|
HCHG CTA ABD&PELVIS, W/CONT, INCL NON CONTR IMG IF PERF IMG PROCESS
|
Facility
|
OP
|
$3,826.00
|
|
|
Service Code
|
HCPCS 74174
|
| Hospital Charge Code |
H3520196
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$316.18 |
| Max. Negotiated Rate |
$3,711.22 |
| Rate for Payer: AlohaCare Medicaid |
$412.14
|
| Rate for Payer: AlohaCare Medicare |
$412.14
|
| Rate for Payer: Cash Price |
$2,486.90
|
| Rate for Payer: Cash Price |
$2,486.90
|
| Rate for Payer: Devoted Health Medicare |
$453.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$316.18
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$515.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$412.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$430.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.14
|
| Rate for Payer: Health Management Network Commercial |
$3,252.10
|
| Rate for Payer: Humana Medicare |
$412.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,410.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,951.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$412.14
|
| Rate for Payer: MDX Hawaii PPO |
$3,711.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$453.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$412.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$316.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$412.14
|
| Rate for Payer: University Health Alliance Commercial |
$851.02
|
|
|
HCHG CTA ABD W/WO CONTR
|
Facility
|
OP
|
$2,506.00
|
|
|
Service Code
|
HCPCS 74175
|
| Hospital Charge Code |
H3520176
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$207.21 |
| Max. Negotiated Rate |
$2,430.82 |
| Rate for Payer: AlohaCare Medicaid |
$207.21
|
| Rate for Payer: AlohaCare Medicare |
$207.21
|
| Rate for Payer: Cash Price |
$1,628.90
|
| Rate for Payer: Cash Price |
$1,628.90
|
| Rate for Payer: Devoted Health Medicare |
$227.93
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$311.76
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$207.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$424.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$2,130.10
|
| Rate for Payer: Humana Medicare |
$207.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,578.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,278.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$207.21
|
| Rate for Payer: MDX Hawaii PPO |
$2,430.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$227.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$207.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$311.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$207.21
|
| Rate for Payer: University Health Alliance Commercial |
$858.03
|
|
|
HCHG CTA ABD W/WO CONTR
|
Facility
|
IP
|
$2,506.00
|
|
|
Service Code
|
HCPCS 74175
|
| Hospital Charge Code |
H3520176
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$2,130.10 |
| Max. Negotiated Rate |
$2,430.82 |
| Rate for Payer: Cash Price |
$1,628.90
|
| Rate for Payer: Health Management Network Commercial |
$2,130.10
|
| Rate for Payer: MDX Hawaii PPO |
$2,430.82
|
|
|
HCHG CTA AORTA ILIOFEM
|
Facility
|
IP
|
$1,823.00
|
|
|
Service Code
|
HCPCS 75635
|
| Hospital Charge Code |
H3520178
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,549.55 |
| Max. Negotiated Rate |
$1,768.31 |
| Rate for Payer: Cash Price |
$1,184.95
|
| Rate for Payer: Health Management Network Commercial |
$1,549.55
|
| Rate for Payer: MDX Hawaii PPO |
$1,768.31
|
|
|
HCHG CTA AORTA ILIOFEM
|
Facility
|
OP
|
$1,823.00
|
|
|
Service Code
|
HCPCS 75635
|
| Hospital Charge Code |
H3520178
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$207.21 |
| Max. Negotiated Rate |
$1,768.31 |
| Rate for Payer: AlohaCare Medicaid |
$207.21
|
| Rate for Payer: AlohaCare Medicare |
$207.21
|
| Rate for Payer: Cash Price |
$1,184.95
|
| Rate for Payer: Cash Price |
$1,184.95
|
| Rate for Payer: Devoted Health Medicare |
$227.93
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$410.29
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$207.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$559.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$1,549.55
|
| Rate for Payer: Humana Medicare |
$207.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,148.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$929.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$207.21
|
| Rate for Payer: MDX Hawaii PPO |
$1,768.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$227.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$207.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$410.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$207.21
|
| Rate for Payer: University Health Alliance Commercial |
$907.28
|
|
|
HCHG CT ABD EXT W CONTR
|
Facility
|
OP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 74160
|
| Hospital Charge Code |
H3520106
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$207.21 |
| Max. Negotiated Rate |
$1,899.26 |
| Rate for Payer: AlohaCare Medicaid |
$207.21
|
| Rate for Payer: AlohaCare Medicare |
$207.21
|
| Rate for Payer: Cash Price |
$1,272.70
|
| Rate for Payer: Cash Price |
$1,272.70
|
| Rate for Payer: Devoted Health Medicare |
$227.93
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$225.48
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$207.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$245.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$1,664.30
|
| Rate for Payer: Humana Medicare |
