|
71270 - CT Chest/Abdomen report
|
Professional
|
Both
|
$335.00
|
|
|
Service Code
|
HCPCS 71270
|
| Hospital Charge Code |
12221171
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$133.95 |
| Max. Negotiated Rate |
$464.02 |
| Rate for Payer: AlohaCare Medicaid |
$133.95
|
| Rate for Payer: AlohaCare Medicare |
$215.28
|
| Rate for Payer: Cash Price |
$217.75
|
| Rate for Payer: Cash Price |
$217.75
|
| Rate for Payer: Devoted Health Medicare |
$236.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$215.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$464.02
|
| Rate for Payer: Health Management Network Commercial |
$284.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$236.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$236.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$236.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$133.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$215.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$133.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$215.28
|
|
|
71271 CT chest Low Dose Screen - PROFEE
|
Professional
|
Both
|
$145.00
|
|
|
Service Code
|
HCPCS 71271 26
|
| Hospital Charge Code |
12054611
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$50.28 |
| Max. Negotiated Rate |
$289.63 |
| Rate for Payer: AlohaCare Medicaid |
$92.92
|
| Rate for Payer: AlohaCare Medicare |
$50.28
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Devoted Health Medicare |
$55.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$50.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$289.63
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$55.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$92.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$50.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$92.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$50.28
|
|
|
7401826- Rad exam, abdomen, 1 vw
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
HCPCS 74018 26
|
| Hospital Charge Code |
8528489
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$8.86 |
| Max. Negotiated Rate |
$34.85 |
| Rate for Payer: AlohaCare Medicaid |
$20.11
|
| Rate for Payer: AlohaCare Medicare |
$8.86
|
| Rate for Payer: Cash Price |
$26.65
|
| Rate for Payer: Cash Price |
$26.65
|
| Rate for Payer: Devoted Health Medicare |
$9.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$32.81
|
| Rate for Payer: Health Management Network Commercial |
$34.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.86
|
|
|
74150 - add on
|
Facility
|
OP
|
$4,459.00
|
|
|
Service Code
|
HCPCS 74150
|
| Hospital Charge Code |
12231025
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$106.81 |
| Max. Negotiated Rate |
$4,325.23 |
| Rate for Payer: AlohaCare Medicaid |
$2,229.50
|
| Rate for Payer: AlohaCare Medicare |
$2,229.50
|
| Rate for Payer: Cash Price |
$2,898.35
|
| Rate for Payer: Cash Price |
$2,898.35
|
| Rate for Payer: Devoted Health Medicare |
$2,452.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$186.48
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$133.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,229.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$202.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.81
|
| Rate for Payer: Health Management Network Commercial |
$3,790.15
|
| Rate for Payer: Humana Medicare |
$2,229.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,013.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,274.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,229.50
|
| Rate for Payer: MDX Hawaii PPO |
$4,325.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,229.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,229.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$186.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,229.50
|
| Rate for Payer: University Health Alliance Commercial |
$505.20
|
|
|
74150 - add on
|
Facility
|
IP
|
$4,459.00
|
|
|
Service Code
|
HCPCS 74150
|
| Hospital Charge Code |
12231025
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$3,790.15 |
| Max. Negotiated Rate |
$4,325.23 |
| Rate for Payer: Cash Price |
$2,898.35
|
| Rate for Payer: Health Management Network Commercial |
$3,790.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,013.10
|
| Rate for Payer: MDX Hawaii PPO |
$4,325.23
|
|
|
74150 - add on report
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
HCPCS 74150
|
| Hospital Charge Code |
12231356
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$92.02 |
| Max. Negotiated Rate |
$313.29 |
| Rate for Payer: AlohaCare Medicaid |
$92.02
|
| Rate for Payer: AlohaCare Medicare |
$148.15
|
| Rate for Payer: Cash Price |
$149.50
|
| Rate for Payer: Cash Price |
$149.50
|
| Rate for Payer: Devoted Health Medicare |
$162.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$148.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$313.29
|
| Rate for Payer: Health Management Network Commercial |
$195.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$162.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$162.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$162.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$92.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$148.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$92.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$148.15
|
|
|
74160 - add on
|
Facility
|
OP
|
$2,064.00
|
|
|
Service Code
|
HCPCS 74160
|
| Hospital Charge Code |
12220861
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$179.20 |
| Max. Negotiated Rate |
$2,002.08 |
| Rate for Payer: AlohaCare Medicaid |
$1,032.00
|
| Rate for Payer: AlohaCare Medicare |
$1,032.00
|
| Rate for Payer: Cash Price |
$1,341.60
|
| Rate for Payer: Cash Price |
$1,341.60
|
| Rate for Payer: Devoted Health Medicare |
