|
CT Orbits Sella w/ + w/o Contrast - Report
|
Professional
|
Both
|
$295.00
|
|
|
Service Code
|
HCPCS 70482 26
|
| Hospital Charge Code |
630099
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$59.10 |
| Max. Negotiated Rate |
$390.00 |
| Rate for Payer: AlohaCare Medicaid |
$144.10
|
| Rate for Payer: AlohaCare Medicare |
$59.10
|
| Rate for Payer: Cash Price |
$191.75
|
| Rate for Payer: Cash Price |
$191.75
|
| Rate for Payer: Devoted Health Medicare |
$65.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$59.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$390.00
|
| Rate for Payer: Health Management Network Commercial |
$250.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$65.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$144.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$59.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$144.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$59.10
|
|
|
CT Paracentesis Abdominal w/ CT Guidance
|
Facility
|
IP
|
$4,535.00
|
|
|
Service Code
|
HCPCS 49083
|
| Hospital Charge Code |
2424827
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$3,854.75 |
| Max. Negotiated Rate |
$4,398.95 |
| Rate for Payer: Cash Price |
$2,947.75
|
| Rate for Payer: Health Management Network Commercial |
$3,854.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,081.50
|
| Rate for Payer: MDX Hawaii PPO |
$4,398.95
|
|
|
CT Paracentesis Abdominal w/ CT Guidance
|
Facility
|
OP
|
$4,535.00
|
|
|
Service Code
|
HCPCS 49083
|
| Hospital Charge Code |
2424827
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$393.00 |
| Max. Negotiated Rate |
$4,398.95 |
| Rate for Payer: AlohaCare Medicaid |
$2,267.50
|
| Rate for Payer: AlohaCare Medicare |
$2,267.50
|
| Rate for Payer: Cash Price |
$2,947.75
|
| Rate for Payer: Cash Price |
$2,947.75
|
| Rate for Payer: Devoted Health Medicare |
$2,494.25
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$393.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,389.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,267.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$407.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,308.25
|
| Rate for Payer: Health Management Network Commercial |
$3,854.75
|
| Rate for Payer: Humana Medicare |
$2,267.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,081.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,312.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,267.50
|
| Rate for Payer: MDX Hawaii PPO |
$4,398.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,267.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,267.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,267.50
|
| Rate for Payer: University Health Alliance Commercial |
$3,305.56
|
|
|
CT Paracentesis Abdominal w/ CT Guidance - Report
|
Professional
|
Both
|
$1,262.00
|
|
|
Service Code
|
HCPCS 49083 26
|
| Hospital Charge Code |
2424829
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$105.50 |
| Max. Negotiated Rate |
$1,072.70 |
| Rate for Payer: AlohaCare Medicaid |
$105.50
|
| Rate for Payer: Cash Price |
$820.30
|
| Rate for Payer: Cash Price |
$820.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$105.50
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$177.92
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$105.50
|
| Rate for Payer: Health Management Network Commercial |
$1,072.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$105.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$105.50
|
| Rate for Payer: University Health Alliance Commercial |
$140.13
|
|
|
CT Pelvis w/ Contrast
|
Facility
|
OP
|
$1,555.00
|
|
|
Service Code
|
HCPCS 72193
|
| Hospital Charge Code |
1168196
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$179.20 |
| Max. Negotiated Rate |
$1,508.35 |
| Rate for Payer: AlohaCare Medicaid |
$777.50
|
| Rate for Payer: AlohaCare Medicare |
$777.50
|
| Rate for Payer: Cash Price |
$1,010.75
|
| Rate for Payer: Cash Price |
$1,010.75
|
| Rate for Payer: Devoted Health Medicare |
$855.25
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$225.48
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$224.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$777.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$245.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$179.20
|
| Rate for Payer: Health Management Network Commercial |
$1,321.75
|
| Rate for Payer: Humana Medicare |
$777.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,399.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$793.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$777.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,508.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$777.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$777.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$225.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$777.50
|
| Rate for Payer: University Health Alliance Commercial |
$680.15
|
|
|
CT Pelvis w/ Contrast
|
Facility
|
IP
|
$1,555.00
|
|
|
Service Code
|
HCPCS 72193
|
| Hospital Charge Code |
1168196
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,321.75 |
| Max. Negotiated Rate |
$1,508.35 |
| Rate for Payer: Cash Price |
$1,010.75
|
| Rate for Payer: Health Management Network Commercial |
$1,321.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,399.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,508.35
|
|
|
CT Pelvis w/ Contrast - Report
|
Professional
|
Both
|
$226.00
|
|
|
Service Code
|
