|
Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing
|
Facility
|
IP
|
$375.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
424704960
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$318.75 |
| Max. Negotiated Rate |
$363.75 |
| Rate for Payer: Cash Price |
$243.75
|
| Rate for Payer: Health Management Network Commercial |
$318.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$337.50
|
| Rate for Payer: MDX Hawaii PPO |
$363.75
|
|
|
Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing
|
Facility
|
OP
|
$375.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
424704960
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$157.50 |
| Max. Negotiated Rate |
$842.03 |
| Rate for Payer: AlohaCare Medicaid |
$187.50
|
| Rate for Payer: AlohaCare Medicare |
$157.50
|
| Rate for Payer: Cash Price |
$243.75
|
| Rate for Payer: Cash Price |
$243.75
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$345.00
|
| Rate for Payer: Devoted Health Medicare |
$157.50
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$279.09
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$157.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$318.75
|
| Rate for Payer: Humana Medicare |
$157.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$337.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$191.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$157.50
|
| Rate for Payer: MDX Hawaii PPO |
$363.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$157.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$157.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$279.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$157.50
|
| Rate for Payer: University Health Alliance Commercial |
$842.03
|
|
|
Computed tomography, abdomen and pelvis; with contrast material(s)
|
Facility
|
OP
|
$392.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
424741779
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$164.64 |
| Max. Negotiated Rate |
$727.57 |
| Rate for Payer: AlohaCare Medicaid |
$196.00
|
| Rate for Payer: AlohaCare Medicaid |
$184.50
|
| Rate for Payer: AlohaCare Medicare |
$164.64
|
| Rate for Payer: AlohaCare Medicare |
$154.98
|
| Rate for Payer: Cash Price |
$254.80
|
| Rate for Payer: Cash Price |
$239.85
|
| Rate for Payer: Cash Price |
$239.85
|
| Rate for Payer: Cash Price |
$254.80
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$360.64
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$339.48
|
| Rate for Payer: Devoted Health Medicare |
$154.98
|
| Rate for Payer: Devoted Health Medicare |
$164.64
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$180.62
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$180.62
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$515.17
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$515.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$154.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$164.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.14
|
| Rate for Payer: Health Management Network Commercial |
$313.65
|
| Rate for Payer: Health Management Network Commercial |
$333.20
|
| Rate for Payer: Humana Medicare |
$164.64
|
| Rate for Payer: Humana Medicare |
$154.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$332.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$352.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$199.92
|
| Rate for Payer: Kaiser Permanente Medicaid |
$188.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$164.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$154.98
|
| Rate for Payer: MDX Hawaii PPO |
$380.24
|
| Rate for Payer: MDX Hawaii PPO |
$357.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$164.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$154.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$154.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$164.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$180.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$180.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$154.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$164.64
|
| Rate for Payer: University Health Alliance Commercial |
$727.57
|
| Rate for Payer: University Health Alliance Commercial |
$727.57
|
|
|
Computed tomography, abdomen and pelvis; with contrast material(s)
|
Facility
|
IP
|
$369.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
424741779
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$313.65 |
| Max. Negotiated Rate |
$357.93 |
| Rate for Payer: Cash Price |
$239.85
|
| Rate for Payer: Cash Price |
$254.80
|
| Rate for Payer: Health Management Network Commercial |
$333.20
|
| Rate for Payer: Health Management Network Commercial |
$313.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$332.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$352.80
|
| Rate for Payer: MDX Hawaii PPO |
$357.93
|
| Rate for Payer: MDX Hawaii PPO |
$380.24
|
|
|
Computed tomography, abdomen and pelvis; without contrast material
|
Facility
|
IP
|
$373.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
424741769
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$317.05 |
| Max. Negotiated Rate |
$361.81 |
| Rate for Payer: Cash Price |
$242.45
|
| Rate for Payer: Cash Price |
$228.80
|
| Rate for Payer: Health Management Network Commercial |
$299.20
|
| Rate for Payer: Health Management Network Commercial |
