|
XR Ribs 2 Views Right
|
Facility
|
OP
|
$431.00
|
|
|
Service Code
|
HCPCS 71100 RT
|
| Hospital Charge Code |
1170373
|
|
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 Right
|
Facility
|
IP
|
$431.00
|
|
|
Service Code
|
HCPCS 71100 RT
|
| Hospital Charge Code |
1170373
|
|
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 Right - Report
|
Professional
|
Both
|
$121.00
|
|
|
Service Code
|
HCPCS 71100 26,RT
|
| Hospital Charge Code |
630228
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$24.35 |
| Max. Negotiated Rate |
$102.85 |
| Rate for Payer: AlohaCare Medicaid |
$24.35
|
| Rate for Payer: Cash Price |
$78.65
|
| Rate for Payer: Cash Price |
$78.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.53
|
| Rate for Payer: Health Management Network Commercial |
$102.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.35
|
|
|
XR Ribs 3 Views Bilateral
|
Facility
|
OP
|
$578.00
|
|
|
Service Code
|
HCPCS 71110
|
| Hospital Charge Code |
1170375
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$25.96 |
| Max. Negotiated Rate |
$560.66 |
| Rate for Payer: AlohaCare Medicaid |
$289.00
|
| Rate for Payer: AlohaCare Medicare |
$289.00
|
| Rate for Payer: Cash Price |
$375.70
|
| Rate for Payer: Cash Price |
$375.70
|
| Rate for Payer: Devoted Health Medicare |
$317.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$25.96
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$133.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$289.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.81
|
| Rate for Payer: Health Management Network Commercial |
$491.30
|
| Rate for Payer: Humana Medicare |
$289.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$520.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$294.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$289.00
|
| Rate for Payer: MDX Hawaii PPO |
$560.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$289.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$289.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$289.00
|
| Rate for Payer: University Health Alliance Commercial |
$85.69
|
|
|
XR Ribs 3 Views Bilateral
|
Professional
|
Both
|
$145.00
|
|
|
Service Code
|
HCPCS 71110
|
| Hospital Charge Code |
1170375
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$29.19 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$29.19
|
| Rate for Payer: AlohaCare Medicare |
$46.96
|
| 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 |
$51.66
|
| 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 |
$49.76
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.35
|
| 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 |
$29.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$46.96
|
| 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 Ribs 3 Views Bilateral
|
Facility
|
IP
|
$578.00
|
|
|
Service Code
|
HCPCS 71110
|
| Hospital Charge Code |
1170375
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$491.30 |
| Max. Negotiated Rate |
$560.66 |
| Rate for Payer: Cash Price |
$375.70
|
| Rate for Payer: Health Management Network Commercial |
$491.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$520.20
|
| Rate for Payer: MDX Hawaii PPO |
$560.66
|
|
|
XR Ribs 3 Views Bilateral - Report
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
HCPCS 71110 26
|
| Hospital Charge Code |
630232
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$102.00 |
| Rate for Payer: AlohaCare Medicaid |
$29.19
|
| Rate for Payer: AlohaCare Medicare |
$13.72
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Devoted Health Medicare |
$15.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$49.76
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.72
|
|
|
XR Ribs w/ PA Chest Bilateral
|
Facility
|
IP
|
$667.00
|
|
|
Service Code
|
HCPCS 71111
|
| Hospital Charge Code |
1170377
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$566.95 |
| Max. Negotiated Rate |
$646.99 |
| Rate for Payer: Cash Price |
$433.55
|
| Rate for Payer: Health Management Network Commercial |
$566.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$600.30
|
| Rate for Payer: MDX Hawaii PPO |
$646.99
|
|
|
XR Ribs w/ PA Chest Bilateral
|
Professional
|
Both
|
$145.00
|
|
|
Service Code
|
HCPCS 71111
|
| Hospital Charge Code |
1170377
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$34.95 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$34.95
|
| Rate for Payer: AlohaCare Medicare |
$56.51
|
| 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 |
$62.16
|
| 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 |
$57.07
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.81
|
| 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 |
$34.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.51
|
| 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 Ribs w/ PA Chest Bilateral
|
Facility
|
OP
|
$667.00
|
|
|
Service Code
|
HCPCS 71111
|
| Hospital Charge Code |
1170377
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$29.64 |
| Max. Negotiated Rate |
$646.99 |
| Rate for Payer: AlohaCare Medicaid |
$333.50
|
| Rate for Payer: AlohaCare Medicare |
$333.50
|
| Rate for Payer: Cash Price |
$433.55
|
| Rate for Payer: Cash Price |
$433.55
|
| Rate for Payer: Devoted Health Medicare |
$366.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$29.64
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$133.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$333.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$32.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.81
|
| Rate for Payer: Health Management Network Commercial |
