|
ULTRASOUND ELASTOGRAPHY PARENCHYMA
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
HCPCS 76981 26
|
| Hospital Charge Code |
5201084
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$57.85 |
| Max. Negotiated Rate |
$57.85 |
| Rate for Payer: Cash Price |
$66.75
|
| Rate for Payer: Galaxy Health Commercial |
$57.85
|
|
|
ULTRASOUND ELASTOGRAPHY PARENCHYMA
|
Facility
|
IP
|
$320.00
|
|
|
Service Code
|
HCPCS 76981 TC
|
| Hospital Charge Code |
4201084
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$208.00 |
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Galaxy Health Commercial |
$208.00
|
|
|
ULTRASOUND ELASTOGRAPHY PARENCHYMA
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
HCPCS 76981 26
|
| Hospital Charge Code |
5201084
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$13.35 |
| Max. Negotiated Rate |
$71.20 |
| Rate for Payer: Aetna of NY Commercial |
$62.30
|
| Rate for Payer: Aetna of NY Medicare |
$40.94
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$35.60
|
| Rate for Payer: Cash Price |
$66.75
|
| Rate for Payer: CDPHP Medicare |
$32.93
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$71.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$71.20
|
| Rate for Payer: EmblemHealth Medicaid |
$71.20
|
| Rate for Payer: EmblemHealth Medicare |
$30.26
|
| Rate for Payer: Fidelis Medicare |
$35.60
|
| Rate for Payer: Galaxy Health Commercial |
$57.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$35.60
|
| Rate for Payer: Humana Medicare |
$35.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$62.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$40.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$66.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$50.11
|
| Rate for Payer: MVP Health Care of NY Medicare |
$37.38
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$13.35
|
| Rate for Payer: United Healthcare Medicare |
$35.60
|
| Rate for Payer: WellCare Medicare |
$48.95
|
|
|
ULTRASOUND ELASTOGRAPHY PARENCHYMA
|
Facility
|
OP
|
$320.00
|
|
|
Service Code
|
HCPCS 76981 TC
|
| Hospital Charge Code |
4201084
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$48.00 |
| Max. Negotiated Rate |
$489.00 |
| Rate for Payer: Aetna of NY Commercial |
$224.00
|
| Rate for Payer: Aetna of NY Medicare |
$147.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$128.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: CDPHP Medicare |
$118.40
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$224.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$256.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$256.00
|
| Rate for Payer: EmblemHealth Medicaid |
$256.00
|
| Rate for Payer: EmblemHealth Medicare |
$108.80
|
| Rate for Payer: EmblemHealth Select Care |
$208.00
|
| Rate for Payer: Fidelis Medicare |
$128.00
|
| Rate for Payer: Galaxy Health Commercial |
$208.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$128.00
|
| Rate for Payer: Humana Medicare |
$128.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$224.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$147.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$240.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$180.16
|
| Rate for Payer: MVP Health Care of NY Medicare |
$134.40
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$48.00
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$128.00
|
| Rate for Payer: WellCare Medicare |
$176.00
|
|
|
ULTRASOUND THERAPY EA 15 MINS
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS 97035 GP
|
| Hospital Charge Code |
4650041
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$9.45 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$28.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$25.20
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: CDPHP Medicare |
$23.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$21.42
|
| Rate for Payer: EmblemHealth Select Care |
$45.36
|
| Rate for Payer: Fidelis Medicare |
$25.20
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$25.20
|
| Rate for Payer: Humana Medicare |
$25.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$28.98
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$26.46
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$9.45
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$25.20
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$34.65
|
|
|
ULTRASOUND THERAPY EA 15 MINS
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS 97035 GP
|
| Hospital Charge Code |
4650041
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$40.95 |
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
|
|
ULTRASOUND THERAPY EA 15 MINS (MOD 59)
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS 97035 GP,59
|
| Hospital Charge Code |
4650378
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$9.45 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$28.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$25.20
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: CDPHP Medicare |
$23.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$21.42
|
| Rate for Payer: EmblemHealth Select Care |
$45.36
|
| Rate for Payer: Fidelis Medicare |
$25.20
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$25.20
|
| Rate for Payer: Humana Medicare |
$25.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$28.98
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$26.46
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$9.45
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$25.20
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$34.65
|
|
|
ULTRASOUND THERAPY EA 15 MINS (MOD 59)
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS 97035 GP,59
|
| Hospital Charge Code |
4650378