$317.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$335.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$316.80
|
| Rate for Payer: MDX Hawaii PPO |
$341.44
|
| Rate for Payer: MDX Hawaii PPO |
$361.81
|
|
|
Computed tomography, abdomen and pelvis; without contrast material
|
Facility
|
OP
|
$352.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
424741769
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$94.66 |
| Max. Negotiated Rate |
$454.47 |
| Rate for Payer: AlohaCare Medicaid |
$176.00
|
| Rate for Payer: AlohaCare Medicaid |
$186.50
|
| Rate for Payer: AlohaCare Medicare |
$156.66
|
| Rate for Payer: AlohaCare Medicare |
$147.84
|
| Rate for Payer: Cash Price |
$228.80
|
| Rate for Payer: Cash Price |
$228.80
|
| Rate for Payer: Cash Price |
$242.45
|
| Rate for Payer: Cash Price |
$242.45
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$343.16
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$323.84
|
| Rate for Payer: Devoted Health Medicare |
$147.84
|
| Rate for Payer: Devoted Health Medicare |
$156.66
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$94.66
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$94.66
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$352.34
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$352.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$147.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$156.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$281.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$281.87
|
| Rate for Payer: Health Management Network Commercial |
$317.05
|
| Rate for Payer: Health Management Network Commercial |
$299.20
|
| Rate for Payer: Humana Medicare |
$147.84
|
| Rate for Payer: Humana Medicare |
$156.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$316.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$335.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$179.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$190.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$156.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$147.84
|
| Rate for Payer: MDX Hawaii PPO |
$341.44
|
| Rate for Payer: MDX Hawaii PPO |
$361.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$147.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$156.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$147.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$156.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$94.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$94.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$156.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$147.84
|
| Rate for Payer: University Health Alliance Commercial |
$454.47
|
| Rate for Payer: University Health Alliance Commercial |
$454.47
|
|
|
Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions
|
Facility
|
OP
|
$431.00
|
|
|
Service Code
|
HCPCS 74178
|
| Hospital Charge Code |
424741789
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$181.02 |
| Max. Negotiated Rate |
$924.87 |
| Rate for Payer: AlohaCare Medicaid |
$215.50
|
| Rate for Payer: AlohaCare Medicaid |
$203.00
|
| Rate for Payer: AlohaCare Medicare |
$181.02
|
| Rate for Payer: AlohaCare Medicare |
$170.52
|
| Rate for Payer: Cash Price |
$280.15
|
| Rate for Payer: Cash Price |
$263.90
|
| Rate for Payer: Cash Price |
$263.90
|
| Rate for Payer: Cash Price |
$280.15
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$396.52
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$373.52
|
| Rate for Payer: Devoted Health Medicare |
$170.52
|
| Rate for Payer: Devoted Health Medicare |
$181.02
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$238.75
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$238.75
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$515.17
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$515.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$170.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.14
|
| Rate for Payer: Health Management Network Commercial |
$345.10
|
| Rate for Payer: Health Management Network Commercial |
$366.35
|
| Rate for Payer: Humana Medicare |
$181.02
|
| Rate for Payer: Humana Medicare |
$170.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$365.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$387.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$219.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$207.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$170.52
|
| Rate for Payer: MDX Hawaii PPO |
$418.07
|
| Rate for Payer: MDX Hawaii PPO |
$393.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$181.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$170.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$170.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$181.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$238.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$238.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$170.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.02
|
| Rate for Payer: University Health Alliance Commercial |
$924.87
|
| Rate for Payer: University Health Alliance Commercial |
$924.87
|
|
|
Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions
|
Facility
|
IP
|
$406.00
|
|
|
Service Code
|
HCPCS 74178
|
| Hospital Charge Code |
424741789
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$345.10 |
| Max. Negotiated Rate |
$393.82 |
| Rate for Payer: Cash Price |
$263.90
|
| Rate for Payer: Cash Price |