$207.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,233.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$998.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$207.21
|
| Rate for Payer: MDX Hawaii PPO |
$1,899.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$227.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$207.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$225.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$207.21
|
| Rate for Payer: University Health Alliance Commercial |
$691.79
|
|
|
HCHG CT ABD EXT W CONTR
|
Facility
|
IP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 74160
|
| Hospital Charge Code |
H3520106
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,664.30 |
| Max. Negotiated Rate |
$1,899.26 |
| Rate for Payer: Cash Price |
$1,272.70
|
| Rate for Payer: Health Management Network Commercial |
$1,664.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,899.26
|
|
|
HCHG CT, ABDOMEN & PELVIS, W CONTRAST MATERIAL
|
Facility
|
OP
|
$3,806.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
H3510143
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$180.62 |
| Max. Negotiated Rate |
$3,691.82 |
| Rate for Payer: AlohaCare Medicaid |
$412.14
|
| Rate for Payer: AlohaCare Medicare |
$412.14
|
| Rate for Payer: Cash Price |
$2,473.90
|
| Rate for Payer: Cash Price |
$2,473.90
|
| Rate for Payer: Devoted Health Medicare |
$453.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$180.62
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$515.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$412.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$490.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.14
|
| Rate for Payer: Health Management Network Commercial |
$3,235.10
|
| Rate for Payer: Humana Medicare |
$412.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,397.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,941.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$412.14
|
| Rate for Payer: MDX Hawaii PPO |
$3,691.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$453.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$412.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$180.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$412.14
|
| Rate for Payer: University Health Alliance Commercial |
$727.57
|
|
|
HCHG CT, ABDOMEN & PELVIS, W CONTRAST MATERIAL
|
Facility
|
IP
|
$3,806.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
H3510143
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$3,235.10 |
| Max. Negotiated Rate |
$3,691.82 |
| Rate for Payer: Cash Price |
$2,473.90
|
| Rate for Payer: Health Management Network Commercial |
$3,235.10
|
| Rate for Payer: MDX Hawaii PPO |
$3,691.82
|
|
|
HCHG CT, ABDOMEN & PELVIS, WO CONTRAST MATERIAL
|
Facility
|
IP
|
$3,032.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
H3510145
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,577.20 |
| Max. Negotiated Rate |
$2,941.04 |
| Rate for Payer: Cash Price |
$1,970.80
|
| Rate for Payer: Health Management Network Commercial |
$2,577.20
|
| Rate for Payer: MDX Hawaii PPO |
$2,941.04
|
|
|
HCHG CT, ABDOMEN & PELVIS, WO CONTRAST MATERIAL
|
Facility
|
OP
|
$3,032.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
H3510145
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$94.66 |
| Max. Negotiated Rate |
$2,941.04 |
| Rate for Payer: AlohaCare Medicaid |
$281.87
|
| Rate for Payer: AlohaCare Medicare |
$281.87
|
| Rate for Payer: Cash Price |
$1,970.80
|
| Rate for Payer: Cash Price |
$1,970.80
|
| Rate for Payer: Devoted Health Medicare |
$310.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$94.66
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$352.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$281.87
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$413.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$281.87
|
| Rate for Payer: Health Management Network Commercial |
$2,577.20
|
| Rate for Payer: Humana Medicare |
$281.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,910.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,546.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$281.87
|
| Rate for Payer: MDX Hawaii PPO |
$2,941.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$310.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$281.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$94.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$281.87
|
| Rate for Payer: University Health Alliance Commercial |
$454.47
|
|
|
HCHG CT, ABDOMEN & PELVIS, WO FOLLOWED BY W CONTRAST MATERIAL
|
Facility
|
IP
|
$4,264.00
|
|
|
Service Code
|
HCPCS 74178
|
| Hospital Charge Code |
H3510144
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$3,624.40 |
| Max. Negotiated Rate |
$4,136.08 |
| Rate for Payer: Cash Price |
$2,771.60
|
| Rate for Payer: Health Management Network Commercial |
$3,624.40
|
| Rate for Payer: MDX Hawaii PPO |
$4,136.08
|
|
|
HCHG CT, ABDOMEN & PELVIS, WO FOLLOWED BY W CONTRAST MATERIAL
|
Facility
|
OP
|
$4,264.00
|
|
|
Service Code
|
HCPCS 74178
|
| Hospital Charge Code |
H3510144
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$238.75 |
| Max. Negotiated Rate |
$4,136.08 |
| Rate for Payer: AlohaCare Medicaid |
$412.14
|
| Rate for Payer: AlohaCare Medicare |
$412.14
|
| Rate for Payer: Cash Price |
$2,771.60
|
| Rate for Payer: Cash Price |
$2,771.60
|
| Rate for Payer: Devoted Health Medicare |
