|
70486 - add on
|
Facility
|
OP
|
$4,657.00
|
|
|
Service Code
|
HCPCS 70486
|
| Hospital Charge Code |
12231525
|
|
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
|
|
|
70486 - add on
|
Facility
|
IP
|
$4,657.00
|
|
|
Service Code
|
HCPCS 70486
|
| Hospital Charge Code |
12231525
|
|
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
|
|
|
70486 - add on report
|
Professional
|
Both
|
$218.00
|
|
|
Service Code
|
HCPCS 70486
|
| Hospital Charge Code |
12221352
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$87.30 |
| Max. Negotiated Rate |
$269.56 |
| Rate for Payer: AlohaCare Medicaid |
$87.30
|
| Rate for Payer: AlohaCare Medicare |
$140.91
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Devoted Health Medicare |
$155.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$140.91
|
| 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 |
$169.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$169.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$169.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$87.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$140.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$140.91
|
|
|
70486 CT MAXLFCL AREA C-MATRL ProFee
|
Professional
|
Both
|
$208.00
|
|
|
Service Code
|
HCPCS 70486 26
|
| Hospital Charge Code |
8102603
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$40.46 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$87.30
|
| Rate for Payer: AlohaCare Medicare |
$40.46
|
| Rate for Payer: Cash Price |
$135.20
|
| Rate for Payer: Cash Price |
$135.20
|
| Rate for Payer: Cash Price |
$135.20
|
| Rate for Payer: Devoted Health Medicare |
$44.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$269.56
|
| Rate for Payer: Health Management Network Commercial |
$176.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$87.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
|
|
70491 - add on
|
Facility
|
OP
|
$5,408.00
|
|
|
Service Code
|
HCPCS 70491
|
| Hospital Charge Code |
12221351
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$179.20 |
| Max. Negotiated Rate |
$5,245.76 |
| Rate for Payer: AlohaCare Medicaid |
$2,704.00
|
| Rate for Payer: AlohaCare Medicare |
$2,704.00
|
| Rate for Payer: Cash Price |
$3,515.20
|
| Rate for Payer: Cash Price |
$3,515.20
|
| Rate for Payer: Devoted Health Medicare |
$2,974.40
|
| 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 |
$2,704.00
|
| 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 |
$4,596.80
|
| Rate for Payer: Humana Medicare |
$2,704.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,867.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,758.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,704.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,245.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,704.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,704.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$186.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,704.00
|
| Rate for Payer: University Health Alliance Commercial |
$671.68
|
|
|
70491 - add on
|
Facility
|
IP
|
$5,408.00
|
|
|
Service Code
|
HCPCS 70491
|
| Hospital Charge Code |
12221351
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$4,596.80 |
| Max. Negotiated Rate |
$5,245.76 |
| Rate for Payer: Cash Price |
$3,515.20
|
| Rate for Payer: Health Management Network Commercial |
$4,596.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,867.20
|
| Rate for Payer: MDX Hawaii PPO |
$5,245.76
|
|
|
70491 - add on report
|
Professional
|
Both
|
$312.00
|
|
|
Service Code
|
HCPCS 70491
|
| Hospital Charge Code |
12241245
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$124.95 |
| Max. Negotiated Rate |
$323.80 |
| Rate for Payer: AlohaCare Medicaid |
$124.95
|
| Rate for Payer: AlohaCare Medicare |
$200.64
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Devoted Health Medicare |
$220.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$200.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$323.80
|
| Rate for Payer: Health Management Network Commercial |
$265.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$240.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$240.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$240.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$124.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$200.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$124.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$200.64
|
|
|
70491 CT SOFT TISS NCK C+ MATRL ProFee
|
Professional
|
Both
|
$256.00
|
|
|
Service Code
|
HCPCS 70491 26
|
| Hospital Charge Code |