$280.15
|
| Rate for Payer: Health Management Network Commercial |
$366.35
|
| Rate for Payer: Health Management Network Commercial |
$345.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$365.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$387.90
|
| Rate for Payer: MDX Hawaii PPO |
$393.82
|
| Rate for Payer: MDX Hawaii PPO |
$418.07
|
|
|
Computed tomography, abdomen; with contrast material(s)
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
HCPCS 74160
|
| Hospital Charge Code |
424741609
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$220.15 |
| Max. Negotiated Rate |
$251.23 |
| Rate for Payer: Cash Price |
$168.35
|
| Rate for Payer: Cash Price |
$177.45
|
| Rate for Payer: Health Management Network Commercial |
$232.05
|
| Rate for Payer: Health Management Network Commercial |
$220.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$233.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$245.70
|
| Rate for Payer: MDX Hawaii PPO |
$251.23
|
| Rate for Payer: MDX Hawaii PPO |
$264.81
|
|
|
Computed tomography, abdomen; with contrast material(s)
|
Facility
|
OP
|
$273.00
|
|
|
Service Code
|
HCPCS 74160
|
| Hospital Charge Code |
424741609
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$691.79 |
| Rate for Payer: AlohaCare Medicaid |
$136.50
|
| Rate for Payer: AlohaCare Medicaid |
$129.50
|
| Rate for Payer: AlohaCare Medicare |
$114.66
|
| Rate for Payer: AlohaCare Medicare |
$108.78
|
| Rate for Payer: Cash Price |
$177.45
|
| Rate for Payer: Cash Price |
$168.35
|
| Rate for Payer: Cash Price |
$168.35
|
| Rate for Payer: Cash Price |
$177.45
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$251.16
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$238.28
|
| Rate for Payer: Devoted Health Medicare |
$108.78
|
| Rate for Payer: Devoted Health Medicare |
$114.66
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$225.48
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$225.48
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$108.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$114.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$220.15
|
| Rate for Payer: Health Management Network Commercial |
$232.05
|
| Rate for Payer: Humana Medicare |
$114.66
|
| Rate for Payer: Humana Medicare |
$108.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$233.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$245.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$139.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$132.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$114.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$108.78
|
| Rate for Payer: MDX Hawaii PPO |
$264.81
|
| Rate for Payer: MDX Hawaii PPO |
$251.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$114.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$108.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$108.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$114.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$225.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$225.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$108.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$114.66
|
| Rate for Payer: University Health Alliance Commercial |
$691.79
|
| Rate for Payer: University Health Alliance Commercial |
$691.79
|
|
|
Computed tomography, abdomen; without contrast material
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
HCPCS 74150
|
| Hospital Charge Code |
424741509
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$505.20 |
| Rate for Payer: AlohaCare Medicaid |
$120.00
|
| Rate for Payer: AlohaCare Medicaid |
$127.50
|
| Rate for Payer: AlohaCare Medicare |
$107.10
|
| Rate for Payer: AlohaCare Medicare |
$100.80
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cash Price |
$165.75
|
| Rate for Payer: Cash Price |
$165.75
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$234.60
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$220.80
|
| Rate for Payer: Devoted Health Medicare |
$100.80
|
| Rate for Payer: Devoted Health Medicare |
$107.10
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$186.48
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$186.48
|
| 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 |
$100.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$107.10
|
| 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 |
$216.75
|
| Rate for Payer: Health Management Network Commercial |
$204.00
|
| Rate for Payer: Humana Medicare |
$100.80
|
| Rate for Payer: Humana Medicare |
$107.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$216.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$229.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$122.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$130.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$107.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$100.80
|
| Rate for Payer: MDX Hawaii PPO |
$232.80
|
| Rate for Payer: MDX Hawaii PPO |
$247.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$100.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$107.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$100.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$107.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$186.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$186.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$107.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$100.80