$1,135.20
|
| 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 |
$1,032.00
|
| 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 |
$1,754.40
|
| Rate for Payer: Humana Medicare |
$1,032.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,857.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,052.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,032.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,002.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,032.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,032.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$225.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,032.00
|
| Rate for Payer: University Health Alliance Commercial |
$691.79
|
|
|
74160 - add on
|
Facility
|
IP
|
$2,064.00
|
|
|
Service Code
|
HCPCS 74160
|
| Hospital Charge Code |
12220861
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,754.40 |
| Max. Negotiated Rate |
$2,002.08 |
| Rate for Payer: Cash Price |
$1,341.60
|
| Rate for Payer: Health Management Network Commercial |
$1,754.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,857.60
|
| Rate for Payer: MDX Hawaii PPO |
$2,002.08
|
|
|
74160 - add on report
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 74160
|
| Hospital Charge Code |
12221172
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$159.93 |
| Max. Negotiated Rate |
$370.34 |
| Rate for Payer: AlohaCare Medicaid |
$159.93
|
| Rate for Payer: AlohaCare Medicare |
$254.31
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Devoted Health Medicare |
$279.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$254.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$370.34
|
| Rate for Payer: Health Management Network Commercial |
$340.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$279.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$279.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$159.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$254.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$159.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$254.31
|
|
|
74170 - add on report
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 74170
|
| Hospital Charge Code |
12231357
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$179.97 |
| Max. Negotiated Rate |
$449.50 |
| Rate for Payer: AlohaCare Medicaid |
$179.97
|
| Rate for Payer: AlohaCare Medicare |
$286.37
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Devoted Health Medicare |
$315.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$286.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$449.50
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$315.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$315.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$315.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$179.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$286.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$179.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$286.37
|
|
|
74175 - CT Angio Chest/Abdomen
|
Facility
|
IP
|
$6,353.00
|
|
|
Service Code
|
HCPCS 74175
|
| Hospital Charge Code |
12218580
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$5,400.05 |
| Max. Negotiated Rate |
$6,162.41 |
| Rate for Payer: Cash Price |
$4,129.45
|
| Rate for Payer: Health Management Network Commercial |
$5,400.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,717.70
|
| Rate for Payer: MDX Hawaii PPO |
$6,162.41
|
|
|
74175 - CT Angio Chest/Abdomen
|
Facility
|
OP
|
$6,353.00
|
|
|
Service Code
|
HCPCS 74175
|
| Hospital Charge Code |
12218580
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$179.20 |
| Max. Negotiated Rate |
$6,162.41 |
| Rate for Payer: AlohaCare Medicaid |
$3,176.50
|
| Rate for Payer: AlohaCare Medicare |
$3,176.50
|
| Rate for Payer: Cash Price |
$4,129.45
|
| Rate for Payer: Cash Price |
$4,129.45
|
| Rate for Payer: Devoted Health Medicare |
$3,494.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$311.76
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$224.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,176.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$424.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$179.20
|
| Rate for Payer: Health Management Network Commercial |
$5,400.05
|
| Rate for Payer: Humana Medicare |
$3,176.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,717.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,240.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,176.50
|
| Rate for Payer: MDX Hawaii PPO |
$6,162.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,176.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,176.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$311.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,176.50
|
| Rate for Payer: University Health Alliance Commercial |
$858.03
|
|
|
74175 - CT Angio Chest/Abdomen Report
|
Professional
|
Both
|
$523.00
|
|
|
Service Code
|
HCPCS 74175
|
| Hospital Charge Code |
12218581
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$209.00 |
| Max. Negotiated Rate |
$622.29 |
| Rate for Payer: AlohaCare Medicaid |
$209.00
|
| Rate for Payer: AlohaCare Medicare |
$335.26
|
| Rate for Payer: Cash Price |
$339.95
|
| Rate for Payer: Cash Price |
$339.95
|
| Rate for Payer: Devoted Health Medicare |
$368.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$335.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$622.29
|
| Rate for Payer: Health Management Network Commercial |
$444.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$368.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$368.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$368.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$209.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$335.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$209.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$335.26
