|
APOLIPOPROTEIN A-1
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
HCPCS 82172
|
| Hospital Charge Code |
4300096
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.09 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna of NY Commercial |
$52.00
|
| Rate for Payer: Aetna of NY Medicare |
$36.80
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$60.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$60.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$29.60
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$40.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: CDPHP Commercial |
$64.40
|
| Rate for Payer: CDPHP Medicare |
$29.60
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$48.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$64.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$64.00
|
| Rate for Payer: EmblemHealth Medicaid |
$64.00
|
| Rate for Payer: EmblemHealth Medicare |
$27.20
|
| Rate for Payer: EmblemHealth Select Care |
$48.00
|
| Rate for Payer: Fidelis Medicare |
$30.49
|
| Rate for Payer: Galaxy Health Commercial |
$52.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$29.60
|
| Rate for Payer: Humana Medicare |
$29.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$52.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$36.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$60.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$45.04
|
| Rate for Payer: MVP Health Care of NY Medicare |
$31.08
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$60.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$16.09
|
| Rate for Payer: United Healthcare Commercial |
$60.00
|
| Rate for Payer: United Healthcare Medicare |
$29.60
|
| Rate for Payer: WellCare Medicare |
$44.00
|
|
|
APOLIPOPROTEIN A-1
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
HCPCS 82172
|
| Hospital Charge Code |
4300096
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Galaxy Health Commercial |
$52.00
|
|
|
APPLICATION LONG ARM SPLINT
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
4856663
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$293.15 |
| Max. Negotiated Rate |
$293.15 |
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
|
|
APPLICATION LONG ARM SPLINT
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
4856663
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$150.13 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$315.70
|
| Rate for Payer: Aetna of NY Medicare |
$207.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$166.87
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$225.50
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: CDPHP Commercial |
$363.06
|
| Rate for Payer: CDPHP Medicare |
$166.87
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$360.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$360.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$360.80
|
| Rate for Payer: EmblemHealth Medicaid |
$360.80
|
| Rate for Payer: EmblemHealth Medicare |
$153.34
|
| Rate for Payer: EmblemHealth Select Care |
$324.72
|
| Rate for Payer: Fidelis Medicare |
$171.88
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$166.87
|
| Rate for Payer: Humana Medicare |
$166.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$315.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$207.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$338.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$253.91
|
| Rate for Payer: MVP Health Care of NY Medicare |
$175.21
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$150.13
|
| Rate for Payer: United Healthcare Medicare |
$166.87
|
| Rate for Payer: WellCare Medicare |
$248.05
|
|
|
APPLICATION-LONG ARM SPLINT
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
4600028
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$293.15 |
| Max. Negotiated Rate |
$293.15 |
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
|
|
APPLICATION-LONG ARM SPLINT
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
4600028
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$150.13 |
| Max. Negotiated Rate |
$1,189.18 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$207.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$950.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,189.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$166.87
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$225.50
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: CDPHP Commercial |
$363.06
|
| Rate for Payer: CDPHP Medicare |
$166.87
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$360.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$360.80
|
| Rate for Payer: EmblemHealth Medicaid |
$360.80
|
| Rate for Payer: EmblemHealth Medicare |
$153.34
|
| Rate for Payer: EmblemHealth Select Care |
$1,064.00
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$250.00
|
| Rate for Payer: Fidelis Medicare |
$171.88
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$166.87
|
| Rate for Payer: Humana Medicare |
$166.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$207.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,174.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$881.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$175.21
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$150.13
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$166.87
|
| Rate for Payer: WellCare Medicare |
$248.05
|
|
|
APPLICATION LONG LEG SPLINT
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
HCPCS 29505
|
| Hospital Charge Code |
4600016
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$150.13 |
| Max. Negotiated Rate |
$1,189.18 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$207.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$950.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,189.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$166.87
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$225.50
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: CDPHP Commercial |
$363.06
|
| Rate for Payer: CDPHP Medicare |
$166.87
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$360.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$360.80
|
| Rate for Payer: EmblemHealth Medicaid |
$360.80
|
| Rate for Payer: EmblemHealth Medicare |
$153.34
|
| Rate for Payer: EmblemHealth Select Care |
$1,064.00
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$250.00
|
| Rate for Payer: Fidelis Medicare |
$171.88
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$166.87
|
| Rate for Payer: Humana Medicare |
$166.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$207.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,174.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$881.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$175.21
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$150.13
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$166.87
|
| Rate for Payer: WellCare Medicare |
$248.05
|
|
|
APPLICATION LONG LEG SPLINT
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
HCPCS 29505
|
| Hospital Charge Code |
4600016
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$293.15 |
| Max. Negotiated Rate |
$293.15 |
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
|
|
APPLICATION SHORT LEG SPLINT
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
4600018
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$293.15 |
| Max. Negotiated Rate |
$293.15 |
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
|
|
APPLICATION SHORT LEG SPLINT
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
4600018
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$150.13 |
| Max. Negotiated Rate |
$1,189.18 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$207.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$950.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,189.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$166.87