|
| Rate for Payer: University Health Alliance Commercial |
$505.20
|
| Rate for Payer: University Health Alliance Commercial |
$505.20
|
|
|
Computed tomography, abdomen; without contrast material
|
Facility
|
IP
|
$255.00
|
|
|
Service Code
|
HCPCS 74150
|
| Hospital Charge Code |
424741509
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$216.75 |
| Max. Negotiated Rate |
$247.35 |
| Rate for Payer: Cash Price |
$165.75
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Health Management Network Commercial |
$204.00
|
| Rate for Payer: Health Management Network Commercial |
$216.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$229.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$216.00
|
| Rate for Payer: MDX Hawaii PPO |
$232.80
|
| Rate for Payer: MDX Hawaii PPO |
$247.35
|
|
|
Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections
|
Facility
|
IP
|
$283.00
|
|
|
Service Code
|
HCPCS 74170
|
| Hospital Charge Code |
424741709
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$240.55 |
| Max. Negotiated Rate |
$274.51 |
| Rate for Payer: Cash Price |
$183.95
|
| Rate for Payer: Cash Price |
$195.65
|
| Rate for Payer: Health Management Network Commercial |
$255.85
|
| Rate for Payer: Health Management Network Commercial |
$240.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$254.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$270.90
|
| Rate for Payer: MDX Hawaii PPO |
$274.51
|
| Rate for Payer: MDX Hawaii PPO |
$291.97
|
|
|
Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
HCPCS 74170
|
| Hospital Charge Code |
424741709
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$126.42 |
| Max. Negotiated Rate |
$803.12 |
| Rate for Payer: AlohaCare Medicaid |
$150.50
|
| Rate for Payer: AlohaCare Medicaid |
$141.50
|
| Rate for Payer: AlohaCare Medicare |
$126.42
|
| Rate for Payer: AlohaCare Medicare |
$118.86
|
| Rate for Payer: Cash Price |
$195.65
|
| Rate for Payer: Cash Price |
$183.95
|
| Rate for Payer: Cash Price |
$183.95
|
| Rate for Payer: Cash Price |
$195.65
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$276.92
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$260.36
|
| Rate for Payer: Devoted Health Medicare |
$118.86
|
| Rate for Payer: Devoted Health Medicare |
$126.42
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$279.37
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$279.37
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$118.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$126.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$240.55
|
| Rate for Payer: Health Management Network Commercial |
$255.85
|
| Rate for Payer: Humana Medicare |
$126.42
|
| Rate for Payer: Humana Medicare |
$118.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$254.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$270.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$153.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$144.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$126.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$118.86
|
| Rate for Payer: MDX Hawaii PPO |
$291.97
|
| Rate for Payer: MDX Hawaii PPO |
$274.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$126.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$118.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$118.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$126.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$279.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$279.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$118.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$126.42
|
| Rate for Payer: University Health Alliance Commercial |
$803.12
|
| Rate for Payer: University Health Alliance Commercial |
$803.12
|
|
|
Computed tomography, limited or localized follow-up study
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
HCPCS 76380
|
| Hospital Charge Code |
424763809
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$169.15 |
| Max. Negotiated Rate |
$193.03 |
| Rate for Payer: Cash Price |
$129.35
|
| Rate for Payer: Cash Price |
$136.50
|
| Rate for Payer: Health Management Network Commercial |
$178.50
|
| Rate for Payer: Health Management Network Commercial |
$169.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$179.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$189.00
|
| Rate for Payer: MDX Hawaii PPO |
$193.03
|
| Rate for Payer: MDX Hawaii PPO |
$203.70
|
|
|
Computed tomography, limited or localized follow-up study
|
Facility
|
OP
|
$210.00
|
|
|
Service Code
|
HCPCS 76380
|
| Hospital Charge Code |
424763809
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$88.20 |
| Max. Negotiated Rate |
$297.96 |
| Rate for Payer: AlohaCare Medicaid |
$105.00
|
| Rate for Payer: AlohaCare Medicaid |
$99.50
|
| Rate for Payer: AlohaCare Medicare |
$88.20
|
| Rate for Payer: AlohaCare Medicare |
$83.58
|
| Rate for Payer: Cash Price |
$136.50
|
| Rate for Payer: Cash Price |
$129.35
|
| Rate for Payer: Cash Price |
$129.35
|
| Rate for Payer: Cash Price |
$136.50
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$193.20
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$183.08
|
| Rate for Payer: Devoted Health Medicare |
$83.58
|
| Rate for Payer: Devoted Health Medicare |
$88.20
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$115.11
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$115.11
|
