|
XR Orbits Complete
|
Facility
|
IP
|
$488.00
|
|
|
Service Code
|
HCPCS 70200
|
| Hospital Charge Code |
1170339
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$414.80 |
| Max. Negotiated Rate |
$473.36 |
| Rate for Payer: Cash Price |
$317.20
|
| Rate for Payer: Health Management Network Commercial |
$414.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$439.20
|
| Rate for Payer: MDX Hawaii PPO |
$473.36
|
|
|
XR Orbits Complete - Report
|
Professional
|
Both
|
$132.00
|
|
|
Service Code
|
HCPCS 70200 26
|
| Hospital Charge Code |
630300
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$13.39 |
| Max. Negotiated Rate |
$112.20 |
| Rate for Payer: AlohaCare Medicaid |
$31.98
|
| Rate for Payer: AlohaCare Medicare |
$13.39
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Devoted Health Medicare |
$14.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.39
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.11
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$31.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.39
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.39
|
|
|
XR Osseous Survey Complete
|
Professional
|
Both
|
$195.00
|
|
|
Service Code
|
HCPCS 77075
|
| Hospital Charge Code |
1170018
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$66.39 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$66.39
|
| Rate for Payer: AlohaCare Medicare |
$107.87
|
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Devoted Health Medicare |
$118.66
|
| 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 |
$105.93
|
| Rate for Payer: Health Management Network Commercial |
$165.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$129.44
|
| 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 |
$66.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$107.87
|
| 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
|
|
|
XR Osseous Survey Complete
|
Facility
|
OP
|
$746.00
|
|
|
Service Code
|
HCPCS 77075
|
| Hospital Charge Code |
1170018
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$48.32 |
| Max. Negotiated Rate |
$723.62 |
| Rate for Payer: AlohaCare Medicaid |
$373.00
|
| Rate for Payer: AlohaCare Medicare |
$373.00
|
| Rate for Payer: Cash Price |
$484.90
|
| Rate for Payer: Cash Price |
$484.90
|
| Rate for Payer: Devoted Health Medicare |
$410.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$48.32
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$133.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$373.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$51.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.81
|
| Rate for Payer: Health Management Network Commercial |
$634.10
|
| Rate for Payer: Humana Medicare |
$373.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$671.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$380.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$373.00
|
| Rate for Payer: MDX Hawaii PPO |
$723.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$373.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$373.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$48.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$373.00
|
| Rate for Payer: University Health Alliance Commercial |
$195.99
|
|
|
XR Osseous Survey Complete
|
Facility
|
IP
|
$746.00
|
|
|
Service Code
|
HCPCS 77075
|
| Hospital Charge Code |
1170018
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$634.10 |
| Max. Negotiated Rate |
$723.62 |
| Rate for Payer: Cash Price |
$484.90
|
| Rate for Payer: Health Management Network Commercial |
$634.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$671.40
|
| Rate for Payer: MDX Hawaii PPO |
$723.62
|
|
|
XR Osseous Survey Complete - Report
|
Professional
|
Both
|
$136.00
|
|
|
Service Code
|
HCPCS 77075 26
|
| Hospital Charge Code |
627659
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$26.21 |
| Max. Negotiated Rate |
$115.60 |
| Rate for Payer: AlohaCare Medicaid |
$66.39
|
| Rate for Payer: AlohaCare Medicare |
$26.21
|
| Rate for Payer: Cash Price |
$88.40
|
| Rate for Payer: Cash Price |
$88.40
|
| Rate for Payer: Devoted Health Medicare |
$28.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$105.93
|
| Rate for Payer: Health Management Network Commercial |
$115.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$31.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$66.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.21
|
|
|
XR Osseous Survey Infant
|
Facility
|
OP
|
$580.00
|
|
|
Service Code
|
HCPCS 77076
|
| Hospital Charge Code |
1170020
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$29.05 |
| Max. Negotiated Rate |
$562.60 |
| Rate for Payer: AlohaCare Medicaid |
$290.00
|
| Rate for Payer: AlohaCare Medicare |
$290.00
|
| Rate for Payer: Cash Price |
$377.00
|
| Rate for Payer: Cash Price |
$377.00
|