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$40.95 |
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
|
|
ULTRASOUND THERAPY EA 15 MINS (MOD 59 W KX)
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS 97035 GP,59,KX
|
| Hospital Charge Code |
4650430
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$9.45 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$28.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$25.20
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: CDPHP Medicare |
$23.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$21.42
|
| Rate for Payer: EmblemHealth Select Care |
$45.36
|
| Rate for Payer: Fidelis Medicare |
$25.20
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$25.20
|
| Rate for Payer: Humana Medicare |
$25.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$28.98
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$26.46
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$9.45
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$25.20
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$34.65
|
|
|
ULTRASOUND THERAPY EA 15 MINS (MOD 59 W KX)
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS 97035 GP,59,KX
|
| Hospital Charge Code |
4650430
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$40.95 |
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
|
|
ULTRASOUND THERAPY EA 15 MINS (W/ KX)
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS 97035 GP,KX
|
| Hospital Charge Code |
4650323
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$9.45 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of NY Commercial |
$115.00
|
| Rate for Payer: Aetna of NY Medicare |
$28.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$25.20
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: CDPHP Medicare |
$23.31
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$50.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$26.90
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.42
|
| Rate for Payer: EmblemHealth Medicaid |
$22.42
|
| Rate for Payer: EmblemHealth Medicare |
$21.42
|
| Rate for Payer: EmblemHealth Select Care |
$45.36
|
| Rate for Payer: Fidelis Medicare |
$25.20
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
| Rate for Payer: Galaxy Health Workers Comp |
$21.97
|
| Rate for Payer: Hamaspik Choice Medicaid |
$22.42
|
| Rate for Payer: Hamaspik Choice Medicare |
$25.20
|
| Rate for Payer: Humana Medicare |
$25.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$115.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$28.98
|
| Rate for Payer: MVP Health Care of NY Child Health Plus/Family Health Plus/HARP/Medicaid |
$23.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$187.00
|
| Rate for Payer: MVP Health Care of NY Essential Plan 1&2 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Essential Plan 3&4 |
$48.20
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$141.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$26.46
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$161.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$9.45
|
| Rate for Payer: United Healthcare Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicare |
$25.20
|
| Rate for Payer: WellCare Child Health Plus/Family Health Plus/Medicaid |
$23.54
|
| Rate for Payer: WellCare Medicare |
$34.65
|
|
|
ULTRASOUND THERAPY EA 15 MINS (W/ KX)
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS 97035 GP,KX
|
| Hospital Charge Code |
4650323
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$40.95 |
| Rate for Payer: Cash Price |
$47.25
|
| Rate for Payer: Galaxy Health Commercial |
$40.95
|
|
|
ULTRASOUND TRGT DYNAMIC MICROBUBBLE 1ST LESION
|
Facility
|
OP
|
$1,069.00
|
|
|
Service Code
|
HCPCS 76978 TC
|
| Hospital Charge Code |
4201087
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$160.35 |
| Max. Negotiated Rate |
$855.20 |
| Rate for Payer: Aetna of NY Commercial |
$748.30
|
| Rate for Payer: Aetna of NY Medicare |
$491.74
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$427.60
|
| Rate for Payer: Cash Price |
$801.75
|
| Rate for Payer: Cash Price |
$801.75
|
| Rate for Payer: CDPHP Medicare |
$395.53
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$748.30
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$855.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$855.20
|
| Rate for Payer: EmblemHealth Medicaid |
$855.20
|
| Rate for Payer: EmblemHealth Medicare |
$363.46
|
| Rate for Payer: EmblemHealth Select Care |
$694.85
|
| Rate for Payer: Fidelis Medicare |
$427.60
|
| Rate for Payer: Galaxy Health Commercial |
$694.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$427.60
|
| Rate for Payer: Humana Medicare |
$427.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$748.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$491.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$801.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$601.85
|
| Rate for Payer: MVP Health Care of NY Medicare |
$448.98
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$160.35
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$427.60
|
| Rate for Payer: WellCare Medicare |
$587.95
|
|
|
ULTRASOUND TRGT DYNAMIC MICROBUBBLE 1ST LESION
|
Facility
|
OP
|
$237.00
|
|
|
Service Code
|
HCPCS 76978 26
|
| Hospital Charge Code |
5201087
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$35.55 |
| Max. Negotiated Rate |
$189.60 |
| Rate for Payer: Aetna of NY Commercial |
$165.90
|
| Rate for Payer: Aetna of NY Medicare |
$109.02
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$94.80
|
| Rate for Payer: Cash Price |
$177.75
|
| Rate for Payer: CDPHP Medicare |
$87.69
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$189.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$189.60