$566.95
|
| Rate for Payer: Humana Medicare |
$333.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$600.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$340.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$333.50
|
| Rate for Payer: MDX Hawaii PPO |
$646.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$333.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$333.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$333.50
|
| Rate for Payer: University Health Alliance Commercial |
$105.84
|
|
|
XR Ribs w/ PA Chest Bilateral - Report
|
Professional
|
Both
|
$145.00
|
|
|
Service Code
|
HCPCS 71111 26
|
| Hospital Charge Code |
630226
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$123.25 |
| Rate for Payer: AlohaCare Medicaid |
$34.95
|
| Rate for Payer: AlohaCare Medicare |
$15.30
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Devoted Health Medicare |
$16.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.07
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.30
|
|
|
XR Ribs w/ PA Chest Left
|
Professional
|
Both
|
$201.00
|
|
|
Service Code
|
HCPCS 71101 LT
|
| Hospital Charge Code |
1170379
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$28.11 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$28.11
|
| Rate for Payer: Cash Price |
$130.65
|
| Rate for Payer: Cash Price |
$130.65
|
| Rate for Payer: Cash Price |
$130.65
|
| 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 |
$44.50
|
| Rate for Payer: Health Management Network Commercial |
$170.85
|
| 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 |
$28.11
|
| 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 w/ PA Chest Left
|
Facility
|
OP
|
$525.00
|
|
|
Service Code
|
HCPCS 71101 LT
|
| Hospital Charge Code |
1170379
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$21.96 |
| Max. Negotiated Rate |
$509.25 |
| Rate for Payer: AlohaCare Medicaid |
$262.50
|
| Rate for Payer: AlohaCare Medicare |
$262.50
|
| Rate for Payer: Cash Price |
$341.25
|
| Rate for Payer: Cash Price |
$341.25
|
| Rate for Payer: Devoted Health Medicare |
$288.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$21.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$262.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$24.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$498.75
|
| Rate for Payer: Health Management Network Commercial |
$446.25
|
| Rate for Payer: Humana Medicare |
$262.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$472.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$267.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$262.50
|
| Rate for Payer: MDX Hawaii PPO |
$509.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$262.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$262.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$21.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$262.50
|
| Rate for Payer: University Health Alliance Commercial |
$80.36
|
|
|
XR Ribs w/ PA Chest Left
|
Facility
|
IP
|
$525.00
|
|
|
Service Code
|
HCPCS 71101 LT
|
| Hospital Charge Code |
1170379
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$446.25 |
| Max. Negotiated Rate |
$509.25 |
| Rate for Payer: Cash Price |
$341.25
|
| Rate for Payer: Health Management Network Commercial |
$446.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$472.50
|
| Rate for Payer: MDX Hawaii PPO |
$509.25
|
|
|
XR Ribs w/ PA Chest Left - Report
|
Professional
|
Both
|
$98.00
|
|
|
Service Code
|
HCPCS 71101 26,LT
|
| Hospital Charge Code |
630224
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$28.11 |
| Max. Negotiated Rate |
$83.30 |
| Rate for Payer: AlohaCare Medicaid |
$28.11
|
| Rate for Payer: Cash Price |
$63.70
|
| Rate for Payer: Cash Price |
$63.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.50
|
| Rate for Payer: Health Management Network Commercial |
$83.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.11
|
|
|
XR Ribs w/ PA Chest Right
|
Facility
|
IP
|
$525.00
|
|
|
Service Code
|
HCPCS 71101 RT
|
| Hospital Charge Code |
1170381
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$446.25 |
| Max. Negotiated Rate |
$509.25 |
| Rate for Payer: Cash Price |
$341.25
|
| Rate for Payer: Health Management Network Commercial |
$446.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$472.50
|
| Rate for Payer: MDX Hawaii PPO |
$509.25
|
|
|
XR Ribs w/ PA Chest Right
|
Facility
|
OP
|
$525.00
|
|
|
Service Code
|
HCPCS 71101 RT
|
| Hospital Charge Code |
1170381
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$21.96 |
| Max. Negotiated Rate |
$509.25 |
| Rate for Payer: AlohaCare Medicaid |
$262.50
|
| Rate for Payer: AlohaCare Medicare |
$262.50
|
| Rate for Payer: Cash Price |
$341.25
|
| Rate for Payer: Cash Price |
$341.25
|
| Rate for Payer: Devoted Health Medicare |
$288.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$21.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$262.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$24.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$498.75
|
| Rate for Payer: Health Management Network Commercial |
$446.25
|
| Rate for Payer: Humana Medicare |
$262.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$472.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$267.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$262.50
|
| Rate for Payer: MDX Hawaii PPO |
$509.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$262.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$262.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$21.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$262.50
