|
CT MAX FAC WO CON
|
Facility
|
OP
|
$1,218.00
|
|
|
Service Code
|
HCPCS 70486
|
| Hospital Charge Code |
424704860
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$123.50 |
| Max. Negotiated Rate |
$1,181.46 |
| Rate for Payer: AlohaCare Medicaid |
$609.00
|
| Rate for Payer: AlohaCare Medicare |
$511.56
|
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,120.56
|
| Rate for Payer: Devoted Health Medicare |
$511.56
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$155.53
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$511.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$1,035.30
|
| Rate for Payer: Humana Medicare |
$511.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,096.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$621.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$511.56
|
| Rate for Payer: MDX Hawaii PPO |
$1,181.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$511.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$511.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$155.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$511.56
|
| Rate for Payer: University Health Alliance Commercial |
$500.94
|
|
|
CT MAX FAC WO CON
|
Facility
|
IP
|
$1,218.00
|
|
|
Service Code
|
HCPCS 70486
|
| Hospital Charge Code |
424704860
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,035.30 |
| Max. Negotiated Rate |
$1,181.46 |
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Health Management Network Commercial |
$1,035.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,096.20
|
| Rate for Payer: MDX Hawaii PPO |
$1,181.46
|
|
|
CT MAX FAC WO W CON FS
|
Facility
|
OP
|
$1,966.00
|
|
|
Service Code
|
HCPCS 70488
|
| Hospital Charge Code |
424704880
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$207.21 |
| Max. Negotiated Rate |
$1,907.02 |
| Rate for Payer: AlohaCare Medicaid |
$983.00
|
| Rate for Payer: AlohaCare Medicare |
$825.72
|
| Rate for Payer: Cash Price |
$1,277.90
|
| Rate for Payer: Cash Price |
$1,277.90
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,808.72
|
| Rate for Payer: Devoted Health Medicare |
$825.72
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$232.90
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$825.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$1,671.10
|
| Rate for Payer: Humana Medicare |
$825.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,769.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,002.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$825.72
|
| Rate for Payer: MDX Hawaii PPO |
$1,907.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$825.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$825.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$232.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$825.72
|
| Rate for Payer: University Health Alliance Commercial |
$804.23
|
|
|
CT MAX FAC WO W CON FS
|
Facility
|
IP
|
$1,966.00
|
|
|
Service Code
|
HCPCS 70488
|
| Hospital Charge Code |
424704880
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,671.10 |
| Max. Negotiated Rate |
$1,907.02 |
| Rate for Payer: Cash Price |
$1,277.90
|
| Rate for Payer: Health Management Network Commercial |
$1,671.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,769.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,907.02
|
|
|
CT NECK ST WO CON
|
Facility
|
OP
|
$1,218.00
|
|
|
Service Code
|
HCPCS 70490
|
| Hospital Charge Code |
424704900
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$123.50 |
| Max. Negotiated Rate |
$1,181.46 |
| Rate for Payer: AlohaCare Medicaid |
$609.00
|
| Rate for Payer: AlohaCare Medicare |
$511.56
|
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,120.56
|
| Rate for Payer: Devoted Health Medicare |
$511.56
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$155.53
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$511.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$1,035.30
|
| Rate for Payer: Humana Medicare |
$511.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,096.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$621.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$511.56
|
| Rate for Payer: MDX Hawaii PPO |
$1,181.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$511.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$511.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$155.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$511.56
|
| Rate for Payer: University Health Alliance Commercial |
$514.61
|
|
|
CT NECK ST WO CON
|
Facility
|
IP
|
$1,218.00
|
|
|
Service Code
|
HCPCS 70490
|
| Hospital Charge Code |
424704900
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,035.30 |
| Max. Negotiated Rate |
$1,181.46 |
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Health Management Network Commercial |
$1,035.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,096.20
|
| Rate for Payer: MDX Hawaii PPO |
$1,181.46
|
|
|
CT NECK WO W CON FS
|
Facility
|
IP
|
$1,966.00
|
|
| Hospital Charge Code |
424704920
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,671.10 |
| Max. Negotiated Rate |
$1,907.02 |
| Rate for Payer: Cash Price |
$1,277.90
|
| Rate for Payer: Health Management Network Commercial |
$1,671.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,769.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,907.02
