|
XARELTO 20 MG TABLET
|
Facility
|
IP
|
$44.55
|
|
|
Service Code
|
NDC 50458057910
|
| Hospital Charge Code |
4409128
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$28.96 |
| Rate for Payer: Cash Price |
$33.41
|
| Rate for Payer: Galaxy Health Commercial |
$28.96
|
| Rate for Payer: WellCare Medicare |
$24.50
|
|
|
XIFAXAN 550 MG TABLET 550 mg, 60 eaches
|
Facility
|
OP
|
$190.00
|
|
|
Service Code
|
NDC 65649030303
|
| Hospital Charge Code |
4401339
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.60 |
| Max. Negotiated Rate |
$152.95 |
| Rate for Payer: Aetna of NY Commercial |
$133.00
|
| Rate for Payer: Aetna of NY Medicare |
$87.40
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$142.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$142.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$70.30
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$95.00
|
| Rate for Payer: Cash Price |
$142.50
|
| Rate for Payer: CDPHP Commercial |
$152.95
|
| Rate for Payer: CDPHP Medicare |
$70.30
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$152.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$152.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$152.00
|
| Rate for Payer: EmblemHealth Medicaid |
$152.00
|
| Rate for Payer: EmblemHealth Medicare |
$64.60
|
| Rate for Payer: EmblemHealth Select Care |
$136.80
|
| Rate for Payer: Fidelis Medicare |
$72.41
|
| Rate for Payer: Galaxy Health Commercial |
$123.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$70.30
|
| Rate for Payer: Humana Medicare |
$70.30
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$133.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$87.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$142.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$106.97
|
| Rate for Payer: MVP Health Care of NY Medicare |
$73.82
|
| Rate for Payer: United Healthcare Medicare |
$70.30
|
| Rate for Payer: WellCare Medicare |
$104.50
|
|
|
XIFAXAN 550 MG TABLET 550 mg, 60 eaches
|
Facility
|
IP
|
$190.00
|
|
|
Service Code
|
NDC 65649030303
|
| Hospital Charge Code |
4401339
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$104.50 |
| Max. Negotiated Rate |
$123.50 |
| Rate for Payer: Cash Price |
$142.50
|
| Rate for Payer: Galaxy Health Commercial |
$123.50
|
| Rate for Payer: WellCare Medicare |
$104.50
|
|
|
XLARGE LEFT COMFORTFORM WRIST
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
4471573
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: Aetna of NY Commercial |
$18.90
|
| Rate for Payer: Aetna of NY Medicare |
$12.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$20.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$20.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.99
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$13.50
|
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: CDPHP Commercial |
$21.74
|
| Rate for Payer: CDPHP Medicare |
$9.99
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$21.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$21.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$21.60
|
| Rate for Payer: EmblemHealth Medicaid |
$21.60
|
| Rate for Payer: EmblemHealth Medicare |
$9.18
|
| Rate for Payer: EmblemHealth Select Care |
$19.44
|
| Rate for Payer: Fidelis Medicare |
$10.29
|
| Rate for Payer: Galaxy Health Commercial |
$17.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$9.99
|
| Rate for Payer: Humana Medicare |
$9.99
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$18.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$12.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$20.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$15.20
|
| Rate for Payer: MVP Health Care of NY Medicare |
$10.49
|
| Rate for Payer: United Healthcare Medicare |
$9.99
|
| Rate for Payer: WellCare Medicare |
$14.85
|
|
|
XLARGE LEFT COMFORTFORM WRIST
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
4471573
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.55 |
| Max. Negotiated Rate |
$17.55 |
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Galaxy Health Commercial |
$17.55
|
|
|
XLARGE RIGHT COMFORTFORM WRIST
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
4471568
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: Aetna of NY Commercial |
$18.90
|
| Rate for Payer: Aetna of NY Medicare |
$12.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$20.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$20.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.99
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$13.50
|
