|
TB TEST CELL IMMUN MEASURE
|
Facility
|
IP
|
$324.00
|
|
|
Service Code
|
HCPCS 86480
|
| Hospital Charge Code |
4304879
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$210.60 |
| Max. Negotiated Rate |
$210.60 |
| Rate for Payer: Cash Price |
$243.00
|
| Rate for Payer: Galaxy Health Commercial |
$210.60
|
|
|
TC99M CHOLETEC =< 15 MCI MEBROFENIN
|
Facility
|
OP
|
$494.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
4210060
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$167.96 |
| Max. Negotiated Rate |
$397.67 |
| Rate for Payer: Aetna of NY Medicare |
$227.24
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$370.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$370.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$182.78
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$247.00
|
| Rate for Payer: Cash Price |
$370.50
|
| Rate for Payer: Cash Price |
$370.50
|
| Rate for Payer: CDPHP Commercial |
$397.67
|
| Rate for Payer: CDPHP Medicare |
$182.78
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$395.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$395.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$395.20
|
| Rate for Payer: EmblemHealth Medicaid |
$395.20
|
| Rate for Payer: EmblemHealth Medicare |
$167.96
|
| Rate for Payer: EmblemHealth Select Care |
$355.68
|
| Rate for Payer: Fidelis Medicare |
$188.26
|
| Rate for Payer: Galaxy Health Commercial |
$321.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$182.78
|
| Rate for Payer: Humana Medicare |
$182.78
|
| Rate for Payer: Local 1199SEIU Medicare |
$227.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$370.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$278.12
|
| Rate for Payer: MVP Health Care of NY Medicare |
$191.92
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$187.21
|
| Rate for Payer: United Healthcare Commercial |
$187.21
|
| Rate for Payer: United Healthcare Medicare |
$182.78
|
| Rate for Payer: WellCare Medicare |
$271.70
|
|
|
TC99M CHOLETEC =< 15 MCI MEBROFENIN
|
Facility
|
IP
|
$494.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
4210060
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$321.10 |
| Max. Negotiated Rate |
$321.10 |
| Rate for Payer: Cash Price |
$370.50
|
| Rate for Payer: Galaxy Health Commercial |
$321.10
|
|
|
TC99M EXAMETAZIME =< 25 MCI
|
Facility
|
OP
|
$2,610.00
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
4210059
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$887.40 |
| Max. Negotiated Rate |
$2,535.14 |
| Rate for Payer: Aetna of NY Medicare |
$1,200.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,957.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,957.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$965.70
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,305.00
|
| Rate for Payer: Cash Price |
$1,957.50
|
| Rate for Payer: Cash Price |
$1,957.50
|
| Rate for Payer: CDPHP Commercial |
$2,101.05
|
| Rate for Payer: CDPHP Medicare |
$965.70
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$2,088.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$2,088.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$2,088.00
|
| Rate for Payer: EmblemHealth Medicaid |
$2,088.00
|
| Rate for Payer: EmblemHealth Medicare |
$887.40
|
| Rate for Payer: EmblemHealth Select Care |
$1,879.20
|
| Rate for Payer: Fidelis Medicare |
$994.67
|
| Rate for Payer: Galaxy Health Commercial |
$1,696.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$965.70
|
| Rate for Payer: Humana Medicare |
$965.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,200.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,957.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,469.43
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,013.98
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$2,535.14
|
| Rate for Payer: United Healthcare Commercial |
$2,535.14
|
| Rate for Payer: United Healthcare Medicare |
$965.70
|
| Rate for Payer: WellCare Medicare |
$1,435.50
|
|
|
TC99M EXAMETAZIME =< 25 MCI
|
Facility
|
IP
|
$2,610.00
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
4210059
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,696.50 |
| Max. Negotiated Rate |
$1,696.50 |
| Rate for Payer: Cash Price |
$1,957.50
|
| Rate for Payer: Galaxy Health Commercial |
$1,696.50
|
|
|
TC99M HEPATOLITE
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
HCPCS A9510
|
| Hospital Charge Code |
4211214
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$46.92 |
| Max. Negotiated Rate |
$118.54 |
| Rate for Payer: Aetna of NY Medicare |
$63.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$103.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$103.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$51.06
