|
Ultrasound, pregnant uterus, real time with image documentation, transvaginal
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
HCPCS 76817
|
| Hospital Charge Code |
424768179
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$139.40 |
| Max. Negotiated Rate |
$159.08 |
| Rate for Payer: Cash Price |
$106.60
|
| Rate for Payer: Cash Price |
$102.05
|
| Rate for Payer: Health Management Network Commercial |
$133.45
|
| Rate for Payer: Health Management Network Commercial |
$139.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.30
|
| Rate for Payer: MDX Hawaii PPO |
$152.29
|
| Rate for Payer: MDX Hawaii PPO |
$159.08
|
|
|
Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
HCPCS 76770
|
| Hospital Charge Code |
424767709
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$64.94 |
| Max. Negotiated Rate |
$258.91 |
| Rate for Payer: AlohaCare Medicaid |
$79.00
|
| Rate for Payer: AlohaCare Medicaid |
$75.00
|
| Rate for Payer: AlohaCare Medicare |
$66.36
|
| Rate for Payer: AlohaCare Medicare |
$63.00
|
| Rate for Payer: Cash Price |
$102.70
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cash Price |
$102.70
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$145.36
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$138.00
|
| Rate for Payer: Devoted Health Medicare |
$63.00
|
| Rate for Payer: Devoted Health Medicare |
$66.36
|
| 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 |
$63.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.36
|
| 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 |
$127.50
|
| Rate for Payer: Health Management Network Commercial |
$134.30
|
| Rate for Payer: Humana Medicare |
$66.36
|
| Rate for Payer: Humana Medicare |
$63.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$142.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$80.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$76.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.00
|
| Rate for Payer: MDX Hawaii PPO |
$153.26
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.36
|
| Rate for Payer: University Health Alliance Commercial |
$258.91
|
| Rate for Payer: University Health Alliance Commercial |
$258.91
|
|
|
Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS 76770
|
| Hospital Charge Code |
424767709
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$127.50 |
| Max. Negotiated Rate |
$145.50 |
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cash Price |
$102.70
|
| Rate for Payer: Health Management Network Commercial |
$134.30
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$142.20
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
| Rate for Payer: MDX Hawaii PPO |
$153.26
|
|
|
Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
HCPCS 76775
|
| Hospital Charge Code |
424767759
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$46.98 |
| Max. Negotiated Rate |
$202.63 |
| Rate for Payer: AlohaCare Medicaid |
$61.00
|
| Rate for Payer: AlohaCare Medicaid |
$58.00
|
| Rate for Payer: AlohaCare Medicare |
$51.24
|
| Rate for Payer: AlohaCare Medicare |
$48.72
|
| Rate for Payer: Cash Price |
$79.30
|
| Rate for Payer: Cash Price |
$75.40
|
| Rate for Payer: Cash Price |
$75.40
|
| Rate for Payer: Cash Price |
$79.30
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$112.24
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$106.72
|
| Rate for Payer: Devoted Health Medicare |
$48.72
|
| Rate for Payer: Devoted Health Medicare |
$51.24
|
| 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 |
$48.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$51.24
|
| 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 |
$98.60
|
| Rate for Payer: Health Management Network Commercial |
$103.70
|
| Rate for Payer: Humana Medicare |
$51.24
|
| Rate for Payer: Humana Medicare |
$48.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$109.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$62.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$51.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.72
|
| Rate for Payer: MDX Hawaii PPO |
$118.34
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$51.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$51.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$51.24
|
| Rate for Payer: University Health Alliance Commercial |
$202.63
|
| Rate for Payer: University Health Alliance Commercial |
$202.63
|
|
|
Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS 76775
|
| Hospital Charge Code |
424767759
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$98.60 |
| Max. Negotiated Rate |
$112.52 |
| Rate for Payer: Cash Price |
$75.40
|
| Rate for Payer: Cash Price |
$79.30
|
| Rate for Payer: Health Management Network Commercial |
$103.70
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$109.80
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
| Rate for Payer: MDX Hawaii PPO |
$118.34
|
|
|
Ultrasound, scrotum and contents
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
424768709
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$50.35 |
| Max. Negotiated Rate |
$228.81 |
| Rate for Payer: AlohaCare Medicaid |
$68.00
|
| Rate for Payer: AlohaCare Medicaid |
$64.50
|
| Rate for Payer: AlohaCare Medicare |
$57.12
|
| Rate for Payer: AlohaCare Medicare |
$54.18
|
| Rate for Payer: Cash Price |
$88.40
|
| Rate for Payer: Cash Price |
$83.85
|
| Rate for Payer: Cash Price |
$83.85
|
| Rate for Payer: Cash Price |