| 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 |
$83.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$88.20
|
| 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 |
$169.15
|
| Rate for Payer: Health Management Network Commercial |
$178.50
|
| Rate for Payer: Humana Medicare |
$88.20
|
| Rate for Payer: Humana Medicare |
$83.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$179.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$189.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$107.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$101.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$88.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$83.58
|
| Rate for Payer: MDX Hawaii PPO |
$203.70
|
| Rate for Payer: MDX Hawaii PPO |
$193.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$88.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$83.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$83.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$88.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$115.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$115.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$83.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$88.20
|
| Rate for Payer: University Health Alliance Commercial |
$297.96
|
| Rate for Payer: University Health Alliance Commercial |
$297.96
|
|
|
Computed tomography, lower extremity; with contrast material(s)
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
424737019
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$199.75 |
| Max. Negotiated Rate |
$227.95 |
| Rate for Payer: Cash Price |
$152.75
|
| Rate for Payer: Cash Price |
$161.85
|
| Rate for Payer: Health Management Network Commercial |
$211.65
|
| Rate for Payer: Health Management Network Commercial |
$199.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$211.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$224.10
|
| Rate for Payer: MDX Hawaii PPO |
$227.95
|
| Rate for Payer: MDX Hawaii PPO |
$241.53
|
|
|
Computed tomography, lower extremity; with contrast material(s)
|
Facility
|
OP
|
$249.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
424737019
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$104.58 |
| Max. Negotiated Rate |
$662.37 |
| Rate for Payer: AlohaCare Medicaid |
$124.50
|
| Rate for Payer: AlohaCare Medicaid |
$117.50
|
| Rate for Payer: AlohaCare Medicare |
$104.58
|
| Rate for Payer: AlohaCare Medicare |
$98.70
|
| Rate for Payer: Cash Price |
$161.85
|
| Rate for Payer: Cash Price |
$152.75
|
| Rate for Payer: Cash Price |
$152.75
|
| Rate for Payer: Cash Price |
$161.85
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$229.08
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$216.20
|
| Rate for Payer: Devoted Health Medicare |
$98.70
|
| Rate for Payer: Devoted Health Medicare |
$104.58
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$194.84
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$194.84
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$98.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$104.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$199.75
|
| Rate for Payer: Health Management Network Commercial |
$211.65
|
| Rate for Payer: Humana Medicare |
$104.58
|
| Rate for Payer: Humana Medicare |
$98.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$211.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$224.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$126.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$119.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$104.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$98.70
|
| Rate for Payer: MDX Hawaii PPO |
$241.53
|
| Rate for Payer: MDX Hawaii PPO |
$227.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$104.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$98.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$98.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$104.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$194.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$194.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$98.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$104.58
|
| Rate for Payer: University Health Alliance Commercial |
$662.37
|
| Rate for Payer: University Health Alliance Commercial |
$662.37
|
|
|
Computed tomography, lower extremity; without contrast material
|
Facility
|
OP
|
$215.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
424737009
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$90.30 |
| Max. Negotiated Rate |
$497.32 |
| Rate for Payer: AlohaCare Medicaid |
$107.50
|
| Rate for Payer: AlohaCare Medicaid |
$101.50
|
| Rate for Payer: AlohaCare Medicare |
$90.30
|
| Rate for Payer: AlohaCare Medicare |
$85.26
|
| Rate for Payer: Cash Price |
$139.75
|
| Rate for Payer: Cash Price |
$131.95
|
| Rate for Payer: Cash Price |
$131.95
|
| Rate for Payer: Cash Price |
$139.75
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$197.80
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$186.76
|
| Rate for Payer: Devoted Health Medicare |
$85.26
|
| Rate for Payer: Devoted Health Medicare |
$90.30
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$163.33
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$163.33
|
| 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 |
$85.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$90.30
|
| 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 |