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$69.00
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: CDPHP Commercial |
$111.09
|
| Rate for Payer: CDPHP Medicare |
$51.06
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$110.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$110.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$110.40
|
| Rate for Payer: EmblemHealth Medicaid |
$110.40
|
| Rate for Payer: EmblemHealth Medicare |
$46.92
|
| Rate for Payer: EmblemHealth Select Care |
$99.36
|
| Rate for Payer: Fidelis Medicare |
$52.59
|
| Rate for Payer: Galaxy Health Commercial |
$89.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$51.06
|
| Rate for Payer: Humana Medicare |
$51.06
|
| Rate for Payer: Local 1199SEIU Medicare |
$63.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$103.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$77.69
|
| Rate for Payer: MVP Health Care of NY Medicare |
$53.61
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$118.54
|
| Rate for Payer: United Healthcare Commercial |
$118.54
|
| Rate for Payer: United Healthcare Medicare |
$51.06
|
| Rate for Payer: WellCare Medicare |
$75.90
|
|
|
TC99M HEPATOLITE
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
HCPCS A9510
|
| Hospital Charge Code |
4211214
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$89.70 |
| Max. Negotiated Rate |
$89.70 |
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Galaxy Health Commercial |
$89.70
|
|
|
TC99M LABELED RBC =< 30 MCI
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
4210066
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$135.32 |
| Max. Negotiated Rate |
$320.39 |
| Rate for Payer: Aetna of NY Medicare |
$183.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$298.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$298.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$147.26
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$199.00
|
| Rate for Payer: Cash Price |
$298.50
|
| Rate for Payer: Cash Price |
$298.50
|
| Rate for Payer: CDPHP Commercial |
$320.39
|
| Rate for Payer: CDPHP Medicare |
$147.26
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$318.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$318.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$318.40
|
| Rate for Payer: EmblemHealth Medicaid |
$318.40
|
| Rate for Payer: EmblemHealth Medicare |
$135.32
|
| Rate for Payer: EmblemHealth Select Care |
$286.56
|
| Rate for Payer: Fidelis Medicare |
$151.68
|
| Rate for Payer: Galaxy Health Commercial |
$258.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$147.26
|
| Rate for Payer: Humana Medicare |
$147.26
|
| Rate for Payer: Local 1199SEIU Medicare |
$183.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$298.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$224.07
|
| Rate for Payer: MVP Health Care of NY Medicare |
$154.62
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$172.21
|
| Rate for Payer: United Healthcare Commercial |
$172.21
|
| Rate for Payer: United Healthcare Medicare |
$147.26
|
| Rate for Payer: WellCare Medicare |
$218.90
|
|
|
TC99M LABELED RBC =< 30 MCI
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
4210066
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$258.70 |
| Max. Negotiated Rate |
$258.70 |
| Rate for Payer: Cash Price |
$298.50
|
| Rate for Payer: Galaxy Health Commercial |
$258.70
|
|
|
TC99M MAA =< 10 MCI
|
Facility
|
IP
|
$314.00
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
4210062
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$204.10 |
| Max. Negotiated Rate |
$204.10 |
| Rate for Payer: Cash Price |
$235.50
|
| Rate for Payer: Galaxy Health Commercial |
$204.10
|
|
|
TC99M MAA =< 10 MCI
|
Facility
|
OP
|
$314.00
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
4210062
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$54.80 |
| Max. Negotiated Rate |
$252.77 |
| Rate for Payer: Aetna of NY Medicare |
$144.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$235.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$235.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$116.18
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$157.00
|
| Rate for Payer: Cash Price |
$235.50
|
| Rate for Payer: Cash Price |
$235.50
|
| Rate for Payer: CDPHP Commercial |
$252.77
|
| Rate for Payer: CDPHP Medicare |
$116.18
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$251.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$251.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$251.20
|
| Rate for Payer: EmblemHealth Medicaid |
$251.20
|
| Rate for Payer: EmblemHealth Medicare |
$106.76
|
| Rate for Payer: EmblemHealth Select Care |
$226.08
|
| Rate for Payer: Fidelis Medicare |
$119.67
|
| Rate for Payer: Galaxy Health Commercial |