HCPCS 72193 26
|
| Hospital Charge Code |
630113
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$54.29 |
| Max. Negotiated Rate |
$364.03 |
| Rate for Payer: AlohaCare Medicaid |
$157.39
|
| Rate for Payer: AlohaCare Medicare |
$54.29
|
| Rate for Payer: Cash Price |
$146.90
|
| Rate for Payer: Cash Price |
$146.90
|
| Rate for Payer: Devoted Health Medicare |
$59.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$364.03
|
| Rate for Payer: Health Management Network Commercial |
$192.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$59.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$157.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$157.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.29
|
|
|
CT Pelvis w/o Contrast
|
Facility
|
OP
|
$1,120.00
|
|
|
Service Code
|
HCPCS 72192
|
| Hospital Charge Code |
1168198
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$106.81 |
| Max. Negotiated Rate |
$1,086.40 |
| Rate for Payer: AlohaCare Medicaid |
$560.00
|
| Rate for Payer: AlohaCare Medicare |
$560.00
|
| Rate for Payer: Cash Price |
$728.00
|
| Rate for Payer: Cash Price |
$728.00
|
| Rate for Payer: Devoted Health Medicare |
$616.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$194.84
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$133.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$560.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$211.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.81
|
| Rate for Payer: Health Management Network Commercial |
$952.00
|
| Rate for Payer: Humana Medicare |
$560.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,008.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$571.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$560.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,086.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$560.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$560.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$194.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$560.00
|
| Rate for Payer: University Health Alliance Commercial |
$496.15
|
|
|
CT Pelvis w/o Contrast
|
Facility
|
IP
|
$1,120.00
|
|
|
Service Code
|
HCPCS 72192
|
| Hospital Charge Code |
1168198
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$952.00 |
| Max. Negotiated Rate |
$1,086.40 |
| Rate for Payer: Cash Price |
$728.00
|
| Rate for Payer: Health Management Network Commercial |
$952.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,008.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,086.40
|
|
|
CT Pelvis w/o Contrast - Report
|
Professional
|
Both
|
$198.00
|
|
|
Service Code
|
HCPCS 72192 26
|
| Hospital Charge Code |
630115
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$50.62 |
| Max. Negotiated Rate |
$318.97 |
| Rate for Payer: AlohaCare Medicaid |
$89.79
|
| Rate for Payer: AlohaCare Medicare |
$50.62
|
| Rate for Payer: Cash Price |
$128.70
|
| Rate for Payer: Cash Price |
$128.70
|
| Rate for Payer: Devoted Health Medicare |
$55.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$50.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$318.97
|
| Rate for Payer: Health Management Network Commercial |
$168.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$55.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$89.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$50.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$89.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$50.62
|
|
|
CT Pelvis w/ + w/o Contrast
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS 72194
|
| Hospital Charge Code |
1168194
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$179.20 |
| Max. Negotiated Rate |
$1,593.71 |
| Rate for Payer: AlohaCare Medicaid |
$821.50
|
| Rate for Payer: AlohaCare Medicare |
$821.50
|
| Rate for Payer: Cash Price |
$1,067.95
|
| Rate for Payer: Cash Price |
$1,067.95
|
| Rate for Payer: Devoted Health Medicare |
$903.65
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$279.37
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$224.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$821.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$303.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$179.20
|
| Rate for Payer: Health Management Network Commercial |
$1,396.55
|
| Rate for Payer: Humana Medicare |
$821.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,478.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$837.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$821.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,593.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$821.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$821.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$279.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$821.50
|
| Rate for Payer: University Health Alliance Commercial |
$784.55
|
|
|
CT Pelvis w/ + w/o Contrast
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS 72194
|
| Hospital Charge Code |
1168194
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,396.55 |
| Max. Negotiated Rate |
$1,593.71 |
| Rate for Payer: Cash Price |
$1,067.95
|
| Rate for Payer: Health Management Network Commercial |
$1,396.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,478.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,593.71
|
|
|
CT Pelvis w/ + w/o Contrast - Report
|
Professional
|
Both
|
$322.00
|
|
|
Service Code
|
HCPCS 72194 26
|
| Hospital Charge Code |
630109