$172.55
|
| Rate for Payer: Health Management Network Commercial |
$182.75
|
| Rate for Payer: Humana Medicare |
$90.30
|
| Rate for Payer: Humana Medicare |
$85.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$182.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$193.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$109.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$103.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$90.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$85.26
|
| Rate for Payer: MDX Hawaii PPO |
$208.55
|
| Rate for Payer: MDX Hawaii PPO |
$196.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$90.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$85.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$85.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$90.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$163.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$163.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$85.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$90.30
|
| Rate for Payer: University Health Alliance Commercial |
$497.32
|
| Rate for Payer: University Health Alliance Commercial |
$497.32
|
|
|
Computed tomography, lower extremity; without contrast material
|
Facility
|
IP
|
$203.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
424737009
|
|
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 |
$139.75
|
| Rate for Payer: Health Management Network Commercial |
$182.75
|
| Rate for Payer: Health Management Network Commercial |
$172.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$182.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$193.50
|
| Rate for Payer: MDX Hawaii PPO |
$196.91
|
| Rate for Payer: MDX Hawaii PPO |
$208.55
|
|
|
Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections
|
Facility
|
OP
|
$260.00
|
|
|
Service Code
|
HCPCS 73702
|
| Hospital Charge Code |
424737029
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$109.20 |
| Max. Negotiated Rate |
$786.23 |
| Rate for Payer: AlohaCare Medicaid |
$130.00
|
| Rate for Payer: AlohaCare Medicaid |
$122.00
|
| Rate for Payer: AlohaCare Medicare |
$109.20
|
| Rate for Payer: AlohaCare Medicare |
$102.48
|
| Rate for Payer: Cash Price |
$169.00
|
| Rate for Payer: Cash Price |
$158.60
|
| Rate for Payer: Cash Price |
$158.60
|
| Rate for Payer: Cash Price |
$169.00
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$239.20
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$224.48
|
| Rate for Payer: Devoted Health Medicare |
$102.48
|
| Rate for Payer: Devoted Health Medicare |
$109.20
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$244.38
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$244.38
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$102.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$109.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$207.40
|
| Rate for Payer: Health Management Network Commercial |
$221.00
|
| Rate for Payer: Humana Medicare |
$109.20
|
| Rate for Payer: Humana Medicare |
$102.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$219.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$234.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$132.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$124.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$109.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$102.48
|
| Rate for Payer: MDX Hawaii PPO |
$252.20
|
| Rate for Payer: MDX Hawaii PPO |
$236.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$109.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$102.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$102.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$109.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$244.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$244.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$102.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$109.20
|
| Rate for Payer: University Health Alliance Commercial |
$786.23
|
| Rate for Payer: University Health Alliance Commercial |
$786.23
|
|
|
Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
HCPCS 73702
|
| Hospital Charge Code |
424737029
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$207.40 |
| Max. Negotiated Rate |
$236.68 |
| Rate for Payer: Cash Price |
$158.60
|
| Rate for Payer: Cash Price |
$169.00
|
| Rate for Payer: Health Management Network Commercial |
$221.00
|
| Rate for Payer: Health Management Network Commercial |
$207.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$219.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$234.00
|
| Rate for Payer: MDX Hawaii PPO |
$236.68
|
| Rate for Payer: MDX Hawaii PPO |
$252.20
|
|
|
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES
|
Facility
|
IP
|
$127,540.46
|
|
|
Service Code
|
MSDRG 212
|
| Min. Negotiated Rate |
$127,540.46 |
| Max. Negotiated Rate |
$127,540.46 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$127,540.46
|
|
|
CONCUSSION WITH CC
|
Facility
|
IP
|
$22,493.20
|
|
|
Service Code
|
MSDRG 089
|
| Min. Negotiated Rate |
$22,493.20 |
| Max. Negotiated Rate |
$22,493.20 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$22,493.20
|
|
|
CONCUSSION WITH MCC
|
Facility
|
IP
|
$22,493.20
|
|
|
Service Code
|
MSDRG 088
|
| Min. Negotiated Rate |
$22,493.20 |
| Max. Negotiated Rate |
$22,493.20 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$22,493.20
|
|