$88.40
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$125.12
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$118.68
|
| Rate for Payer: Devoted Health Medicare |
$54.18
|
| Rate for Payer: Devoted Health Medicare |
$57.12
|
| 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 Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.12
|
| 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 |
$109.65
|
| Rate for Payer: Health Management Network Commercial |
$115.60
|
| Rate for Payer: Humana Medicare |
$57.12
|
| Rate for Payer: Humana Medicare |
$54.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$116.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$122.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$69.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.18
|
| Rate for Payer: MDX Hawaii PPO |
$131.92
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.12
|
| Rate for Payer: University Health Alliance Commercial |
$228.81
|
| Rate for Payer: University Health Alliance Commercial |
$228.81
|
|
|
Ultrasound, scrotum and contents
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
424768709
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$109.65 |
| Max. Negotiated Rate |
$125.13 |
| Rate for Payer: Cash Price |
$83.85
|
| Rate for Payer: Cash Price |
$88.40
|
| Rate for Payer: Health Management Network Commercial |
$115.60
|
| Rate for Payer: Health Management Network Commercial |
$109.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$116.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$122.40
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
| Rate for Payer: MDX Hawaii PPO |
$131.92
|
|
|
ULTRASOUND SCROTUM AND CONTENTS
|
Facility
|
OP
|
$689.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
424768700
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$50.35 |
| 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 |
$50.35
|
| 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 |
$50.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$289.38
|
| Rate for Payer: University Health Alliance Commercial |
$228.81
|
|
|
ULTRASOUND SCROTUM AND CONTENTS
|
Facility
|
IP
|
$689.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
424768700
|
|
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, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS 76536
|
| Hospital Charge Code |
424765369
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$46.98 |
| Max. Negotiated Rate |
$211.12 |
| Rate for Payer: AlohaCare Medicaid |
$59.50
|
| Rate for Payer: AlohaCare Medicaid |
$57.00
|
| Rate for Payer: AlohaCare Medicare |
$49.98
|
| Rate for Payer: AlohaCare Medicare |
$47.88
|
| Rate for Payer: Cash Price |
$77.35
|
| Rate for Payer: Cash Price |
$74.10
|
| Rate for Payer: Cash Price |
$74.10
|
| Rate for Payer: Cash Price |
$77.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$109.48
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$104.88
|
| Rate for Payer: Devoted Health Medicare |
$47.88
|
| Rate for Payer: Devoted Health Medicare |
$49.98
|
| 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 |
$47.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.98
|
| 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 |
$96.90
|
| Rate for Payer: Health Management Network Commercial |
$101.15
|
| Rate for Payer: Humana Medicare |
$49.98
|
| Rate for Payer: Humana Medicare |
$47.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.88
|
| Rate for Payer: MDX Hawaii PPO |
$115.43
|
| Rate for Payer: MDX Hawaii PPO |
$110.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.98
|
| Rate for Payer: University Health Alliance Commercial |
$211.12
|
| Rate for Payer: University Health Alliance Commercial |
$211.12
|
|
|
Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
HCPCS 76536
|
| Hospital Charge Code |
424765369
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$96.90 |
| Max. Negotiated Rate |
$110.58 |
| Rate for Payer: Cash Price |
$74.10
|
| Rate for Payer: Cash Price |
$77.35
|
| Rate for Payer: Health Management Network Commercial |
$101.15
|
| Rate for Payer: Health Management Network Commercial |
$96.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.10
|
| Rate for Payer: MDX Hawaii PPO |
$110.58
|
| Rate for Payer: MDX Hawaii PPO |
$115.43
|
|
|
Ultrasound study follow-up (specify)
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS 76970
|
| Hospital Charge Code |
424769709
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$36.54 |
| Max. Negotiated Rate |
$155.36 |
| Rate for Payer: AlohaCare Medicaid |
$43.50
|
| Rate for Payer: AlohaCare Medicaid |
$41.00
|
| Rate for Payer: AlohaCare Medicare |
$34.44
|
| Rate for Payer: AlohaCare Medicare |
$36.54
|
| Rate for Payer: Cash Price |
$56.55
|
| Rate for Payer: Cash Price |
$53.30
|
| Rate for Payer: Cash Price |
$53.30
|
| Rate for Payer: Cash Price |
$56.55
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$75.44
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$80.04
|
| Rate for Payer: Devoted Health Medicare |
$36.54
|
| Rate for Payer: Devoted Health Medicare |
$34.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$34.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$77.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$82.65
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: Health Management Network Commercial |
$73.95
|
| Rate for Payer: Humana Medicare |
$36.54
|