$453.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$238.75
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$515.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$412.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$606.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.14
|
| Rate for Payer: Health Management Network Commercial |
$3,624.40
|
| Rate for Payer: Humana Medicare |
$412.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,686.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,174.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$412.14
|
| Rate for Payer: MDX Hawaii PPO |
$4,136.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$453.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$412.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$238.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$412.14
|
| Rate for Payer: University Health Alliance Commercial |
$924.87
|
|
|
HCHG CT ABD W/O CONTR
|
Facility
|
OP
|
$1,572.00
|
|
|
Service Code
|
HCPCS 74150
|
| Hospital Charge Code |
H3520108
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$123.50 |
| Max. Negotiated Rate |
$1,524.84 |
| Rate for Payer: AlohaCare Medicaid |
$123.50
|
| Rate for Payer: AlohaCare Medicare |
$123.50
|
| Rate for Payer: Cash Price |
$1,021.80
|
| Rate for Payer: Cash Price |
$1,021.80
|
| Rate for Payer: Devoted Health Medicare |
$135.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$186.48
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$123.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$202.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$1,336.20
|
| Rate for Payer: Humana Medicare |
$123.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$990.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$801.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$123.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,524.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$135.85
|
| Rate for Payer: Ohana Health Plan Medicare |
$123.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$186.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$123.50
|
| Rate for Payer: University Health Alliance Commercial |
$505.20
|
|
|
HCHG CT ABD W/O CONTR
|
Facility
|
IP
|
$1,572.00
|
|
|
Service Code
|
HCPCS 74150
|
| Hospital Charge Code |
H3520108
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,336.20 |
| Max. Negotiated Rate |
$1,524.84 |
| Rate for Payer: Cash Price |
$1,021.80
|
| Rate for Payer: Health Management Network Commercial |
$1,336.20
|
| Rate for Payer: MDX Hawaii PPO |
$1,524.84
|
|
|
HCHG CT ABD W/WO CONTR
|
Facility
|
IP
|
$2,103.00
|
|
|
Service Code
|
HCPCS 74170
|
| Hospital Charge Code |
H3520110
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,787.55 |
| Max. Negotiated Rate |
$2,039.91 |
| Rate for Payer: Cash Price |
$1,366.95
|
| Rate for Payer: Health Management Network Commercial |
$1,787.55
|
| Rate for Payer: MDX Hawaii PPO |
$2,039.91
|
|
|
HCHG CT ABD W/WO CONTR
|
Facility
|
OP
|
$2,103.00
|
|
|
Service Code
|
HCPCS 74170
|
| Hospital Charge Code |
H3520110
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$207.21 |
| Max. Negotiated Rate |
$2,039.91 |
| Rate for Payer: AlohaCare Medicaid |
$207.21
|
| Rate for Payer: AlohaCare Medicare |
$207.21
|
| Rate for Payer: Cash Price |
$1,366.95
|
| Rate for Payer: Cash Price |
$1,366.95
|
| Rate for Payer: Devoted Health Medicare |
$227.93
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$279.37
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$207.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$303.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$1,787.55
|
| Rate for Payer: Humana Medicare |
$207.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,324.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,072.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$207.21
|
| Rate for Payer: MDX Hawaii PPO |
$2,039.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$227.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$207.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$279.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$207.21
|
| Rate for Payer: University Health Alliance Commercial |
$803.12
|
|
|
HCHG CT ACETABULUM, WO CONTR
|
Facility
|
OP
|
$1,539.00
|
|
|
Service Code
|
HCPCS 72192
|
| Hospital Charge Code |
H3520104
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$123.50 |
| Max. Negotiated Rate |
$1,492.83 |
| Rate for Payer: AlohaCare Medicaid |
$123.50
|
| Rate for Payer: AlohaCare Medicare |
$123.50
|
| Rate for Payer: Cash Price |
$1,000.35
|
| Rate for Payer: Cash Price |
$1,000.35
|
| Rate for Payer: Devoted Health Medicare |
$135.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$194.84
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$123.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$211.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$1,308.15
|
| Rate for Payer: Humana Medicare |
$123.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$969.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$784.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$123.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,492.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$135.85
|
| Rate for Payer: Ohana Health Plan Medicare |
$123.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$194.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$123.50
|
| Rate for Payer: University Health Alliance Commercial |