8102607
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$64.67 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$124.95
|
| Rate for Payer: AlohaCare Medicare |
$64.67
|
| Rate for Payer: Cash Price |
$166.40
|
| Rate for Payer: Cash Price |
$166.40
|
| Rate for Payer: Cash Price |
$166.40
|
| Rate for Payer: Devoted Health Medicare |
$71.14
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$323.80
|
| Rate for Payer: Health Management Network Commercial |
$217.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$77.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$124.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$64.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
|
|
70492 - add on
|
Facility
|
OP
|
$5,798.00
|
|
|
Service Code
|
HCPCS 70492
|
| Hospital Charge Code |
12221349
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$179.20 |
| Max. Negotiated Rate |
$5,624.06 |
| Rate for Payer: AlohaCare Medicaid |
$2,899.00
|
| Rate for Payer: AlohaCare Medicare |
$2,899.00
|
| Rate for Payer: Cash Price |
$3,768.70
|
| Rate for Payer: Cash Price |
$3,768.70
|
| Rate for Payer: Devoted Health Medicare |
$3,188.90
|
| 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 |
$2,899.00
|
| 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 |
$4,928.30
|
| Rate for Payer: Humana Medicare |
$2,899.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,218.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,956.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,899.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,624.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,899.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,899.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$186.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,899.00
|
| Rate for Payer: University Health Alliance Commercial |
$807.15
|
|
|
70492 - add on
|
Facility
|
IP
|
$5,798.00
|
|
|
Service Code
|
HCPCS 70492
|
| Hospital Charge Code |
12221349
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$4,928.30 |
| Max. Negotiated Rate |
$5,624.06 |
| Rate for Payer: Cash Price |
$3,768.70
|
| Rate for Payer: Health Management Network Commercial |
$4,928.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,218.20
|
| Rate for Payer: MDX Hawaii PPO |
$5,624.06
|
|
|
70492 - add on report
|
Professional
|
Both
|
$375.00
|
|
|
Service Code
|
HCPCS 70492
|
| Hospital Charge Code |
12221350
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$150.05 |
| Max. Negotiated Rate |
$389.90 |
| Rate for Payer: AlohaCare Medicaid |
$150.05
|
| Rate for Payer: AlohaCare Medicare |
$240.79
|
| Rate for Payer: Cash Price |
$243.75
|
| Rate for Payer: Cash Price |
$243.75
|
| Rate for Payer: Devoted Health Medicare |
$264.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$240.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$389.90
|
| Rate for Payer: Health Management Network Commercial |
$318.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$288.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$288.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$288.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$150.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$240.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$150.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$240.79
|
|
|
7.0MM FLAT WASHER
|
Facility
|
IP
|
$105.00
|
|
| Hospital Charge Code |
12969395
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$101.85 |
| Rate for Payer: Cash Price |
$68.25
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$94.50
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
|
|
7.0MM FLAT WASHER
|
Facility
|
OP
|
$105.00
|
|
| Hospital Charge Code |
12969395
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$101.85 |
| Rate for Payer: AlohaCare Medicaid |
$52.50
|
| Rate for Payer: AlohaCare Medicare |
$52.50
|
| Rate for Payer: Cash Price |
$68.25
|
| Rate for Payer: Devoted Health Medicare |
$57.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$99.75
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Humana Medicare |
$52.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$94.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.50
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.50
|
| Rate for Payer: University Health Alliance Commercial |
$76.53
|
|
|
71045 RADIOLOGIC EXAM CHEST SINGLE VIEW ProFee
|
Professional
|
Both
|
$121.00
|
|
|
Service Code
|
HCPCS 71045
|
| Hospital Charge Code |
8102638
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$16.90 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$16.90