|
|
|
CT NECK WO W CON FS
|
Facility
|
OP
|
$1,966.00
|
|
| Hospital Charge Code |
424704920
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$825.72 |
| Max. Negotiated Rate |
$1,907.02 |
| Rate for Payer: AlohaCare Medicaid |
$983.00
|
| Rate for Payer: AlohaCare Medicare |
$825.72
|
| Rate for Payer: Cash Price |
$1,277.90
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,808.72
|
| Rate for Payer: Devoted Health Medicare |
$825.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$825.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,867.70
|
| Rate for Payer: Health Management Network Commercial |
$1,671.10
|
| Rate for Payer: Humana Medicare |
$825.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,769.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,002.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$825.72
|
| Rate for Payer: MDX Hawaii PPO |
$1,907.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$825.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$825.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$825.72
|
| Rate for Payer: University Health Alliance Commercial |
$1,433.02
|
|
|
CT ORB SLLREAR W CON
|
Facility
|
IP
|
$1,652.00
|
|
|
Service Code
|
HCPCS 70481
|
| Hospital Charge Code |
424704810
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,404.20 |
| Max. Negotiated Rate |
$1,602.44 |
| Rate for Payer: Cash Price |
$1,073.80
|
| Rate for Payer: Health Management Network Commercial |
$1,404.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,486.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,602.44
|
|
|
CT ORB SLLREAR W CON
|
Facility
|
OP
|
$1,652.00
|
|
|
Service Code
|
HCPCS 70481
|
| Hospital Charge Code |
424704810
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$186.48 |
| Max. Negotiated Rate |
$1,602.44 |
| Rate for Payer: AlohaCare Medicaid |
$826.00
|
| Rate for Payer: AlohaCare Medicare |
$693.84
|
| Rate for Payer: Cash Price |
$1,073.80
|
| Rate for Payer: Cash Price |
$1,073.80
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,519.84
|
| Rate for Payer: Devoted Health Medicare |
$693.84
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$186.48
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$693.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$1,404.20
|
| Rate for Payer: Humana Medicare |
$693.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,486.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$842.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$693.84
|
| Rate for Payer: MDX Hawaii PPO |
$1,602.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$693.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$693.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$186.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$693.84
|
| Rate for Payer: University Health Alliance Commercial |
$702.69
|
|
|
CT ORB SLLREAR WO CON
|
Facility
|
IP
|
$795.00
|
|
|
Service Code
|
HCPCS 70480
|
| Hospital Charge Code |
424704800
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$675.75 |
| Max. Negotiated Rate |
$771.15 |
| Rate for Payer: Cash Price |
$516.75
|
| Rate for Payer: Health Management Network Commercial |
$675.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$715.50
|
| Rate for Payer: MDX Hawaii PPO |
$771.15
|
|
|
CT ORB SLLREAR WO CON
|
Facility
|
OP
|
$795.00
|
|
|
Service Code
|
HCPCS 70480
|
| Hospital Charge Code |
424704800
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$123.50 |
| Max. Negotiated Rate |
$771.15 |
| Rate for Payer: AlohaCare Medicaid |
$397.50
|
| Rate for Payer: AlohaCare Medicare |
$333.90
|
| Rate for Payer: Cash Price |
$516.75
|
| Rate for Payer: Cash Price |
$516.75
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$731.40
|
| Rate for Payer: Devoted Health Medicare |
$333.90
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$155.53
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$333.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$675.75
|
| Rate for Payer: Humana Medicare |
$333.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$715.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$405.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$333.90
|
| Rate for Payer: MDX Hawaii PPO |
$771.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$333.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$333.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$155.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$333.90
|
| Rate for Payer: University Health Alliance Commercial |
$515.48
|
|
|
CT ORB SLLREAR WO W CON
|
Facility
|
IP
|
$1,966.00
|
|
|
Service Code
|
HCPCS 70482
|
| Hospital Charge Code |
424704820
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,671.10 |
| Max. Negotiated Rate |
$1,907.02 |
| Rate for Payer: Cash Price |
$1,277.90
|
| Rate for Payer: Health Management Network Commercial |
$1,671.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,769.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,907.02
|
|
|
CT ORB SLLREAR WO W CON
|
Facility
|
OP
|
$1,966.00
|
|
|
Service Code
|
HCPCS 70482
|
| Hospital Charge Code |
424704820
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$207.21 |
| Max. Negotiated Rate |
$1,907.02 |
| Rate for Payer: AlohaCare Medicaid |
$983.00
|