| Rate for Payer: Humana Medicare |
$34.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.37
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$34.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.54
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
| Rate for Payer: MDX Hawaii PPO |
$84.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$36.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$34.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$34.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.54
|
| Rate for Payer: University Health Alliance Commercial |
$155.36
|
| Rate for Payer: University Health Alliance Commercial |
$155.36
|
|
|
Ultrasound study follow-up (specify)
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS 76970
|
| Hospital Charge Code |
424769709
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$73.95 |
| Max. Negotiated Rate |
$84.39 |
| Rate for Payer: Cash Price |
$56.55
|
| Rate for Payer: Cash Price |
$53.30
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: Health Management Network Commercial |
$73.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.30
|
| Rate for Payer: MDX Hawaii PPO |
$84.39
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
|
|
Ultrasound, transvaginal
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
HCPCS 76830
|
| Hospital Charge Code |
424768309
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$50.35 |
| Max. Negotiated Rate |
$230.73 |
| Rate for Payer: AlohaCare Medicaid |
$70.50
|
| Rate for Payer: AlohaCare Medicaid |
$76.00
|
| Rate for Payer: AlohaCare Medicare |
$63.84
|
| Rate for Payer: AlohaCare Medicare |
$59.22
|
| Rate for Payer: Cash Price |
$91.65
|
| Rate for Payer: Cash Price |
$91.65
|
| Rate for Payer: Cash Price |
$98.80
|
| Rate for Payer: Cash Price |
$98.80
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$139.84
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$129.72
|
| Rate for Payer: Devoted Health Medicare |
$59.22
|
| Rate for Payer: Devoted Health Medicare |
$63.84
|
| 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 Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$59.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.84
|
| 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 |
$129.20
|
| Rate for Payer: Health Management Network Commercial |
$119.85
|
| Rate for Payer: Humana Medicare |
$59.22
|
| Rate for Payer: Humana Medicare |
$63.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$136.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$77.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$59.22
|
| Rate for Payer: MDX Hawaii PPO |
$136.77
|
| Rate for Payer: MDX Hawaii PPO |
$147.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$59.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$59.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$59.22
|
| Rate for Payer: University Health Alliance Commercial |
$230.73
|
| Rate for Payer: University Health Alliance Commercial |
$230.73
|
|
|
Ultrasound, transvaginal
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
HCPCS 76830
|
| Hospital Charge Code |
424768309
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$129.20 |
| Max. Negotiated Rate |
$147.44 |
| Rate for Payer: Cash Price |
$98.80
|
| Rate for Payer: Cash Price |
$91.65
|
| Rate for Payer: Health Management Network Commercial |
$119.85
|
| Rate for Payer: Health Management Network Commercial |
$129.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$136.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.90
|
| Rate for Payer: MDX Hawaii PPO |
$136.77
|
| Rate for Payer: MDX Hawaii PPO |
$147.44
|
|
|
umeclidinium 62.5 mcg inhaler [KMC]
|
Facility
|
OP
|
$1,555.48
|
|
|
Service Code
|
NDC 00173087310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$653.30 |
| Max. Negotiated Rate |
$1,508.82 |
| Rate for Payer: AlohaCare Medicaid |
$777.74
|
| Rate for Payer: AlohaCare Medicare |
$653.30
|
| Rate for Payer: Cash Price |
$1,011.06
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,431.04
|
| Rate for Payer: Devoted Health Medicare |
$653.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$653.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,477.71
|
| Rate for Payer: Health Management Network Commercial |
$1,322.16
|
| Rate for Payer: Humana Medicare |
$653.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,399.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$793.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$653.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,508.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$653.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$653.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$933.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$653.30
|
| Rate for Payer: University Health Alliance Commercial |
$1,133.79
|
|
|
umeclidinium 62.5 mcg inhaler [KMC]
|
Facility
|
IP
|
$1,555.48
|
|
|
Service Code
|
NDC 00173087310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,322.16 |
| Max. Negotiated Rate |
$1,508.82 |
| Rate for Payer: Cash Price |
$1,011.06
|
| Rate for Payer: Health Management Network Commercial |
$1,322.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,399.93
|
| Rate for Payer: MDX Hawaii PPO |
$1,508.82
|
|
|
umeclidinium-vilanterol 62.5-25 mcg inhaler [KMC]
|
Facility
|
IP
|
$57.84
|
|
|
Service Code
|
NDC 00173086910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.16 |