$204.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$116.18
|
| Rate for Payer: Humana Medicare |
$116.18
|
| Rate for Payer: Local 1199SEIU Medicare |
$144.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$235.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$176.78
|
| Rate for Payer: MVP Health Care of NY Medicare |
$121.99
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$54.80
|
| Rate for Payer: United Healthcare Commercial |
$54.80
|
| Rate for Payer: United Healthcare Medicare |
$116.18
|
| Rate for Payer: WellCare Medicare |
$172.70
|
|
|
TC99M MAG 3 =< 15 MCI MERTIATIDE
|
Facility
|
OP
|
$513.00
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
4210067
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$174.42 |
| Max. Negotiated Rate |
$1,327.95 |
| Rate for Payer: Aetna of NY Medicare |
$235.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$384.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$384.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$189.81
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$256.50
|
| Rate for Payer: Cash Price |
$384.75
|
| Rate for Payer: Cash Price |
$384.75
|
| Rate for Payer: CDPHP Commercial |
$412.96
|
| Rate for Payer: CDPHP Medicare |
$189.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$410.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$410.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$410.40
|
| Rate for Payer: EmblemHealth Medicaid |
$410.40
|
| Rate for Payer: EmblemHealth Medicare |
$174.42
|
| Rate for Payer: EmblemHealth Select Care |
$369.36
|
| Rate for Payer: Fidelis Medicare |
$195.50
|
| Rate for Payer: Galaxy Health Commercial |
$333.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$189.81
|
| Rate for Payer: Humana Medicare |
$189.81
|
| Rate for Payer: Local 1199SEIU Medicare |
$235.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$384.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$288.82
|
| Rate for Payer: MVP Health Care of NY Medicare |
$199.30
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,327.95
|
| Rate for Payer: United Healthcare Commercial |
$1,327.95
|
| Rate for Payer: United Healthcare Medicare |
$189.81
|
| Rate for Payer: WellCare Medicare |
$282.15
|
|
|
TC99M MAG 3 =< 15 MCI MERTIATIDE
|
Facility
|
IP
|
$513.00
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
4210067
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$333.45 |
| Max. Negotiated Rate |
$333.45 |
| Rate for Payer: Cash Price |
$384.75
|
| Rate for Payer: Galaxy Health Commercial |
$333.45
|
|
|
TC99M MDP =< 30 MCI
|
Facility
|
OP
|
$438.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
4210054
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$50.89 |
| Max. Negotiated Rate |
$352.59 |
| Rate for Payer: Aetna of NY Medicare |
$201.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$328.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$328.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$162.06
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$219.00
|
| Rate for Payer: Cash Price |
$328.50
|
| Rate for Payer: Cash Price |
$328.50
|
| Rate for Payer: CDPHP Commercial |
$352.59
|
| Rate for Payer: CDPHP Medicare |
$162.06
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$350.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$350.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$350.40
|
| Rate for Payer: EmblemHealth Medicaid |
$350.40
|
| Rate for Payer: EmblemHealth Medicare |
$148.92
|
| Rate for Payer: EmblemHealth Select Care |
$315.36
|
| Rate for Payer: Fidelis Medicare |
$166.92
|
| Rate for Payer: Galaxy Health Commercial |
$284.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$162.06
|
| Rate for Payer: Humana Medicare |
$162.06
|
| Rate for Payer: Local 1199SEIU Medicare |
$201.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$328.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$246.59
|
| Rate for Payer: MVP Health Care of NY Medicare |
$170.16
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$50.89
|
| Rate for Payer: United Healthcare Commercial |
$50.89
|
| Rate for Payer: United Healthcare Medicare |
$162.06
|
| Rate for Payer: WellCare Medicare |
$240.90
|
|
|
TC99M MDP =< 30 MCI
|
Facility
|
IP
|
$438.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
4210054
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$284.70 |
| Max. Negotiated Rate |
$284.70 |
| Rate for Payer: Cash Price |
$328.50
|
| Rate for Payer: Galaxy Health Commercial |
$284.70
|
|
|
TC99M PENTETATE =< 25 MCI
|
Facility
|
OP
|
$557.00
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
4210061
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$50.89 |
| Max. Negotiated Rate |
$448.38 |
| Rate for Payer: Aetna of NY Medicare |