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: CDPHP Commercial |
$21.74
|
| Rate for Payer: CDPHP Medicare |
$9.99
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$21.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$21.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$21.60
|
| Rate for Payer: EmblemHealth Medicaid |
$21.60
|
| Rate for Payer: EmblemHealth Medicare |
$9.18
|
| Rate for Payer: EmblemHealth Select Care |
$19.44
|
| Rate for Payer: Fidelis Medicare |
$10.29
|
| Rate for Payer: Galaxy Health Commercial |
$17.55
|
| Rate for Payer: Hamaspik Choice Medicare |
$9.99
|
| Rate for Payer: Humana Medicare |
$9.99
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$18.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$12.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$20.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$15.20
|
| Rate for Payer: MVP Health Care of NY Medicare |
$10.49
|
| Rate for Payer: United Healthcare Medicare |
$9.99
|
| Rate for Payer: WellCare Medicare |
$14.85
|
|
|
XLARGE RIGHT COMFORTFORM WRIST
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
4471568
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.55 |
| Max. Negotiated Rate |
$17.55 |
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Galaxy Health Commercial |
$17.55
|
|
|
XLARGE SPECIALTY ARM SLING
|
Facility
|
OP
|
$14.00
|
|
| Hospital Charge Code |
4471559
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.76 |
| Max. Negotiated Rate |
$11.27 |
| Rate for Payer: Aetna of NY Commercial |
$9.80
|
| Rate for Payer: Aetna of NY Medicare |
$6.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$10.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$10.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.18
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$7.00
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: CDPHP Commercial |
$11.27
|
| Rate for Payer: CDPHP Medicare |
$5.18
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$11.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$11.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$11.20
|
| Rate for Payer: EmblemHealth Medicaid |
$11.20
|
| Rate for Payer: EmblemHealth Medicare |
$4.76
|
| Rate for Payer: EmblemHealth Select Care |
$10.08
|
| Rate for Payer: Fidelis Medicare |
$5.34
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.18
|
| Rate for Payer: Humana Medicare |
$5.18
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.44
|
| Rate for Payer: United Healthcare Medicare |
$5.18
|
| Rate for Payer: WellCare Medicare |
$7.70
|
|
|
XLARGE SPECIALTY ARM SLING
|
Facility
|
IP
|
$14.00
|
|
| Hospital Charge Code |
4471559
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$9.10 |
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
|
|
XL HEELBO
|
Facility
|
OP
|
$24.00
|
|
| Hospital Charge Code |
4471291
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$19.32 |
| Rate for Payer: Aetna of NY Commercial |
$16.80
|
| Rate for Payer: Aetna of NY Medicare |
$11.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$8.88
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$12.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: CDPHP Commercial |
$19.32
|
| Rate for Payer: CDPHP Medicare |
$8.88
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$19.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$19.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$19.20
|
| Rate for Payer: EmblemHealth Medicaid |
$19.20
|
| Rate for Payer: EmblemHealth Medicare |
$8.16
|
| Rate for Payer: EmblemHealth Select Care |
$17.28
|
| Rate for Payer: Fidelis Medicare |
$9.15
|
| Rate for Payer: Galaxy Health Commercial |
$15.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$8.88
|
| Rate for Payer: Humana Medicare |
$8.88
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$11.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$18.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$13.51
|
| Rate for Payer: MVP Health Care of NY Medicare |
$9.32
|
| Rate for Payer: United Healthcare Medicare |
$8.88
|
| Rate for Payer: WellCare Medicare |
$13.20
|
|
|
XL HEELBO
|
Facility
|
IP
|
$24.00
|
|
| Hospital Charge Code |
4471291
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Galaxy Health Commercial |
$15.60
|
|
|
XL STOCKING ANTI-EMB THIGH
|
Facility
|
OP
|
$19.00
|
|
| Hospital Charge Code |
4471190
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.46 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna of NY Commercial |
$13.30
|
| Rate for Payer: Aetna of NY Medicare |
$8.74