| Rate for Payer: AlohaCare Medicare |
$825.72
|
| Rate for Payer: Cash Price |
$1,277.90
|
| Rate for Payer: Cash Price |
$1,277.90
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,808.72
|
| Rate for Payer: Devoted Health Medicare |
$825.72
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$232.90
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$825.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$1,671.10
|
| Rate for Payer: Humana Medicare |
$825.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,769.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,002.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$825.72
|
| Rate for Payer: MDX Hawaii PPO |
$1,907.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$825.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$825.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$232.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$825.72
|
| Rate for Payer: University Health Alliance Commercial |
$807.73
|
|
|
CT PE Chest w/ Contrast
|
Facility
|
IP
|
$1,302.00
|
|
|
Service Code
|
HCPCS 71275
|
| Hospital Charge Code |
424712750
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,106.70 |
| Max. Negotiated Rate |
$1,262.94 |
| Rate for Payer: Cash Price |
$846.30
|
| Rate for Payer: Health Management Network Commercial |
$1,106.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,171.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,262.94
|
|
|
CT PE Chest w/ Contrast
|
Facility
|
OP
|
$1,302.00
|
|
|
Service Code
|
HCPCS 71275
|
| Hospital Charge Code |
424712750
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$207.21 |
| Max. Negotiated Rate |
$1,262.94 |
| Rate for Payer: AlohaCare Medicaid |
$651.00
|
| Rate for Payer: AlohaCare Medicare |
$546.84
|
| Rate for Payer: Cash Price |
$846.30
|
| Rate for Payer: Cash Price |
$846.30
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,197.84
|
| Rate for Payer: Devoted Health Medicare |
$546.84
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$320.86
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$546.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$1,106.70
|
| Rate for Payer: Humana Medicare |
$546.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,171.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$664.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$546.84
|
| Rate for Payer: MDX Hawaii PPO |
$1,262.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$546.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$546.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$320.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$546.84
|
| Rate for Payer: University Health Alliance Commercial |
$860.75
|
|
|
CT PELVIS W CON
|
Facility
|
OP
|
$1,652.00
|
|
|
Service Code
|
HCPCS 72193
|
| Hospital Charge Code |
424721930
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$207.21 |
| Max. Negotiated Rate |
$1,602.44 |
| Rate for Payer: AlohaCare Medicaid |
$826.00
|
| Rate for Payer: AlohaCare Medicare |
$693.84
|
| Rate for Payer: Cash Price |
$1,073.80
|
| Rate for Payer: Cash Price |
$1,073.80
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,519.84
|
| Rate for Payer: Devoted Health Medicare |
$693.84
|
| 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 Medicare |
$693.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$1,404.20
|
| Rate for Payer: Humana Medicare |
$693.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,486.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$842.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$693.84
|
| Rate for Payer: MDX Hawaii PPO |
$1,602.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$693.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$693.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$225.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$693.84
|
| Rate for Payer: University Health Alliance Commercial |
$680.15
|
|
|
CT PELVIS W CON
|
Facility
|
IP
|
$1,652.00
|
|
|
Service Code
|
HCPCS 72193
|
| Hospital Charge Code |
424721930
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,404.20 |
| Max. Negotiated Rate |
$1,602.44 |
| Rate for Payer: Cash Price |
$1,073.80
|
| Rate for Payer: Health Management Network Commercial |
$1,404.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,486.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,602.44
|
|
|
CT PELVIS WO CON
|
Facility
|
OP
|
$795.00
|
|
|
Service Code
|
HCPCS 72192
|
| Hospital Charge Code |
424721920
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$123.50 |
| Max. Negotiated Rate |
$771.15 |
| Rate for Payer: AlohaCare Medicaid |
$397.50
|
| Rate for Payer: AlohaCare Medicare |
$333.90
|
| Rate for Payer: Cash Price |
$516.75
|
| Rate for Payer: Cash Price |
$516.75
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$731.40
|
| Rate for Payer: Devoted Health Medicare |
$333.90
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$194.84
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$333.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$675.75
|
| Rate for Payer: Humana Medicare |
$333.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$715.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$405.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$333.90
|
| Rate for Payer: MDX Hawaii PPO |