|
|
|
74176 - add on
|
Facility
|
IP
|
$8,836.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
12231587
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$7,510.60 |
| Max. Negotiated Rate |
$8,570.92 |
| Rate for Payer: Cash Price |
$5,743.40
|
| Rate for Payer: Health Management Network Commercial |
$7,510.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,952.40
|
| Rate for Payer: MDX Hawaii PPO |
$8,570.92
|
|
|
74176 - add on
|
Facility
|
OP
|
$8,836.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
12231587
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$94.66 |
| Max. Negotiated Rate |
$8,570.92 |
| Rate for Payer: AlohaCare Medicaid |
$4,418.00
|
| Rate for Payer: AlohaCare Medicare |
$4,418.00
|
| Rate for Payer: Cash Price |
$5,743.40
|
| Rate for Payer: Cash Price |
$5,743.40
|
| Rate for Payer: Devoted Health Medicare |
$4,859.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$94.66
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$304.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,418.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$413.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$243.77
|
| Rate for Payer: Health Management Network Commercial |
$7,510.60
|
| Rate for Payer: Humana Medicare |
$4,418.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,952.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,506.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,418.00
|
| Rate for Payer: MDX Hawaii PPO |
$8,570.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,418.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,418.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$94.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,418.00
|
| Rate for Payer: University Health Alliance Commercial |
$454.47
|
|
|
74176 - add on report
|
Professional
|
Both
|
$307.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
12221389
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$122.73 |
| Max. Negotiated Rate |
$260.95 |
| Rate for Payer: AlohaCare Medicaid |
$122.73
|
| Rate for Payer: AlohaCare Medicare |
$198.28
|
| Rate for Payer: Cash Price |
$199.55
|
| Rate for Payer: Cash Price |
$199.55
|
| Rate for Payer: Devoted Health Medicare |
$218.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$198.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$245.66
|
| Rate for Payer: Health Management Network Commercial |
$260.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$218.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$218.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$218.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$122.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$198.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$122.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$198.28
|
|
|
74177 - add on
|
Facility
|
OP
|
$10,205.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
12231527
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$180.62 |
| Max. Negotiated Rate |
$9,898.85 |
| Rate for Payer: AlohaCare Medicaid |
$5,102.50
|
| Rate for Payer: AlohaCare Medicare |
$5,102.50
|
| Rate for Payer: Cash Price |
$6,633.25
|
| Rate for Payer: Cash Price |
$6,633.25
|
| Rate for Payer: Devoted Health Medicare |
$5,612.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$180.62
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$445.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,102.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$490.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$356.43
|
| Rate for Payer: Health Management Network Commercial |
$8,674.25
|
| Rate for Payer: Humana Medicare |
$5,102.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,184.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,204.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,102.50
|
| Rate for Payer: MDX Hawaii PPO |
$9,898.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,102.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,102.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$180.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,102.50
|
| Rate for Payer: University Health Alliance Commercial |
$727.57
|
|
|
74177 - add on
|
Facility
|
IP
|
$10,205.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
12231527
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$8,674.25 |
| Max. Negotiated Rate |
$9,898.85 |
| Rate for Payer: Cash Price |
$6,633.25
|
| Rate for Payer: Health Management Network Commercial |
$8,674.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,184.50
|
| Rate for Payer: MDX Hawaii PPO |
$9,898.85
|
|
|
74177 - add on report
|
Professional
|
Both
|
$519.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
12241246
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$207.63 |
| Max. Negotiated Rate |
$441.15 |
| Rate for Payer: AlohaCare Medicaid |
$207.63
|
| Rate for Payer: AlohaCare Medicare |
$330.89
|
| Rate for Payer: Cash Price |
$337.35
|
| Rate for Payer: Cash Price |
$337.35
|
| Rate for Payer: Devoted Health Medicare |
$363.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$330.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$393.28
|
| Rate for Payer: Health Management Network Commercial |
$441.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$363.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$363.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$363.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$207.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$330.89
|
| Rate for Payer: UnitedHealthcare Medicaid |
$207.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$330.89
|
|
|