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$14.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$14.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7.03
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$9.50
|
| Rate for Payer: Cash Price |
$14.25
|
| Rate for Payer: CDPHP Commercial |
$15.30
|
| Rate for Payer: CDPHP Medicare |
$7.03
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$15.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$15.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$15.20
|
| Rate for Payer: EmblemHealth Medicaid |
$15.20
|
| Rate for Payer: EmblemHealth Medicare |
$6.46
|
| Rate for Payer: EmblemHealth Select Care |
$13.68
|
| Rate for Payer: Fidelis Medicare |
$7.24
|
| Rate for Payer: Galaxy Health Commercial |
$12.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$7.03
|
| Rate for Payer: Humana Medicare |
$7.03
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$13.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$8.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$14.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$10.70
|
| Rate for Payer: MVP Health Care of NY Medicare |
$7.38
|
| Rate for Payer: United Healthcare Medicare |
$7.03
|
| Rate for Payer: WellCare Medicare |
$10.45
|
|
|
XL STOCKING ANTI-EMB THIGH
|
Facility
|
IP
|
$19.00
|
|
| Hospital Charge Code |
4471190
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.35 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: Cash Price |
$14.25
|
| Rate for Payer: Galaxy Health Commercial |
$12.35
|
|
|
XL UNIVER KNEE WRAP W/CLOSED P
|
Facility
|
IP
|
$34.00
|
|
| Hospital Charge Code |
4471544
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$22.10 |
| Max. Negotiated Rate |
$22.10 |
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Galaxy Health Commercial |
$22.10
|
|
|
XL UNIVER KNEE WRAP W/CLOSED P
|
Facility
|
OP
|
$34.00
|
|
| Hospital Charge Code |
4471544
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.56 |
| Max. Negotiated Rate |
$27.37 |
| Rate for Payer: Aetna of NY Commercial |
$23.80
|
| Rate for Payer: Aetna of NY Medicare |
$15.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$25.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$25.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$12.58
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$17.00
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: CDPHP Commercial |
$27.37
|
| Rate for Payer: CDPHP Medicare |
$12.58
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$27.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$27.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$27.20
|
| Rate for Payer: EmblemHealth Medicaid |
$27.20
|
| Rate for Payer: EmblemHealth Medicare |
$11.56
|
| Rate for Payer: EmblemHealth Select Care |
$24.48
|
| Rate for Payer: Fidelis Medicare |
$12.96
|
| Rate for Payer: Galaxy Health Commercial |
$22.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$12.58
|
| Rate for Payer: Humana Medicare |
$12.58
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$23.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$15.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$25.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$19.14
|
| Rate for Payer: MVP Health Care of NY Medicare |
$13.21
|
| Rate for Payer: United Healthcare Medicare |
$12.58
|
| Rate for Payer: WellCare Medicare |
$18.70
|
|
|
X-RAY BONE LENGTH STUDIES
|
Facility
|
IP
|
$315.00
|
|
|
Service Code
|
HCPCS 77073 TC
|
| Hospital Charge Code |
4150026
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$204.75 |
| Max. Negotiated Rate |
$204.75 |
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Galaxy Health Commercial |
$204.75
|
|
|
X-RAY BONE LENGTH STUDIES
|
Facility
|
OP
|
$315.00
|
|
|
Service Code
|
HCPCS 77073 TC
|
| Hospital Charge Code |
4150026
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$390.00 |
| Rate for Payer: Aetna of NY Commercial |
$189.00
|
| Rate for Payer: Aetna of NY Medicare |
$144.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$236.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$236.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$116.55
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$157.50
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: CDPHP Commercial |
$253.58
|
| Rate for Payer: CDPHP Medicare |
$116.55
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$220.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$252.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$252.00
|
| Rate for Payer: EmblemHealth Medicaid |
$252.00
|