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$57.05 |
| Max. Negotiated Rate |
$439.32 |
| Rate for Payer: AlohaCare Medicaid |
$173.97
|
| Rate for Payer: AlohaCare Medicare |
$57.05
|
| Rate for Payer: Cash Price |
$209.30
|
| Rate for Payer: Cash Price |
$209.30
|
| Rate for Payer: Devoted Health Medicare |
$62.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$439.32
|
| Rate for Payer: Health Management Network Commercial |
$273.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$62.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$62.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$173.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$173.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.05
|
|
|
CT Sinus
|
Facility
|
IP
|
$4,657.00
|
|
|
Service Code
|
HCPCS 70486
|
| Hospital Charge Code |
9803475
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$3,958.45 |
| Max. Negotiated Rate |
$4,517.29 |
| Rate for Payer: Cash Price |
$3,027.05
|
| Rate for Payer: Health Management Network Commercial |
$3,958.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,191.30
|
| Rate for Payer: MDX Hawaii PPO |
$4,517.29
|
|
|
CT Sinus
|
Facility
|
OP
|
$4,657.00
|
|
|
Service Code
|
HCPCS 70486
|
| Hospital Charge Code |
9803475
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$106.81 |
| Max. Negotiated Rate |
$4,517.29 |
| Rate for Payer: AlohaCare Medicaid |
$2,328.50
|
| Rate for Payer: AlohaCare Medicare |
$2,328.50
|
| Rate for Payer: Cash Price |
$3,027.05
|
| Rate for Payer: Cash Price |
$3,027.05
|
| Rate for Payer: Devoted Health Medicare |
$2,561.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$155.53
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$133.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,328.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$169.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.81
|
| Rate for Payer: Health Management Network Commercial |
$3,958.45
|
| Rate for Payer: Humana Medicare |
$2,328.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,191.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,375.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,328.50
|
| Rate for Payer: MDX Hawaii PPO |
$4,517.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,328.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,328.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$155.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,328.50
|
| Rate for Payer: University Health Alliance Commercial |
$500.94
|
|
|
CT Sinus - Report
|
Professional
|
Both
|
$218.00
|
|
|
Service Code
|
HCPCS 70486 26
|
| Hospital Charge Code |
9803477
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$40.46 |
| Max. Negotiated Rate |
$269.56 |
| Rate for Payer: AlohaCare Medicaid |
$87.30
|
| Rate for Payer: AlohaCare Medicare |
$40.46
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Devoted Health Medicare |
$44.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$269.56
|
| Rate for Payer: Health Management Network Commercial |
$185.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$87.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.46
|
|
|
CT Sinus w/o Contrast
|
Facility
|
OP
|
$5,502.00
|
|
|
Service Code
|
HCPCS 70487
|
| Hospital Charge Code |
8100154
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$179.20 |
| Max. Negotiated Rate |
$5,336.94 |
| Rate for Payer: AlohaCare Medicaid |
$2,751.00
|
| Rate for Payer: AlohaCare Medicare |
$2,751.00
|
| Rate for Payer: Cash Price |
$3,576.30
|
| Rate for Payer: Cash Price |
$3,576.30
|
| Rate for Payer: Devoted Health Medicare |
$3,026.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$186.48
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$224.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,751.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$202.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$179.20
|
| Rate for Payer: Health Management Network Commercial |
$4,676.70
|
| Rate for Payer: Humana Medicare |
$2,751.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,951.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,806.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,751.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,336.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,751.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,751.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$186.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,751.00
|
| Rate for Payer: University Health Alliance Commercial |
$678.04
|
|
|
CT Sinus w/o Contrast
|
Facility
|
OP
|
$4,657.00
|
|
|
Service Code
|
HCPCS 70486
|
| Hospital Charge Code |
1168228
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$106.81 |
| Max. Negotiated Rate |
$4,517.29 |
| Rate for Payer: AlohaCare Medicaid |
$2,328.50
|
| Rate for Payer: AlohaCare Medicare |
$2,328.50
|
| Rate for Payer: Cash Price |
$3,027.05
|
| Rate for Payer: Cash Price |
$3,027.05
|
| Rate for Payer: Devoted Health Medicare |
$2,561.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$155.53
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$133.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,328.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$169.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.81
|
| Rate for Payer: Health Management Network Commercial |
$3,958.45
|
| Rate for Payer: Humana Medicare |
$2,328.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,191.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,375.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,328.50