|
| Rate for Payer: AlohaCare Medicare |
$27.67
|
| Rate for Payer: Cash Price |
$78.65
|
| Rate for Payer: Cash Price |
$78.65
|
| Rate for Payer: Cash Price |
$78.65
|
| Rate for Payer: Devoted Health Medicare |
$30.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$34.57
|
| Rate for Payer: Health Management Network Commercial |
$102.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
|
|
71045 RADIOLOGIC EXAM CHEST SINGLE VIEW ProFee
|
Professional
|
Both
|
$121.00
|
|
|
Service Code
|
HCPCS 71045
|
| Hospital Charge Code |
8102638
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$16.90 |
| Max. Negotiated Rate |
$102.85 |
| Rate for Payer: AlohaCare Medicaid |
$16.90
|
| Rate for Payer: AlohaCare Medicare |
$27.67
|
| Rate for Payer: Cash Price |
$78.65
|
| Rate for Payer: Cash Price |
$78.65
|
| Rate for Payer: Devoted Health Medicare |
$30.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$34.57
|
| Rate for Payer: Health Management Network Commercial |
$102.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$33.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.67
|
|
|
71046 RADIOLOGIC EXAM CHEST 2 VIEWS ProFee
|
Professional
|
Both
|
$121.00
|
|
|
Service Code
|
HCPCS 71046
|
| Hospital Charge Code |
8102639
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$22.29 |
| Max. Negotiated Rate |
$102.85 |
| Rate for Payer: AlohaCare Medicaid |
$22.29
|
| Rate for Payer: AlohaCare Medicare |
$36.26
|
| Rate for Payer: Cash Price |
$78.65
|
| Rate for Payer: Cash Price |
$78.65
|
| Rate for Payer: Devoted Health Medicare |
$39.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.25
|
| Rate for Payer: Health Management Network Commercial |
$102.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$43.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.26
|
|
|
71046 RADIOLOGIC EXAM CHEST 2 VIEWS ProFee
|
Professional
|
Both
|
$131.00
|
|
|
Service Code
|
HCPCS 71046
|
| Hospital Charge Code |
8102639
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$22.29 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$22.29
|
| Rate for Payer: AlohaCare Medicare |
$36.26
|
| Rate for Payer: Cash Price |
$85.15
|
| Rate for Payer: Cash Price |
$85.15
|
| Rate for Payer: Cash Price |
$85.15
|
| Rate for Payer: Devoted Health Medicare |
$39.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.25
|
| Rate for Payer: Health Management Network Commercial |
$111.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
|
|
71100 RADEX RIBS UNI 2 VIEWS ProFee
|
Professional
|
Both
|
$121.00
|
|
|
Service Code
|
HCPCS 71100 26
|
| Hospital Charge Code |
8102641
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$10.63 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$24.35
|
| Rate for Payer: AlohaCare Medicare |
$10.63
|
| Rate for Payer: Cash Price |
$78.65
|
| Rate for Payer: Cash Price |
$78.65
|
| Rate for Payer: Cash Price |
$78.65
|
| Rate for Payer: Devoted Health Medicare |
$11.69
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.53
|
| Rate for Payer: Health Management Network Commercial |
$102.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
|
|
71250 - CT Chest/Abdomen
|
Facility
|
IP
|
$4,747.00
|
|
|
Service Code
|
HCPCS 71250
|
| Hospital Charge Code |
12231023
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$4,034.95 |
| Max. Negotiated Rate |
$4,604.59 |
| Rate for Payer: Cash Price |
$3,085.55
|
| Rate for Payer: Health Management Network Commercial |
$4,034.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,272.30
|
| Rate for Payer: MDX Hawaii PPO |
$4,604.59
|
|
|
71250 - CT Chest/Abdomen
|
Facility
|
OP
|
$4,747.00
|
|
|
Service Code
|
HCPCS 71250
|
| Hospital Charge Code |
12231023
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$106.81 |
| Max. Negotiated Rate |
$4,604.59 |
| Rate for Payer: AlohaCare Medicaid |
$2,373.50
|
| Rate for Payer: AlohaCare Medicare |
$2,373.50
|
| Rate for Payer: Cash Price |
$3,085.55
|
| Rate for Payer: Cash Price |
$3,085.55
|
| Rate for Payer: Devoted Health Medicare |
$2,610.85
|
| 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 |
$2,373.50
|
| 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 |
$4,034.95
|
| Rate for Payer: Humana Medicare |
$2,373.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,272.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,420.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,373.50
|
| Rate for Payer: MDX Hawaii PPO |
$4,604.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,373.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,373.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$194.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,373.50