| Rate for Payer: EmblemHealth Medicare |
$107.10
|
| Rate for Payer: EmblemHealth Select Care |
$204.75
|
| Rate for Payer: Fidelis Medicare |
$120.05
|
| Rate for Payer: Galaxy Health Commercial |
$204.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$116.55
|
| Rate for Payer: Humana Medicare |
$116.55
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$189.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$144.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$236.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$177.34
|
| Rate for Payer: MVP Health Care of NY Medicare |
$122.38
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$390.00
|
| Rate for Payer: United Healthcare Commercial |
$390.00
|
| Rate for Payer: United Healthcare Medicare |
$116.55
|
| Rate for Payer: WellCare Medicare |
$173.25
|
|
|
X-RAY BONE SURVEY COMPLETE
|
Facility
|
IP
|
$742.00
|
|
|
Service Code
|
HCPCS 77075
|
| Hospital Charge Code |
4150325
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$482.30 |
| Max. Negotiated Rate |
$482.30 |
| Rate for Payer: Cash Price |
$556.50
|
| Rate for Payer: Galaxy Health Commercial |
$482.30
|
|
|
X-RAY BONE SURVEY COMPLETE
|
Facility
|
OP
|
$742.00
|
|
|
Service Code
|
HCPCS 77075
|
| Hospital Charge Code |
4150325
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$50.50 |
| Max. Negotiated Rate |
$597.31 |
| Rate for Payer: Aetna of NY Commercial |
$445.20
|
| Rate for Payer: Aetna of NY Medicare |
$341.32
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$556.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$556.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$274.54
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$371.00
|
| Rate for Payer: Cash Price |
$556.50
|
| Rate for Payer: Cash Price |
$556.50
|
| Rate for Payer: CDPHP Commercial |
$597.31
|
| Rate for Payer: CDPHP Medicare |
$274.54
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$519.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$593.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$593.60
|
| Rate for Payer: EmblemHealth Medicaid |
$593.60
|
| Rate for Payer: EmblemHealth Medicare |
$252.28
|
| Rate for Payer: EmblemHealth Select Care |
$482.30
|
| Rate for Payer: Fidelis Medicare |
$282.78
|
| Rate for Payer: Galaxy Health Commercial |
$482.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$274.54
|
| Rate for Payer: Humana Medicare |
$274.54
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$445.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$341.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$556.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$417.75
|
| Rate for Payer: MVP Health Care of NY Medicare |
$288.27
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$390.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$50.50
|
| Rate for Payer: United Healthcare Commercial |
$390.00
|
| Rate for Payer: United Healthcare Medicare |
$274.54
|
| Rate for Payer: WellCare Medicare |
$408.10
|
|
|
X-RAY BONE SURVEY INFANT
|
Facility
|
IP
|
$315.00
|
|
|
Service Code
|
HCPCS 77076
|
| Hospital Charge Code |
4150522
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$204.75 |
| Max. Negotiated Rate |
$204.75 |
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Galaxy Health Commercial |
$204.75
|
|
|
X-RAY BONE SURVEY INFANT
|
Facility
|
OP
|
$315.00
|
|
|
Service Code
|
HCPCS 77076
|
| Hospital Charge Code |
4150522
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$35.35 |
| Max. Negotiated Rate |
$390.00 |
| Rate for Payer: Aetna of NY Commercial |
$189.00
|
| Rate for Payer: Aetna of NY Medicare |
$144.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$236.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$236.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$116.55
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$157.50
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: CDPHP Commercial |
$253.58
|
| Rate for Payer: CDPHP Medicare |
$116.55
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$220.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$252.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$252.00
|
| Rate for Payer: EmblemHealth Medicaid |
$252.00
|
| Rate for Payer: EmblemHealth Medicare |
$107.10
|
| Rate for Payer: EmblemHealth Select Care |
$204.75
|
| Rate for Payer: Fidelis Medicare |
$120.05
|
| Rate for Payer: Galaxy Health Commercial |
$204.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$116.55
|
| Rate for Payer: Humana Medicare |
$116.55