| Max. Negotiated Rate |
$56.10 |
| Rate for Payer: Cash Price |
$37.60
|
| Rate for Payer: Health Management Network Commercial |
$49.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.06
|
| Rate for Payer: MDX Hawaii PPO |
$56.10
|
|
|
umeclidinium-vilanterol 62.5-25 mcg inhaler [KMC]
|
Facility
|
OP
|
$57.84
|
|
|
Service Code
|
NDC 00173086910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.29 |
| Max. Negotiated Rate |
$56.10 |
| Rate for Payer: AlohaCare Medicaid |
$28.92
|
| Rate for Payer: AlohaCare Medicare |
$24.29
|
| Rate for Payer: Cash Price |
$37.60
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$53.21
|
| Rate for Payer: Devoted Health Medicare |
$24.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$54.95
|
| Rate for Payer: Health Management Network Commercial |
$49.16
|
| Rate for Payer: Humana Medicare |
$24.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.29
|
| Rate for Payer: MDX Hawaii PPO |
$56.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.29
|
| Rate for Payer: University Health Alliance Commercial |
$42.16
|
|
|
UNCOMPLICATED PEPTIC ULCER WITH MCC
|
Facility
|
IP
|
$19,625.26
|
|
|
Service Code
|
MSDRG 383
|
| Min. Negotiated Rate |
$19,625.26 |
| Max. Negotiated Rate |
$19,625.26 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,625.26
|
|
|
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC
|
Facility
|
IP
|
$19,625.26
|
|
|
Service Code
|
MSDRG 384
|
| Min. Negotiated Rate |
$19,625.26 |
| Max. Negotiated Rate |
$19,625.26 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,625.26
|
|
|
UNIVERSAL CRICOTHYROTOMY CATH SET
|
Facility
|
IP
|
$553.00
|
|
| Hospital Charge Code |
8376
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$470.05 |
| Max. Negotiated Rate |
$536.41 |
| Rate for Payer: Cash Price |
$359.45
|
| Rate for Payer: Health Management Network Commercial |
$470.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$497.70
|
| Rate for Payer: MDX Hawaii PPO |
$536.41
|
|
|
UNIVERSAL CRICOTHYROTOMY CATH SET
|
Facility
|
OP
|
$553.00
|
|
| Hospital Charge Code |
8376
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$232.26 |
| Max. Negotiated Rate |
$536.41 |
| Rate for Payer: AlohaCare Medicaid |
$276.50
|
| Rate for Payer: AlohaCare Medicare |
$232.26
|
| Rate for Payer: Cash Price |
$359.45
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$508.76
|
| Rate for Payer: Devoted Health Medicare |
$232.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$232.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$525.35
|
| Rate for Payer: Health Management Network Commercial |
$470.05
|
| Rate for Payer: Humana Medicare |
$232.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$497.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$282.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$232.26
|
| Rate for Payer: MDX Hawaii PPO |
$536.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$232.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$232.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$232.26
|
| Rate for Payer: University Health Alliance Commercial |
$403.08
|
|
|
Unlisted computed tomography procedure (eg, diagnostic, interventional)
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS 76497
|
| Hospital Charge Code |
424764979
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cash Price |
$74.75
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Health Management Network Commercial |
$97.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.50
|
| Rate for Payer: MDX Hawaii PPO |
$116.40
|
| Rate for Payer: MDX Hawaii PPO |
$111.55
|
|
|
Unlisted computed tomography procedure (eg, diagnostic, interventional)
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS 76497
|
| Hospital Charge Code |
424764979
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$128.51 |
| Rate for Payer: AlohaCare Medicaid |
$57.50
|
| Rate for Payer: AlohaCare Medicaid |
$60.00
|
| Rate for Payer: AlohaCare Medicare |
$50.40
|
| Rate for Payer: AlohaCare Medicare |
$48.30
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cash Price |
$74.75
|
| Rate for Payer: Cash Price |
$74.75
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$110.40
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$105.80
|
| Rate for Payer: Devoted Health Medicare |
$48.30
|
| Rate for Payer: Devoted Health Medicare |
$50.40
|
| 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 |
$50.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.30
|
| 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 |
$97.75
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Humana Medicare |
$50.40
|
| Rate for Payer: Humana Medicare |
$48.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$61.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$50.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.30
|
| Rate for Payer: MDX Hawaii PPO |
$116.40
|
| Rate for Payer: MDX Hawaii PPO |
$111.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$50.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$50.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$66.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$66.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$50.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.30
|
| Rate for Payer: University Health Alliance Commercial |
$83.82
|
| Rate for Payer: University Health Alliance Commercial |
$87.47
|
|