|
| Rate for Payer: University Health Alliance Commercial |
$80.36
|
|
|
XR Ribs w/ PA Chest Right
|
Professional
|
Both
|
$201.00
|
|
|
Service Code
|
HCPCS 71101 RT
|
| Hospital Charge Code |
1170381
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$28.11 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$28.11
|
| Rate for Payer: Cash Price |
$130.65
|
| Rate for Payer: Cash Price |
$130.65
|
| Rate for Payer: Cash Price |
$130.65
|
| 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 |
$44.50
|
| Rate for Payer: Health Management Network Commercial |
$170.85
|
| 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 |
$28.11
|
| 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 w/ PA Chest Right - Report
|
Professional
|
Both
|
$98.00
|
|
|
Service Code
|
HCPCS 71101 26,RT
|
| Hospital Charge Code |
630218
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$28.11 |
| Max. Negotiated Rate |
$83.30 |
| Rate for Payer: AlohaCare Medicaid |
$28.11
|
| Rate for Payer: Cash Price |
$63.70
|
| Rate for Payer: Cash Price |
$63.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.50
|
| Rate for Payer: Health Management Network Commercial |
$83.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.11
|
|
|
XR Sacroiliac Joints 1 or 2 Views
|
Facility
|
IP
|
$419.00
|
|
|
Service Code
|
HCPCS 72200
|
| Hospital Charge Code |
1170385
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$356.15 |
| Max. Negotiated Rate |
$406.43 |
| Rate for Payer: Cash Price |
$272.35
|
| Rate for Payer: Health Management Network Commercial |
$356.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$377.10
|
| Rate for Payer: MDX Hawaii PPO |
$406.43
|
|
|
XR Sacroiliac Joints 1 or 2 Views
|
Facility
|
OP
|
$419.00
|
|
|
Service Code
|
HCPCS 72200
|
| Hospital Charge Code |
1170385
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$17.04 |
| Max. Negotiated Rate |
$406.43 |
| Rate for Payer: AlohaCare Medicaid |
$209.50
|
| Rate for Payer: AlohaCare Medicare |
$209.50
|
| Rate for Payer: Cash Price |
$272.35
|
| Rate for Payer: Cash Price |
$272.35
|
| Rate for Payer: Devoted Health Medicare |
$230.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$17.04
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$133.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$18.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.81
|
| Rate for Payer: Health Management Network Commercial |
$356.15
|
| Rate for Payer: Humana Medicare |
$209.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$377.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$213.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.50
|
| Rate for Payer: MDX Hawaii PPO |
$406.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$209.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$209.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.50
|
| Rate for Payer: University Health Alliance Commercial |
$59.38
|
|
|
XR Sacroiliac Joints 1 or 2 Views - Report
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 72200 26
|
| Hospital Charge Code |
630216
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$8.53 |
| Max. Negotiated Rate |
$63.75 |
| Rate for Payer: AlohaCare Medicaid |
$22.21
|
| Rate for Payer: AlohaCare Medicare |
$8.53
|
| Rate for Payer: Cash Price |
$48.75
|
| Rate for Payer: Cash Price |
$48.75
|
| 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 |
$32.36
|
| Rate for Payer: Health Management Network Commercial |
$63.75
|
| 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 |
$22.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.53
|
|
|
XR Sacroiliac Joints 3+ Views
|
Facility
|
OP
|
$554.00
|
|
|
Service Code
|
HCPCS 72202
|
| Hospital Charge Code |
1170387
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$20.40 |
| Max. Negotiated Rate |
$537.38 |
| Rate for Payer: AlohaCare Medicaid |
$277.00
|
| Rate for Payer: AlohaCare Medicare |
$277.00
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Devoted Health Medicare |
$304.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$20.40
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$133.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$277.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$22.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.81
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Humana Medicare |
$277.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$282.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$277.00
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$277.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$277.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$277.00
|
| Rate for Payer: University Health Alliance Commercial |
$71.43
|
|
|
XR Sacroiliac Joints 3+ Views
|
Facility
|
IP
|
$554.00
|
|
|
Service Code
|
HCPCS 72202
|
| Hospital Charge Code |
1170387
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$470.90 |
| Max. Negotiated Rate |
$537.38 |
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
|
|
XR Sacroiliac Joints 3+ Views - Report
|
Professional
|
Both
|
$66.00
|
|
|
Service Code
|
HCPCS 72202 26
|
| Hospital Charge Code |
630197
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$10.58 |
| Max. Negotiated Rate |
$56.10 |
| Rate for Payer: AlohaCare Medicaid |
$26.16
|
| Rate for Payer: AlohaCare Medicare |
$10.58
|
| Rate for Payer: Cash Price |
$42.90
|
| Rate for Payer: Cash Price |
$42.90
|
| Rate for Payer: Devoted Health Medicare |
$11.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.80
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.58
|
|