$496.15
|
|
|
HCHG CT ACETABULUM, WO CONTR
|
Facility
|
IP
|
$1,539.00
|
|
|
Service Code
|
HCPCS 72192
|
| Hospital Charge Code |
H3520104
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,308.15 |
| Max. Negotiated Rate |
$1,492.83 |
| Rate for Payer: Cash Price |
$1,000.35
|
| Rate for Payer: Health Management Network Commercial |
$1,308.15
|
| Rate for Payer: MDX Hawaii PPO |
$1,492.83
|
|
|
HCHG CTA CHEST W/WO CONTR
|
Facility
|
IP
|
$2,477.00
|
|
|
Service Code
|
HCPCS 71275
|
| Hospital Charge Code |
H3520180
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$2,105.45 |
| Max. Negotiated Rate |
$2,402.69 |
| Rate for Payer: Cash Price |
$1,610.05
|
| Rate for Payer: Health Management Network Commercial |
$2,105.45
|
| Rate for Payer: MDX Hawaii PPO |
$2,402.69
|
|
|
HCHG CTA CHEST W/WO CONTR
|
Facility
|
OP
|
$2,477.00
|
|
|
Service Code
|
HCPCS 71275
|
| Hospital Charge Code |
H3520180
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$207.21 |
| Max. Negotiated Rate |
$2,402.69 |
| Rate for Payer: AlohaCare Medicaid |
$207.21
|
| Rate for Payer: AlohaCare Medicare |
$207.21
|
| Rate for Payer: Cash Price |
$1,610.05
|
| Rate for Payer: Cash Price |
$1,610.05
|
| Rate for Payer: Devoted Health Medicare |
$227.93
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$320.86
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$207.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$437.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$2,105.45
|
| Rate for Payer: Humana Medicare |
$207.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,560.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,263.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$207.21
|
| Rate for Payer: MDX Hawaii PPO |
$2,402.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$227.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$207.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$320.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$207.21
|
| Rate for Payer: University Health Alliance Commercial |
$860.75
|
|
|
HCHG CTA HEAD W/ BRAIN PERFUSION
|
Facility
|
IP
|
$2,477.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
H3510141
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$2,105.45 |
| Max. Negotiated Rate |
$2,402.69 |
| Rate for Payer: Cash Price |
$1,610.05
|
| Rate for Payer: Health Management Network Commercial |
$2,105.45
|
| Rate for Payer: MDX Hawaii PPO |
$2,402.69
|
|
|
HCHG CTA HEAD W/ BRAIN PERFUSION
|
Facility
|
OP
|
$2,477.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
H3510141
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$207.21 |
| Max. Negotiated Rate |
$2,402.69 |
| Rate for Payer: AlohaCare Medicaid |
$207.21
|
| Rate for Payer: AlohaCare Medicare |
$207.21
|
| Rate for Payer: Cash Price |
$1,610.05
|
| Rate for Payer: Cash Price |
$1,610.05
|
| Rate for Payer: Devoted Health Medicare |
$227.93
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$279.09
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$207.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$380.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$2,105.45
|
| Rate for Payer: Humana Medicare |
$207.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,560.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,263.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$207.21
|
| Rate for Payer: MDX Hawaii PPO |
$2,402.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$227.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$207.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$279.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$207.21
|
| Rate for Payer: University Health Alliance Commercial |
$842.03
|
|
|
HCHG CTA HEAD W/WO CONTR
|
Facility
|
OP
|
$2,477.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
H3510132
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$207.21 |
| Max. Negotiated Rate |
$2,402.69 |
| Rate for Payer: AlohaCare Medicaid |
$207.21
|
| Rate for Payer: AlohaCare Medicare |
$207.21
|
| Rate for Payer: Cash Price |
$1,610.05
|
| Rate for Payer: Cash Price |
$1,610.05
|
| Rate for Payer: Devoted Health Medicare |
$227.93
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$279.09
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$259.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$207.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$380.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.21
|
| Rate for Payer: Health Management Network Commercial |
$2,105.45
|
| Rate for Payer: Humana Medicare |
$207.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,560.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,263.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$207.21
|
| Rate for Payer: MDX Hawaii PPO |
$2,402.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$227.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$207.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$279.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$207.21
|
| Rate for Payer: University Health Alliance Commercial |
$842.03
|
|
|
HCHG CTA HEAD W/WO CONTR
|
Facility
|
IP
|
$2,477.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
H3510132
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$2,105.45 |
| Max. Negotiated Rate |
$2,402.69 |
| Rate for Payer: Cash Price |
$1,610.05
|
| Rate for Payer: Health Management Network Commercial |
$2,105.45
|
| Rate for Payer: MDX Hawaii PPO |
$2,402.69
|
|