$256.22
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$417.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$417.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$206.09
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$278.50
|
| Rate for Payer: Cash Price |
$417.75
|
| Rate for Payer: Cash Price |
$417.75
|
| Rate for Payer: CDPHP Commercial |
$448.38
|
| Rate for Payer: CDPHP Medicare |
$206.09
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$445.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$445.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$445.60
|
| Rate for Payer: EmblemHealth Medicaid |
$445.60
|
| Rate for Payer: EmblemHealth Medicare |
$189.38
|
| Rate for Payer: EmblemHealth Select Care |
$401.04
|
| Rate for Payer: Fidelis Medicare |
$212.27
|
| Rate for Payer: Galaxy Health Commercial |
$362.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$206.09
|
| Rate for Payer: Humana Medicare |
$206.09
|
| Rate for Payer: Local 1199SEIU Medicare |
$256.22
|
| Rate for Payer: MVP Health Care of NY Commercial |
$417.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$313.59
|
| Rate for Payer: MVP Health Care of NY Medicare |
$216.39
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$50.89
|
| Rate for Payer: United Healthcare Commercial |
$50.89
|
| Rate for Payer: United Healthcare Medicare |
$206.09
|
| Rate for Payer: WellCare Medicare |
$306.35
|
|
|
TC99M PENTETATE =< 25 MCI
|
Facility
|
IP
|
$557.00
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
4210061
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$362.05 |
| Max. Negotiated Rate |
$362.05 |
| Rate for Payer: Cash Price |
$417.75
|
| Rate for Payer: Galaxy Health Commercial |
$362.05
|
|
|
TC99M PERTECHNETATE
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
HCPCS A9512
|
| Hospital Charge Code |
4211242
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$89.70 |
| Max. Negotiated Rate |
$89.70 |
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Galaxy Health Commercial |
$89.70
|
|
|
TC99M PERTECHNETATE
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
HCPCS A9512
|
| Hospital Charge Code |
4211242
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$8.38 |
| Max. Negotiated Rate |
$111.09 |
| Rate for Payer: Aetna of NY Medicare |
$63.48
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$103.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$103.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$51.06
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$69.00
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: CDPHP Commercial |
$111.09
|
| Rate for Payer: CDPHP Medicare |
$51.06
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$110.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$110.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$110.40
|
| Rate for Payer: EmblemHealth Medicaid |
$110.40
|
| Rate for Payer: EmblemHealth Medicare |
$46.92
|
| Rate for Payer: EmblemHealth Select Care |
$99.36
|
| Rate for Payer: Fidelis Medicare |
$52.59
|
| Rate for Payer: Galaxy Health Commercial |
$89.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$51.06
|
| Rate for Payer: Humana Medicare |
$51.06
|
| Rate for Payer: Local 1199SEIU Medicare |
$63.48
|
| Rate for Payer: MVP Health Care of NY Commercial |
$103.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$77.69
|
| Rate for Payer: MVP Health Care of NY Medicare |
$53.61
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$8.38
|
| Rate for Payer: United Healthcare Commercial |
$8.38
|
| Rate for Payer: United Healthcare Medicare |
$51.06
|
| Rate for Payer: WellCare Medicare |
$75.90
|
|
|
TC99M SULFUR COLLOID =< 20 MCI
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
4210063
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$258.70 |
| Max. Negotiated Rate |
$258.70 |
| Rate for Payer: Cash Price |
$298.50
|
| Rate for Payer: Galaxy Health Commercial |
$258.70
|
|
|
TC99M SULFUR COLLOID =< 20 MCI
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
4210063
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$135.32 |
| Max. Negotiated Rate |
$566.97 |
| Rate for Payer: Aetna of NY Medicare |
$183.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$298.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$298.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$147.26
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$199.00
|
| Rate for Payer: Cash Price |
$298.50
|
| Rate for Payer: Cash Price |
$298.50
|
| Rate for Payer: CDPHP Commercial |
$320.39
|
| Rate for Payer: CDPHP Medicare |
$147.26
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$318.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$318.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$318.40
|