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$189.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$144.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$236.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$177.34
|
| Rate for Payer: MVP Health Care of NY Medicare |
$122.38
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$390.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$35.35
|
| Rate for Payer: United Healthcare Commercial |
$390.00
|
| Rate for Payer: United Healthcare Medicare |
$116.55
|
| Rate for Payer: WellCare Medicare |
$173.25
|
|
|
X-RAY BONE SURVEY LIMITED
|
Facility
|
OP
|
$315.00
|
|
|
Service Code
|
HCPCS 77074
|
| Hospital Charge Code |
4150324
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$35.35 |
| Max. Negotiated Rate |
$390.00 |
| Rate for Payer: Aetna of NY Commercial |
$189.00
|
| Rate for Payer: Aetna of NY Medicare |
$144.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$236.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$236.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$116.55
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$157.50
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: CDPHP Commercial |
$253.58
|
| Rate for Payer: CDPHP Medicare |
$116.55
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$220.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$252.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$252.00
|
| Rate for Payer: EmblemHealth Medicaid |
$252.00
|
| Rate for Payer: EmblemHealth Medicare |
$107.10
|
| Rate for Payer: EmblemHealth Select Care |
$204.75
|
| Rate for Payer: Fidelis Medicare |
$120.05
|
| Rate for Payer: Galaxy Health Commercial |
$204.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$116.55
|
| Rate for Payer: Humana Medicare |
$116.55
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$189.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$144.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$236.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$177.34
|
| Rate for Payer: MVP Health Care of NY Medicare |
$122.38
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$390.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$35.35
|
| Rate for Payer: United Healthcare Commercial |
$390.00
|
| Rate for Payer: United Healthcare Medicare |
$116.55
|
| Rate for Payer: WellCare Medicare |
$173.25
|
|
|
X-RAY BONE SURVEY LIMITED
|
Facility
|
IP
|
$315.00
|
|
|
Service Code
|
HCPCS 77074
|
| Hospital Charge Code |
4150324
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$204.75 |
| Max. Negotiated Rate |
$204.75 |
| Rate for Payer: Cash Price |
$236.25
|
| Rate for Payer: Galaxy Health Commercial |
$204.75
|
|
|
X-RAY EXAM ABDOMEN 1 VIEW
|
Facility
|
IP
|
$260.00
|
|
|
Service Code
|
HCPCS 74018 TC
|
| Hospital Charge Code |
4150507
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$169.00 |
| Max. Negotiated Rate |
$169.00 |
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Galaxy Health Commercial |
$169.00
|
|
|
X-RAY EXAM ABDOMEN 1 VIEW
|
Facility
|
OP
|
$260.00
|
|
|
Service Code
|
HCPCS 74018 TC
|
| Hospital Charge Code |
4150507
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$390.00 |
| Rate for Payer: Aetna of NY Commercial |
$156.00
|
| Rate for Payer: Aetna of NY Medicare |
$119.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$195.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$195.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$96.20
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$130.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: CDPHP Commercial |
$209.30
|
| Rate for Payer: CDPHP Medicare |
$96.20
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$208.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$208.00
|
| Rate for Payer: EmblemHealth Medicaid |
$208.00
|
| Rate for Payer: EmblemHealth Medicare |
$88.40
|
| Rate for Payer: EmblemHealth Select Care |
$169.00
|
| Rate for Payer: Fidelis Medicare |
$99.09
|
| Rate for Payer: Galaxy Health Commercial |
$169.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$96.20
|
| Rate for Payer: Humana Medicare |
$96.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$156.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$119.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$195.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$146.38
|
| Rate for Payer: MVP Health Care of NY Medicare |
$101.01
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$390.00
|
| Rate for Payer: United Healthcare Commercial |
$390.00
|
| Rate for Payer: United Healthcare Medicare |
$96.20
|
| Rate for Payer: WellCare Medicare |
$143.00
|
|
