremity, nonvascular, real-time with image documentation; complete
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
HCPCS 76881
|
| Hospital Charge Code |
424768819
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$57.54 |
| Max. Negotiated Rate |
$246.33 |
| Rate for Payer: AlohaCare Medicaid |
$68.50
|
| Rate for Payer: AlohaCare Medicare |
$57.54
|
| Rate for Payer: Cash Price |
$89.05
|
| Rate for Payer: Cash Price |
$89.05
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$126.04
|
| Rate for Payer: Devoted Health Medicare |
$57.54
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$61.93
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$116.45
|
| Rate for Payer: Humana Medicare |
$57.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$123.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$69.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.54
|
| Rate for Payer: MDX Hawaii PPO |
$132.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$61.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.54
|
| Rate for Payer: University Health Alliance Commercial |
$246.33
|
|
|
Ultrasound guidance for, and monitoring of, parenchymal tissue ablation
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
HCPCS 76940
|
| Hospital Charge Code |
424769409
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$39.48 |
| Max. Negotiated Rate |
$91.18 |
| Rate for Payer: AlohaCare Medicaid |
$47.00
|
| Rate for Payer: AlohaCare Medicaid |
$50.00
|
| Rate for Payer: AlohaCare Medicare |
$39.48
|
| Rate for Payer: AlohaCare Medicare |
$42.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cash Price |
$61.10
|
| Rate for Payer: Cash Price |
$61.10
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$86.48
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$92.00
|
| Rate for Payer: Devoted Health Medicare |
$39.48
|
| Rate for Payer: Devoted Health Medicare |
$42.00
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$52.30
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$52.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$42.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$89.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$95.00
|
| Rate for Payer: Health Management Network Commercial |
$79.90
|
| Rate for Payer: Health Management Network Commercial |
$85.00
|
| Rate for Payer: Humana Medicare |
$42.00
|
| Rate for Payer: Humana Medicare |
$39.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$51.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$42.00
|
| Rate for Payer: MDX Hawaii PPO |
$97.00
|
| Rate for Payer: MDX Hawaii PPO |
$91.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$42.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$42.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$52.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$52.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$42.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.48
|
| Rate for Payer: University Health Alliance Commercial |
$72.89
|
| Rate for Payer: University Health Alliance Commercial |
$68.52
|
|
|
Ultrasound guidance for, and monitoring of, parenchymal tissue ablation
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
HCPCS 76940
|
| Hospital Charge Code |
424769409
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$79.90 |
| Max. Negotiated Rate |
$91.18 |
| Rate for Payer: Cash Price |
$61.10
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Health Management Network Commercial |
$79.90
|
| Rate for Payer: Health Management Network Commercial |
$85.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.60
|
| Rate for Payer: MDX Hawaii PPO |
$91.18
|
| Rate for Payer: MDX Hawaii PPO |
$97.00
|
|
|
Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular n
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS 76937
|
| Hospital Charge Code |
424769379
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$61.11 |
| Rate for Payer: Cash Price |
$40.95
|
| Rate for Payer: Health Management Network Commercial |
$53.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.70
|
| Rate for Payer: MDX Hawaii PPO |
$61.11
|
|
|
Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular n
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS 76937
|
| Hospital Charge Code |
424769379
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$13.38 |
| Max. Negotiated Rate |
$69.04 |
| Rate for Payer: AlohaCare Medicaid |
$31.50
|
| Rate for Payer: AlohaCare Medicare |
$26.46
|
| Rate for Payer: Cash Price |
$40.95
|
| Rate for Payer: Cash Price |
$40.95
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$57.96
|
| Rate for Payer: Devoted Health Medicare |
$26.46
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$13.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$59.85
|
| Rate for Payer: Health Management Network Commercial |
$53.55
|
| Rate for Payer: Humana Medicare |
$26.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$32.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.46
|
| Rate for Payer: MDX Hawaii PPO |
$61.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.46
|
| Rate for Payer: University Health Alliance Commercial |
$69.04
|
|