| Rate for Payer: Devoted Health Medicare |
$319.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$29.98
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$133.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$290.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$29.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.81
|
| Rate for Payer: Health Management Network Commercial |
$493.00
|
| Rate for Payer: Humana Medicare |
$290.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$522.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$295.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$290.00
|
| Rate for Payer: MDX Hawaii PPO |
$562.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$290.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$290.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$290.00
|
| Rate for Payer: University Health Alliance Commercial |
$155.46
|
|
|
XR Osseous Survey Infant
|
Facility
|
IP
|
$580.00
|
|
|
Service Code
|
HCPCS 77076
|
| Hospital Charge Code |
1170020
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$493.00 |
| Max. Negotiated Rate |
$562.60 |
| Rate for Payer: Cash Price |
$377.00
|
| Rate for Payer: Health Management Network Commercial |
$493.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$522.00
|
| Rate for Payer: MDX Hawaii PPO |
$562.60
|
|
|
XR Osseous Survey Infant - Report
|
Professional
|
Both
|
$146.00
|
|
|
Service Code
|
HCPCS 77076 26
|
| Hospital Charge Code |
627661
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$32.98 |
| Max. Negotiated Rate |
$124.10 |
| Rate for Payer: AlohaCare Medicaid |
$71.11
|
| Rate for Payer: AlohaCare Medicare |
$32.98
|
| Rate for Payer: Cash Price |
$94.90
|
| Rate for Payer: Cash Price |
$94.90
|
| Rate for Payer: Devoted Health Medicare |
$36.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.98
|
| Rate for Payer: Health Management Network Commercial |
$124.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$71.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$71.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.98
|
|
|
XR Osseous Survey Limited
|
Facility
|
IP
|
$536.00
|
|
|
Service Code
|
HCPCS 77074
|
| Hospital Charge Code |
1170022
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$455.60 |
| Max. Negotiated Rate |
$519.92 |
| Rate for Payer: Cash Price |
$348.40
|
| Rate for Payer: Health Management Network Commercial |
$455.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$482.40
|
| Rate for Payer: MDX Hawaii PPO |
$519.92
|
|
|
XR Osseous Survey Limited
|
Facility
|
OP
|
$536.00
|
|
|
Service Code
|
HCPCS 77074
|
| Hospital Charge Code |
1170022
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.26 |
| Max. Negotiated Rate |
$519.92 |
| Rate for Payer: AlohaCare Medicaid |
$268.00
|
| Rate for Payer: AlohaCare Medicare |
$268.00
|
| Rate for Payer: Cash Price |
$348.40
|
| Rate for Payer: Cash Price |
$348.40
|
| Rate for Payer: Devoted Health Medicare |
$294.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$32.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$133.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$268.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$36.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.81
|
| Rate for Payer: Health Management Network Commercial |
$455.60
|
| Rate for Payer: Humana Medicare |
$268.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$482.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$273.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$268.00
|
| Rate for Payer: MDX Hawaii PPO |
$519.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$268.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$268.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$268.00
|
| Rate for Payer: University Health Alliance Commercial |
$136.46
|
|
|
XR Osseous Survey Limited - Report
|
Professional
|
Both
|
$145.00
|
|
|
Service Code
|
HCPCS 77074 26
|
| Hospital Charge Code |
627663
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$21.02 |
| Max. Negotiated Rate |
$123.25 |
| Rate for Payer: AlohaCare Medicaid |
$43.32
|
| Rate for Payer: AlohaCare Medicare |
$21.02
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Devoted Health Medicare |
$23.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$73.75
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.02
|
|
|
XR Pelvis 1 or 2 Views
|
Professional
|
Both
|
$154.00
|
|
|
Service Code
|
HCPCS 72170
|
| Hospital Charge Code |
1170351
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$18.54 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$18.54
|
| Rate for Payer: AlohaCare Medicare |
$30.75
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Devoted Health Medicare |
$33.83
|
| 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 |
$32.05
|
| Rate for Payer: Health Management Network Commercial |