|
| Rate for Payer: MDX Hawaii PPO |
$4,517.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,328.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,328.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$155.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,328.50
|
| Rate for Payer: University Health Alliance Commercial |
$500.94
|
|
|
CT Sinus w/o Contrast
|
Facility
|
IP
|
$5,502.00
|
|
|
Service Code
|
HCPCS 70487
|
| Hospital Charge Code |
8100154
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$4,676.70 |
| Max. Negotiated Rate |
$5,336.94 |
| Rate for Payer: Cash Price |
$3,576.30
|
| Rate for Payer: Health Management Network Commercial |
$4,676.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,951.80
|
| Rate for Payer: MDX Hawaii PPO |
$5,336.94
|
|
|
CT Sinus w/o Contrast
|
Facility
|
IP
|
$4,657.00
|
|
|
Service Code
|
HCPCS 70486
|
| Hospital Charge Code |
1168228
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$3,958.45 |
| Max. Negotiated Rate |
$4,517.29 |
| Rate for Payer: Cash Price |
$3,027.05
|
| Rate for Payer: Health Management Network Commercial |
$3,958.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,191.30
|
| Rate for Payer: MDX Hawaii PPO |
$4,517.29
|
|
|
CT Sinus w/o Contrast - Report
|
Professional
|
Both
|
$218.00
|
|
|
Service Code
|
HCPCS 70486 26
|
| Hospital Charge Code |
661604
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$40.46 |
| Max. Negotiated Rate |
$269.56 |
| Rate for Payer: AlohaCare Medicaid |
$87.30
|
| Rate for Payer: AlohaCare Medicare |
$40.46
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Devoted Health Medicare |
$44.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$269.56
|
| Rate for Payer: Health Management Network Commercial |
$185.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$87.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.46
|
|
|
CT Sinus w/o Contrast - Report
|
Professional
|
Both
|
$258.00
|
|
|
Service Code
|
HCPCS 70487 26
|
| Hospital Charge Code |
8100155
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$52.91 |
| Max. Negotiated Rate |
$319.59 |
| Rate for Payer: AlohaCare Medicaid |
$103.10
|
| Rate for Payer: AlohaCare Medicare |
$52.91
|
| Rate for Payer: Cash Price |
$167.70
|
| Rate for Payer: Cash Price |
$167.70
|
| Rate for Payer: Devoted Health Medicare |
$58.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$319.59
|
| Rate for Payer: Health Management Network Commercial |
$219.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$103.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$103.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.91
|
|
|
CT Sinus w/ + w/o Contrast
|
Facility
|
OP
|
$5,786.00
|
|
|
Service Code
|
HCPCS 70488
|
| Hospital Charge Code |
8100151
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$179.20 |
| Max. Negotiated Rate |
$5,612.42 |
| Rate for Payer: AlohaCare Medicaid |
$2,893.00
|
| Rate for Payer: AlohaCare Medicare |
$2,893.00
|
| Rate for Payer: Cash Price |
$3,760.90
|
| Rate for Payer: Cash Price |
$3,760.90
|
| Rate for Payer: Devoted Health Medicare |
$3,182.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$232.90
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$224.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,893.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$253.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$179.20
|
| Rate for Payer: Health Management Network Commercial |
$4,918.10
|
| Rate for Payer: Humana Medicare |
$2,893.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,207.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,950.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,893.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,612.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,893.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,893.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$232.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,893.00
|
| Rate for Payer: University Health Alliance Commercial |
$804.23
|
|
|
CT Sinus w/ + w/o Contrast
|
Facility
|
IP
|
$5,786.00
|
|
|
Service Code
|
HCPCS 70488
|
| Hospital Charge Code |
8100151
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$4,918.10 |
| Max. Negotiated Rate |
$5,612.42 |
| Rate for Payer: Cash Price |
$3,760.90
|
| Rate for Payer: Health Management Network Commercial |
$4,918.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,207.40
|
| Rate for Payer: MDX Hawaii PPO |
$5,612.42
|
|
|
CT Sinus w/ + w/o Contrast - Report
|
Professional
|
Both
|
$313.00
|
|
|
Service Code
|
HCPCS 70488 26
|
| Hospital Charge Code |
8100153
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$59.48 |
| Max. Negotiated Rate |
$388.55 |
| Rate for Payer: AlohaCare Medicaid |
$125.28
|
| Rate for Payer: AlohaCare Medicare |
$59.48
|
| Rate for Payer: Cash Price |
$203.45
|
| Rate for Payer: Cash Price |
$203.45
|
| Rate for Payer: Devoted Health Medicare |
$65.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$59.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$388.55
|
| Rate for Payer: Health Management Network Commercial |
$266.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$65.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$125.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$59.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$125.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$59.48
|
|