| Rate for Payer: EmblemHealth Medicaid |
$318.40
|
| Rate for Payer: EmblemHealth Medicare |
$135.32
|
| Rate for Payer: EmblemHealth Select Care |
$286.56
|
| Rate for Payer: Fidelis Medicare |
$151.68
|
| Rate for Payer: Galaxy Health Commercial |
$258.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$147.26
|
| Rate for Payer: Humana Medicare |
$147.26
|
| Rate for Payer: Local 1199SEIU Medicare |
$183.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$298.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$224.07
|
| Rate for Payer: MVP Health Care of NY Medicare |
$154.62
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$566.97
|
| Rate for Payer: United Healthcare Commercial |
$566.97
|
| Rate for Payer: United Healthcare Medicare |
$147.26
|
| Rate for Payer: WellCare Medicare |
$218.90
|
|
|
TECHNETIUM TC99M AEROSOL =< 75 MCI
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS A9567
|
| Hospital Charge Code |
4210068
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$35.23 |
| Max. Negotiated Rate |
$84.52 |
| Rate for Payer: Aetna of NY Medicare |
$48.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$78.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$78.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$38.85
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$52.50
|
| Rate for Payer: Cash Price |
$78.75
|
| Rate for Payer: Cash Price |
$78.75
|
| Rate for Payer: CDPHP Commercial |
$84.52
|
| Rate for Payer: CDPHP Medicare |
$38.85
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$84.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$84.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$84.00
|
| Rate for Payer: EmblemHealth Medicaid |
$84.00
|
| Rate for Payer: EmblemHealth Medicare |
$35.70
|
| Rate for Payer: EmblemHealth Select Care |
$75.60
|
| Rate for Payer: Fidelis Medicare |
$40.02
|
| Rate for Payer: Galaxy Health Commercial |
$68.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$38.85
|
| Rate for Payer: Humana Medicare |
$38.85
|
| Rate for Payer: Local 1199SEIU Medicare |
$48.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$78.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$59.12
|
| Rate for Payer: MVP Health Care of NY Medicare |
$40.79
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$35.23
|
| Rate for Payer: United Healthcare Commercial |
$35.23
|
| Rate for Payer: United Healthcare Medicare |
$38.85
|
| Rate for Payer: WellCare Medicare |
$57.75
|
|
|
TECHNETIUM TC99M AEROSOL =< 75 MCI
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS A9567
|
| Hospital Charge Code |
4211248
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$35.23 |
| Max. Negotiated Rate |
$84.52 |
| Rate for Payer: Aetna of NY Medicare |
$48.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$78.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$78.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$38.85
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$52.50
|
| Rate for Payer: Cash Price |
$78.75
|
| Rate for Payer: Cash Price |
$78.75
|
| Rate for Payer: CDPHP Commercial |
$84.52
|
| Rate for Payer: CDPHP Medicare |
$38.85
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$84.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$84.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$84.00
|
| Rate for Payer: EmblemHealth Medicaid |
$84.00
|
| Rate for Payer: EmblemHealth Medicare |
$35.70
|
| Rate for Payer: EmblemHealth Select Care |
$75.60
|
| Rate for Payer: Fidelis Medicare |
$40.02
|
| Rate for Payer: Galaxy Health Commercial |
$68.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$38.85
|
| Rate for Payer: Humana Medicare |
$38.85
|
| Rate for Payer: Local 1199SEIU Medicare |
$48.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$78.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$59.12
|
| Rate for Payer: MVP Health Care of NY Medicare |
$40.79
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$35.23
|
| Rate for Payer: United Healthcare Commercial |
$35.23
|
| Rate for Payer: United Healthcare Medicare |
$38.85
|
| Rate for Payer: WellCare Medicare |
$57.75
|
|
|
TECHNETIUM TC99M AEROSOL =< 75 MCI
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
HCPCS A9567
|
| Hospital Charge Code |
4211248
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$68.25 |
| Max. Negotiated Rate |
$68.25 |
| Rate for Payer: Cash Price |
$78.75
|
| Rate for Payer: Galaxy Health Commercial |
$68.25
|
|
|
TECHNETIUM TC99M AEROSOL =< 75 MCI
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
HCPCS A9567
|
| Hospital Charge Code |
4210068
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$68.25 |
| Max. Negotiated Rate |
$68.25 |
| Rate for Payer: Cash Price |
$78.75
|
| Rate for Payer: Galaxy Health Commercial |
$68.25
|
|