$130.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.90
|
| 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 |
$18.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.75
|
| 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
|
|
|
XR Pelvis 1 or 2 Views
|
Facility
|
OP
|
$386.00
|
|
|
Service Code
|
HCPCS 72170
|
| Hospital Charge Code |
1170351
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$18.74 |
| Max. Negotiated Rate |
$374.42 |
| Rate for Payer: AlohaCare Medicaid |
$193.00
|
| Rate for Payer: AlohaCare Medicare |
$193.00
|
| Rate for Payer: Cash Price |
$250.90
|
| Rate for Payer: Cash Price |
$250.90
|
| Rate for Payer: Devoted Health Medicare |
$212.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.74
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$133.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$193.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.81
|
| Rate for Payer: Health Management Network Commercial |
$328.10
|
| Rate for Payer: Humana Medicare |
$193.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$347.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$196.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$193.00
|
| Rate for Payer: MDX Hawaii PPO |
$374.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$193.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$193.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.74
|
| Rate for Payer: UnitedHealthcare Medicare |
$193.00
|
| Rate for Payer: University Health Alliance Commercial |
$55.37
|
|
|
XR Pelvis 1 or 2 Views
|
Facility
|
IP
|
$386.00
|
|
|
Service Code
|
HCPCS 72170
|
| Hospital Charge Code |
1170351
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$328.10 |
| Max. Negotiated Rate |
$374.42 |
| Rate for Payer: Cash Price |
$250.90
|
| Rate for Payer: Health Management Network Commercial |
$328.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$347.40
|
| Rate for Payer: MDX Hawaii PPO |
$374.42
|
|
|
XR Pelvis 1 or 2 Views - Report
|
Professional
|
Both
|
$70.00
|
|
|
Service Code
|
HCPCS 72170 26
|
| Hospital Charge Code |
630286
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$8.53 |
| Max. Negotiated Rate |
$59.50 |
| Rate for Payer: AlohaCare Medicaid |
$18.54
|
| Rate for Payer: AlohaCare Medicare |
$8.53
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Devoted Health Medicare |
$9.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$32.05
|
| Rate for Payer: Health Management Network Commercial |
$59.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.53
|
|
|
XR Pelvis Complete 3+ Views
|
Professional
|
Both
|
$145.00
|
|
|
Service Code
|
HCPCS 72190
|
| Hospital Charge Code |
1170353
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$28.17 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$28.17
|
| Rate for Payer: AlohaCare Medicare |
$47.71
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Devoted Health Medicare |
$52.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| 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 Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.06
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$57.25
|
| 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 |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| 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: Ohana Health Plan Medicaid |
$28.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
|
|
XR Pelvis Complete 3+ Views
|
Facility
|
OP
|
$548.00
|
|
|
Service Code
|
HCPCS 72190
|
| Hospital Charge Code |
1170353
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$21.96 |
| Max. Negotiated Rate |
$531.56 |
| Rate for Payer: AlohaCare Medicaid |
$274.00
|
| Rate for Payer: AlohaCare Medicare |
$274.00
|
| Rate for Payer: Cash Price |
$356.20
|
| Rate for Payer: Cash Price |
$356.20
|
| Rate for Payer: Devoted Health Medicare |
$301.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$21.96
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$133.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$274.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$24.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.81
|
| Rate for Payer: Health Management Network Commercial |
$465.80
|
| Rate for Payer: Humana Medicare |
$274.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$493.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$279.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$274.00
|
| Rate for Payer: MDX Hawaii PPO |
$531.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$274.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$274.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$21.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$274.00
|
| Rate for Payer: University Health Alliance Commercial |
$78.55
|
|
|
XR Pelvis Complete 3+ Views
|
Facility
|
IP
|