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$225.50
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: CDPHP Commercial |
$363.06
|
| Rate for Payer: CDPHP Medicare |
$166.87
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$360.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$360.80
|
| Rate for Payer: EmblemHealth Medicaid |
$360.80
|
| Rate for Payer: EmblemHealth Medicare |
$153.34
|
| Rate for Payer: EmblemHealth Select Care |
$1,064.00
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$250.00
|
| Rate for Payer: Fidelis Medicare |
$171.88
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$166.87
|
| Rate for Payer: Humana Medicare |
$166.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$207.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,174.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$881.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$175.21
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$150.13
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$166.87
|
| Rate for Payer: WellCare Medicare |
$248.05
|
|
|
APPLICATION SPLINT- LONG ARM
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
4650062
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$293.15 |
| Max. Negotiated Rate |
$293.15 |
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
|
|
APPLICATION SPLINT- LONG ARM
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
4650062
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$363.06 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$207.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$338.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$338.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$166.87
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: CDPHP Commercial |
$363.06
|
| Rate for Payer: CDPHP Medicare |
$166.87
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$360.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$360.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$360.80
|
| Rate for Payer: EmblemHealth Medicaid |
$360.80
|
| Rate for Payer: EmblemHealth Medicare |
$153.34
|
| Rate for Payer: EmblemHealth Select Care |
$324.72
|
| Rate for Payer: Fidelis Medicare |
$171.88
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$166.87
|
| Rate for Payer: Humana Medicare |
$166.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$207.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$175.21
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$150.13
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$166.87
|
| Rate for Payer: WellCare Medicare |
$248.05
|
|
|
APPLICATION SPLINT- SHORT LEG
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
4650065
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$150.13 |
| Max. Negotiated Rate |
$1,189.18 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$207.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$950.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,189.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$166.87
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$225.50
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: CDPHP Commercial |
$363.06
|
| Rate for Payer: CDPHP Medicare |
$166.87
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$360.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$360.80
|
| Rate for Payer: EmblemHealth Medicaid |
$360.80
|
| Rate for Payer: EmblemHealth Medicare |
$153.34
|
| Rate for Payer: EmblemHealth Select Care |
$1,064.00
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$250.00
|
| Rate for Payer: Fidelis Medicare |
$171.88
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$166.87
|
| Rate for Payer: Humana Medicare |
$166.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$207.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,174.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$881.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$175.21
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$150.13
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$166.87
|
| Rate for Payer: WellCare Medicare |
$248.05
|
|
|
APPLICATION SPLINT- SHORT LEG
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
4650065
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$293.15 |
| Max. Negotiated Rate |
$293.15 |
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
|
|
APPLICATION STATIC SPLINT- SHORT ARM
|
Facility
|
IP
|
$366.00
|
|
|
Service Code
|
HCPCS 29126 GP
|
| Hospital Charge Code |
4650063
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$237.90 |
| Max. Negotiated Rate |
$237.90 |
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Galaxy Health Commercial |
$237.90
|
|
|
APPLICATION STATIC SPLINT- SHORT ARM
|
Facility
|
OP
|
$366.00
|
|
|
Service Code
|
HCPCS 29126 GP
|
| Hospital Charge Code |
4650063
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$294.63 |
| Rate for Payer: Aetna of NY Commercial |
$112.00
|
| Rate for Payer: Aetna of NY Medicare |
$168.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$274.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$274.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$135.42
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$108.00
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: CDPHP Commercial |
$294.63
|
| Rate for Payer: CDPHP Medicare |
$135.42
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$292.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$292.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$292.80
|
| Rate for Payer: EmblemHealth Medicaid |
$292.80
|
| Rate for Payer: EmblemHealth Medicare |
$124.44
|
| Rate for Payer: EmblemHealth Select Care |
$263.52
|
| Rate for Payer: Fidelis Medicare |
$139.48
|
| Rate for Payer: Galaxy Health Commercial |
$237.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$135.42
|
| Rate for Payer: Humana Medicare |
$135.42
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$112.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$168.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$179.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$134.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$142.19
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$156.00
|
| Rate for Payer: United Healthcare Medicare |
$135.42
|
| Rate for Payer: WellCare Medicare |
$201.30
|
|
|
APPLICATOR SEPP CHLORAPREP 0.
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
4471725
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Aetna of NY Commercial |
$0.70
|
| Rate for Payer: Aetna of NY Medicare |
$0.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$0.37
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$0.50
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: CDPHP Commercial |
$0.81
|
| Rate for Payer: CDPHP Medicare |
$0.37
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$0.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$0.80
|
| Rate for Payer: EmblemHealth Medicaid |
$0.80
|
| Rate for Payer: EmblemHealth Medicare |
$0.34
|
| Rate for Payer: EmblemHealth Select Care |
$0.72
|
| Rate for Payer: Fidelis Medicare |
$0.38
|
| Rate for Payer: Galaxy Health Commercial |
$0.65
|
| Rate for Payer: Hamaspik Choice Medicare |
$0.37
|
| Rate for Payer: Humana Medicare |
$0.37
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$0.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$0.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$0.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$0.56
|
| Rate for Payer: MVP Health Care of NY Medicare |
$0.39
|
| Rate for Payer: United Healthcare Medicare |
$0.37
|
| Rate for Payer: WellCare Medicare |
$0.55
|
|
|
APPLICATOR SEPP CHLORAPREP 0.