|
| Rate for Payer: University Health Alliance Commercial |
$502.27
|
|
|
71250 - CT Chest/Abdomen report
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 71250
|
| Hospital Charge Code |
12221169
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$322.87 |
| Rate for Payer: AlohaCare Medicaid |
$89.82
|
| Rate for Payer: AlohaCare Medicare |
$144.66
|
| Rate for Payer: Cash Price |
$146.25
|
| Rate for Payer: Cash Price |
$146.25
|
| Rate for Payer: Devoted Health Medicare |
$159.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$144.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$322.87
|
| Rate for Payer: Health Management Network Commercial |
$191.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$173.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$173.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$173.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$89.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$144.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$89.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$144.66
|
|
|
71250 CT THORAX C-MATRL ProFee
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
HCPCS 71250 26
|
| Hospital Charge Code |
8102647
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$50.28 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$89.82
|
| Rate for Payer: AlohaCare Medicare |
$50.28
|
| Rate for Payer: Cash Price |
$120.90
|
| Rate for Payer: Cash Price |
$120.90
|
| Rate for Payer: Cash Price |
$120.90
|
| Rate for Payer: Devoted Health Medicare |
$55.31
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$322.87
|
| Rate for Payer: Health Management Network Commercial |
$158.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$89.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$50.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
|
|
71260 - CT Chest/Abdomen
|
Facility
|
IP
|
$5,828.00
|
|
|
Service Code
|
HCPCS 71260
|
| Hospital Charge Code |
12231022
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$4,953.80 |
| Max. Negotiated Rate |
$5,653.16 |
| Rate for Payer: Cash Price |
$3,788.20
|
| Rate for Payer: Health Management Network Commercial |
$4,953.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,245.20
|
| Rate for Payer: MDX Hawaii PPO |
$5,653.16
|
|
|
71260 - CT Chest/Abdomen
|
Facility
|
OP
|
$5,828.00
|
|
|
Service Code
|
HCPCS 71260
|
| Hospital Charge Code |
12231022
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$179.20 |
| Max. Negotiated Rate |
$5,653.16 |
| Rate for Payer: AlohaCare Medicaid |
$2,914.00
|
| Rate for Payer: AlohaCare Medicare |
$2,914.00
|
| Rate for Payer: Cash Price |
$3,788.20
|
| Rate for Payer: Cash Price |
$3,788.20
|
| Rate for Payer: Devoted Health Medicare |
$3,205.40
|
| 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 |
$2,914.00
|
| 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 |
$4,953.80
|
| Rate for Payer: Humana Medicare |
$2,914.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,245.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,972.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,914.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,653.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,914.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,914.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$232.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,914.00
|
| Rate for Payer: University Health Alliance Commercial |
$686.18
|
|
|
71260 - CT Chest/Abdomen report
|
Professional
|
Both
|
$284.00
|
|
|
Service Code
|
HCPCS 71260
|
| Hospital Charge Code |
12221170
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$113.56 |
| Max. Negotiated Rate |
$378.67 |
| Rate for Payer: AlohaCare Medicaid |
$113.56
|
| Rate for Payer: AlohaCare Medicare |
$182.66
|
| Rate for Payer: Cash Price |
$184.60
|
| Rate for Payer: Cash Price |
$184.60
|
| Rate for Payer: Devoted Health Medicare |
$200.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$182.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$378.67
|
| Rate for Payer: Health Management Network Commercial |
$241.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$219.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$219.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$219.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$113.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$182.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$113.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$182.66
|
|