$548.00
|
|
|
Service Code
|
HCPCS 72190
|
| Hospital Charge Code |
1170353
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$465.80 |
| Max. Negotiated Rate |
$531.56 |
| Rate for Payer: Cash Price |
$356.20
|
| Rate for Payer: Health Management Network Commercial |
$465.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$493.20
|
| Rate for Payer: MDX Hawaii PPO |
$531.56
|
|
|
XR Pelvis Complete 3+ Views - Report
|
Professional
|
Both
|
$76.00
|
|
|
Service Code
|
HCPCS 72190 26
|
| Hospital Charge Code |
630282
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$12.58 |
| Max. Negotiated Rate |
$64.60 |
| Rate for Payer: AlohaCare Medicaid |
$28.17
|
| Rate for Payer: AlohaCare Medicare |
$12.58
|
| Rate for Payer: Cash Price |
$49.40
|
| Rate for Payer: Cash Price |
$49.40
|
| Rate for Payer: Devoted Health Medicare |
$13.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.06
|
| Rate for Payer: Health Management Network Commercial |
$64.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.58
|
|
|
XR Ribs 2 Views Left
|
Facility
|
IP
|
$431.00
|
|
|
Service Code
|
HCPCS 71100 LT
|
| Hospital Charge Code |
1170371
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$366.35 |
| Max. Negotiated Rate |
$418.07 |
| Rate for Payer: Cash Price |
$280.15
|
| Rate for Payer: Health Management Network Commercial |
$366.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$387.90
|
| Rate for Payer: MDX Hawaii PPO |
$418.07
|
|
|
XR Ribs 2 Views Left
|
Professional
|
Both
|
$296.00
|
|
|
Service Code
|
HCPCS 71100 LT
|
| Hospital Charge Code |
1170371
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$24.35 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$24.35
|
| Rate for Payer: Cash Price |
$192.40
|
| Rate for Payer: Cash Price |
$192.40
|
| Rate for Payer: Cash Price |
$192.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| 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 Medicare |
$237.64
|
| 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 |
$251.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| 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 |
$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 |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| 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 |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
|
|
XR Ribs 2 Views Left
|
Facility
|
OP
|
$431.00
|
|
|
Service Code
|
HCPCS 71100 LT
|
| Hospital Charge Code |
1170371
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$18.84 |
| Max. Negotiated Rate |
$418.07 |
| Rate for Payer: AlohaCare Medicaid |
$215.50
|
| Rate for Payer: AlohaCare Medicare |
$215.50
|
| Rate for Payer: Cash Price |
$280.15
|
| Rate for Payer: Cash Price |
$280.15
|
| Rate for Payer: Devoted Health Medicare |
$237.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$215.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$20.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$409.45
|
| Rate for Payer: Health Management Network Commercial |
$366.35
|
| Rate for Payer: Humana Medicare |
$215.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$387.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$219.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$215.50
|
| Rate for Payer: MDX Hawaii PPO |
$418.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$215.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$215.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$215.50
|
| Rate for Payer: University Health Alliance Commercial |
$66.43
|
|
|
XR Ribs 2 Views Left - Report
|
Professional
|
Both
|
$82.00
|
|
|
Service Code
|
HCPCS 71100 26,LT
|
| Hospital Charge Code |
630230
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$24.35 |
| Max. Negotiated Rate |
$69.70 |
| Rate for Payer: AlohaCare Medicaid |
$24.35
|
| Rate for Payer: Cash Price |
$53.30
|
| Rate for Payer: Cash Price |
$53.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.53
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.35
|
|
|
XR Ribs 2 Views Right
|
Professional
|
Both
|
$121.00
|
|
|
Service Code
|
HCPCS 71100 RT
|
| Hospital Charge Code |
1170373
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$24.35 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$24.35
|
| Rate for Payer: Cash Price |
$78.65
|
| Rate for Payer: Cash Price |
$78.65
|
| Rate for Payer: Cash Price |
$78.65
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| 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 Medicare |
$237.64
|
| 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 |
$339.46
|
| 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 |
$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 |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| 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 |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
|