74177 CT ABD & PELVIS W/CONTRAST ProFee
|
Professional
|
Both
|
$486.00
|
|
|
Service Code
|
HCPCS 74177 26
|
| Hospital Charge Code |
8102791
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$85.17 |
| Max. Negotiated Rate |
$413.10 |
| Rate for Payer: AlohaCare Medicaid |
$207.63
|
| Rate for Payer: AlohaCare Medicare |
$85.17
|
| Rate for Payer: Cash Price |
$315.90
|
| Rate for Payer: Cash Price |
$315.90
|
| Rate for Payer: Devoted Health Medicare |
$93.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$85.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$393.28
|
| Rate for Payer: Health Management Network Commercial |
$413.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$93.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$93.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$93.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$207.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$85.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$207.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$85.17
|
|
|
74177 - CT Angio Chest PE + Abd/Pelvis w/ Cont
|
Facility
|
OP
|
$10,205.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
12205339
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$180.62 |
| Max. Negotiated Rate |
$9,898.85 |
| Rate for Payer: AlohaCare Medicaid |
$5,102.50
|
| Rate for Payer: AlohaCare Medicare |
$5,102.50
|
| Rate for Payer: Cash Price |
$6,633.25
|
| Rate for Payer: Cash Price |
$6,633.25
|
| Rate for Payer: Devoted Health Medicare |
$5,612.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$180.62
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$445.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,102.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$490.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$356.43
|
| Rate for Payer: Health Management Network Commercial |
$8,674.25
|
| Rate for Payer: Humana Medicare |
$5,102.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,184.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,204.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,102.50
|
| Rate for Payer: MDX Hawaii PPO |
$9,898.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,102.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,102.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$180.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,102.50
|
| Rate for Payer: University Health Alliance Commercial |
$727.57
|
|
|
74177 - CT Angio Chest PE + Abd/Pelvis w/ Cont
|
Facility
|
IP
|
$10,205.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
12205339
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$8,674.25 |
| Max. Negotiated Rate |
$9,898.85 |
| Rate for Payer: Cash Price |
$6,633.25
|
| Rate for Payer: Health Management Network Commercial |
$8,674.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,184.50
|
| Rate for Payer: MDX Hawaii PPO |
$9,898.85
|
|
|
74177 - CT Angio Chest PE + Abd/Pelvis w/ Cont Report
|
Professional
|
Both
|
$519.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
12215543
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$207.63 |
| Max. Negotiated Rate |
$441.15 |
| Rate for Payer: AlohaCare Medicaid |
$207.63
|
| Rate for Payer: AlohaCare Medicare |
$330.89
|
| Rate for Payer: Cash Price |
$337.35
|
| Rate for Payer: Cash Price |
$337.35
|
| Rate for Payer: Devoted Health Medicare |
$363.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$330.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$393.28
|
| Rate for Payer: Health Management Network Commercial |
$441.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$363.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$363.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$363.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$207.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$330.89
|
| Rate for Payer: UnitedHealthcare Medicaid |
$207.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$330.89
|
|
|
74178 - add on
|
Facility
|
OP
|
$11,511.00
|
|
|
Service Code
|
HCPCS 74178
|
| Hospital Charge Code |
12231526
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$238.75 |
| Max. Negotiated Rate |
$11,165.67 |
| Rate for Payer: AlohaCare Medicaid |
$5,755.50
|
| Rate for Payer: AlohaCare Medicare |
$5,755.50
|
| Rate for Payer: Cash Price |
$7,482.15
|
| Rate for Payer: Cash Price |
$7,482.15
|
| Rate for Payer: Devoted Health Medicare |
$6,331.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$238.75
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$445.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,755.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$606.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$356.43
|
| Rate for Payer: Health Management Network Commercial |
$9,784.35
|
| Rate for Payer: Humana Medicare |
$5,755.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,359.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,870.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,755.50
|
| Rate for Payer: MDX Hawaii PPO |
$11,165.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,755.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,755.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$238.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,755.50
|
| Rate for Payer: University Health Alliance Commercial |
$924.87
|
|
|
74178 - add on
|
Facility
|
IP
|
$11,511.00
|
|
|
Service Code
|
HCPCS 74178
|
| Hospital Charge Code |
12231526
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$9,784.35 |
| Max. Negotiated Rate |
$11,165.67 |
| Rate for Payer: Cash Price |
$7,482.15
|
| Rate for Payer: Health Management Network Commercial |
$9,784.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,359.90
|
| Rate for Payer: MDX Hawaii PPO |
$11,165.67
|
|