|
Facility
|
IP
|
$1.00
|
|
| Hospital Charge Code |
4471725
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Galaxy Health Commercial |
$0.65
|
|
|
APPLIC-SHORT ARM SPLINT DYNAM
|
Facility
|
OP
|
$366.00
|
|
|
Service Code
|
HCPCS 29126
|
| Hospital Charge Code |
4600014
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$121.71 |
| Max. Negotiated Rate |
$1,189.18 |
| Rate for Payer: Aetna of NY Commercial |
$955.00
|
| Rate for Payer: Aetna of NY Medicare |
$168.36
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$950.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,189.18
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$135.42
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$183.00
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: CDPHP Commercial |
$294.63
|
| Rate for Payer: CDPHP Medicare |
$135.42
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,182.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$292.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$292.80
|
| Rate for Payer: EmblemHealth Medicaid |
$292.80
|
| Rate for Payer: EmblemHealth Medicare |
$124.44
|
| Rate for Payer: EmblemHealth Select Care |
$1,064.00
|
| Rate for Payer: Fidelis Child Health Plus/Essential Plan/HARP/Medicaid |
$250.00
|
| Rate for Payer: Fidelis Medicare |
$139.48
|
| Rate for Payer: Galaxy Health Commercial |
$237.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$135.42
|
| Rate for Payer: Humana Medicare |
$135.42
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$955.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$168.36
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,174.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$881.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$142.19
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$980.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$121.71
|
| Rate for Payer: United Healthcare Commercial |
$980.00
|
| Rate for Payer: United Healthcare Medicare |
$135.42
|
| Rate for Payer: WellCare Medicare |
$201.30
|
|
|
APPLIC-SHORT ARM SPLINT DYNAM
|
Facility
|
IP
|
$366.00
|
|
|
Service Code
|
HCPCS 29126
|
| Hospital Charge Code |
4600014
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$237.90 |
| Max. Negotiated Rate |
$237.90 |
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Galaxy Health Commercial |
$237.90
|
|
|
APPL MULTLAY COMPRS ARM/HAND
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
HCPCS 29584
|
| Hospital Charge Code |
4851986
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$293.15 |
| Max. Negotiated Rate |
$293.15 |
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
|
|
APPL MULTLAY COMPRS ARM/HAND
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
HCPCS 29584
|
| Hospital Charge Code |
4851986
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$150.13 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$315.70
|
| Rate for Payer: Aetna of NY Medicare |
$207.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$166.87
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$225.50
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: CDPHP Commercial |
$363.06
|
| Rate for Payer: CDPHP Medicare |
$166.87
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$360.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$360.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$360.80
|
| Rate for Payer: EmblemHealth Medicaid |
$360.80
|
| Rate for Payer: EmblemHealth Medicare |
$153.34
|
| Rate for Payer: EmblemHealth Select Care |
$324.72
|
| Rate for Payer: Fidelis Medicare |
$171.88
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$166.87
|
| Rate for Payer: Humana Medicare |
$166.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$315.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$207.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$338.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$253.91
|
| Rate for Payer: MVP Health Care of NY Medicare |
$175.21
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$150.13
|
| Rate for Payer: United Healthcare Medicare |
$166.87
|
| Rate for Payer: WellCare Medicare |
$248.05
|
|
|
APPLY CLUBFOOT CAST LONG OR SHORT LEG
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
HCPCS 29450
|
| Hospital Charge Code |
4850019
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$150.13 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$315.70
|
| Rate for Payer: Aetna of NY Medicare |
$207.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$166.87
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$225.50
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: CDPHP Commercial |
$363.06
|
| Rate for Payer: CDPHP Medicare |
$166.87
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$360.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$360.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$360.80
|
| Rate for Payer: EmblemHealth Medicaid |
$360.80
|
| Rate for Payer: EmblemHealth Medicare |
$153.34
|
| Rate for Payer: EmblemHealth Select Care |
$324.72
|
| Rate for Payer: Fidelis Medicare |
$171.88
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$166.87
|
| Rate for Payer: Humana Medicare |
$166.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$315.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$207.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$338.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$253.91
|
| Rate for Payer: MVP Health Care of NY Medicare |
$175.21
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$150.13
|
| Rate for Payer: United Healthcare Medicare |
$166.87
|
| Rate for Payer: WellCare Medicare |
$248.05
|
|
|
APPLY CLUBFOOT CAST LONG OR SHORT LEG
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
HCPCS 29450
|
| Hospital Charge Code |
4850019
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$293.15 |
| Max. Negotiated Rate |
$293.15 |
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
|
|
APPLY FINGER CAST
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
HCPCS 29086 TC
|
| Hospital Charge Code |
4850126
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$293.15 |
| Max. Negotiated Rate |
$293.15 |
| Rate for Payer: Cash Price |
$338.25
|
| Rate for Payer: Galaxy Health Commercial |
$293.15
|
|