$771.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$333.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$333.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$194.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$333.90
|
| Rate for Payer: University Health Alliance Commercial |
$496.15
|
|
|
CT PELVIS WO CON
|
Facility
|
IP
|
$795.00
|
|
|
Service Code
|
HCPCS 72192
|
| Hospital Charge Code |
424721920
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$675.75 |
| Max. Negotiated Rate |
$771.15 |
| Rate for Payer: Cash Price |
$516.75
|
| Rate for Payer: Health Management Network Commercial |
$675.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$715.50
|
| Rate for Payer: MDX Hawaii PPO |
$771.15
|
|
|
CT PELVIS WO W CON FS
|
Facility
|
OP
|
$1,966.00
|
|
|
Service Code
|
HCPCS 72194
|
| Hospital Charge Code |
424721940
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$207.21 |
| Max. Negotiated Rate |
$1,907.02 |
| Rate for Payer: AlohaCare Medicaid |
$983.00
|
| Rate for Payer: AlohaCare Medicare |
$825.72
|
| Rate for Payer: Cash Price |
$1,277.90
|
| Rate for Payer: Cash Price |
$1,277.90
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,808.72
|
| Rate for Payer: Devoted Health Medicare |
$825.72
|
| 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 Medicare |
$825.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$1,671.10
|
| Rate for Payer: Humana Medicare |
$825.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,769.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,002.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$825.72
|
| Rate for Payer: MDX Hawaii PPO |
$1,907.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$825.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$825.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$279.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$825.72
|
| Rate for Payer: University Health Alliance Commercial |
$784.55
|
|
|
CT PELVIS WO W CON FS
|
Facility
|
IP
|
$1,966.00
|
|
|
Service Code
|
HCPCS 72194
|
| Hospital Charge Code |
424721940
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,671.10 |
| Max. Negotiated Rate |
$1,907.02 |
| Rate for Payer: Cash Price |
$1,277.90
|
| Rate for Payer: Health Management Network Commercial |
$1,671.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,769.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,907.02
|
|
|
CT Sinus Complete W/O Contrast
|
Facility
|
OP
|
$1,218.00
|
|
|
Service Code
|
HCPCS 70486
|
| Hospital Charge Code |
424704860
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$123.50 |
| Max. Negotiated Rate |
$1,181.46 |
| Rate for Payer: AlohaCare Medicaid |
$609.00
|
| Rate for Payer: AlohaCare Medicare |
$511.56
|
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,120.56
|
| Rate for Payer: Devoted Health Medicare |
$511.56
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$155.53
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$511.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$1,035.30
|
| Rate for Payer: Humana Medicare |
$511.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,096.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$621.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$511.56
|
| Rate for Payer: MDX Hawaii PPO |
$1,181.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$511.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$511.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$155.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$511.56
|
| Rate for Payer: University Health Alliance Commercial |
$500.94
|
|
|
CT Sinus Complete W/O Contrast
|
Facility
|
IP
|
$1,218.00
|
|
|
Service Code
|
HCPCS 70486
|
| Hospital Charge Code |
424704860
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,035.30 |
| Max. Negotiated Rate |
$1,181.46 |
| Rate for Payer: Cash Price |
$791.70
|
| Rate for Payer: Health Management Network Commercial |
$1,035.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,096.20
|
| Rate for Payer: MDX Hawaii PPO |
$1,181.46
|
|
|
CT SOFT TISSUE NECK W CON
|
Facility
|
OP
|
$1,652.00
|
|
|
Service Code
|
HCPCS 70491
|
| Hospital Charge Code |
424704910
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$186.48 |
| Max. Negotiated Rate |
$1,602.44 |
| Rate for Payer: AlohaCare Medicaid |
$826.00
|
| Rate for Payer: AlohaCare Medicare |
$693.84
|
| Rate for Payer: Cash Price |
$1,073.80
|
| Rate for Payer: Cash Price |
$1,073.80
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,519.84
|
| Rate for Payer: Devoted Health Medicare |
$693.84
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$186.48
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$693.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$1,404.20
|
| Rate for Payer: Humana Medicare |
$693.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,486.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$842.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$693.84
|
| Rate for Payer: MDX Hawaii PPO |
$1,602.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$693.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$693.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$186.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$693.84
|
| Rate for Payer: University Health Alliance Commercial |
$671.68
|
|