|
| Rate for Payer: EmblemHealth Medicaid |
$189.60
|
| Rate for Payer: EmblemHealth Medicare |
$80.58
|
| Rate for Payer: Fidelis Medicare |
$94.80
|
| Rate for Payer: Galaxy Health Commercial |
$154.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$94.80
|
| Rate for Payer: Humana Medicare |
$94.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$165.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$109.02
|
| Rate for Payer: MVP Health Care of NY Commercial |
$177.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$133.43
|
| Rate for Payer: MVP Health Care of NY Medicare |
$99.54
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$35.55
|
| Rate for Payer: United Healthcare Medicare |
$94.80
|
| Rate for Payer: WellCare Medicare |
$130.35
|
|
|
ULTRASOUND TRGT DYNAMIC MICROBUBBLE 1ST LESION
|
Facility
|
IP
|
$237.00
|
|
|
Service Code
|
HCPCS 76978 26
|
| Hospital Charge Code |
5201087
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$154.05 |
| Max. Negotiated Rate |
$154.05 |
| Rate for Payer: Cash Price |
$177.75
|
| Rate for Payer: Galaxy Health Commercial |
$154.05
|
|
|
ULTRASOUND TRGT DYNAMIC MICROBUBBLE 1ST LESION
|
Facility
|
IP
|
$1,069.00
|
|
|
Service Code
|
HCPCS 76978 TC
|
| Hospital Charge Code |
4201087
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$694.85 |
| Max. Negotiated Rate |
$694.85 |
| Rate for Payer: Cash Price |
$801.75
|
| Rate for Payer: Galaxy Health Commercial |
$694.85
|
|
|
ULTRASOUND TRGT DYNAMIC MICROBUBBLE EA ADDL LES
|
Facility
|
IP
|
$751.00
|
|
|
Service Code
|
HCPCS 76979 TC
|
| Hospital Charge Code |
4201088
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$488.15 |
| Max. Negotiated Rate |
$488.15 |
| Rate for Payer: Cash Price |
$563.25
|
| Rate for Payer: Galaxy Health Commercial |
$488.15
|
|
|
ULTRASOUND TRGT DYNAMIC MICROBUBBLE EA ADDL LES
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
HCPCS 76979 26
|
| Hospital Charge Code |
5201088
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$18.75 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna of NY Commercial |
$87.50
|
| Rate for Payer: Aetna of NY Medicare |
$57.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$50.00
|
| Rate for Payer: Cash Price |
$93.75
|
| Rate for Payer: CDPHP Medicare |
$46.25
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$100.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$100.00
|
| Rate for Payer: EmblemHealth Medicaid |
$100.00
|
| Rate for Payer: EmblemHealth Medicare |
$42.50
|
| Rate for Payer: Fidelis Medicare |
$50.00
|
| Rate for Payer: Galaxy Health Commercial |
$81.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$50.00
|
| Rate for Payer: Humana Medicare |
$50.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$87.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$57.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$93.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$70.38
|
| Rate for Payer: MVP Health Care of NY Medicare |
$52.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$18.75
|
| Rate for Payer: United Healthcare Medicare |
$50.00
|
| Rate for Payer: WellCare Medicare |
$68.75
|
|
|
ULTRASOUND TRGT DYNAMIC MICROBUBBLE EA ADDL LES
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
HCPCS 76979 26
|
| Hospital Charge Code |
5201088
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$81.25 |
| Max. Negotiated Rate |
$81.25 |
| Rate for Payer: Cash Price |
$93.75
|
| Rate for Payer: Galaxy Health Commercial |
$81.25
|
|
|
ULTRASOUND TRGT DYNAMIC MICROBUBBLE EA ADDL LES
|
Facility
|
OP
|
$751.00
|
|
|
Service Code
|
HCPCS 76979 TC
|
| Hospital Charge Code |
4201088
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$112.65 |
| Max. Negotiated Rate |
$600.80 |
| Rate for Payer: Aetna of NY Commercial |
$525.70
|
| Rate for Payer: Aetna of NY Medicare |
$345.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$300.40
|
| Rate for Payer: Cash Price |
$563.25
|
| Rate for Payer: Cash Price |
$563.25
|
| Rate for Payer: CDPHP Medicare |
$277.87
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$525.70
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$600.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$600.80
|
| Rate for Payer: EmblemHealth Medicaid |
$600.80
|
| Rate for Payer: EmblemHealth Medicare |
$255.34
|
| Rate for Payer: EmblemHealth Select Care |
$488.15
|
| Rate for Payer: Fidelis Medicare |
$300.40
|
| Rate for Payer: Galaxy Health Commercial |
$488.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$300.40
|
| Rate for Payer: Humana Medicare |
$300.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$525.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$345.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$563.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$422.81
|
| Rate for Payer: MVP Health Care of NY Medicare |
$315.42
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$112.65
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$300.40
|
| Rate for Payer: WellCare Medicare |
$413.05
|
|
|
UNIVERSAL ANKLE BRACE
|
Facility
|
OP
|
$45.32
|
|
| Hospital Charge Code |
4471168
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$36.26 |
| Rate for Payer: Aetna of NY Commercial |
$31.72
|
| Rate for Payer: Aetna of NY Medicare |
$20.85
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$18.13
|
| Rate for Payer: Cash Price |
$33.99
|
| Rate for Payer: CDPHP Medicare |
$16.77
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$36.26
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$36.26
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$36.26
|
| Rate for Payer: EmblemHealth Medicaid |
$36.26
|
| Rate for Payer: EmblemHealth Medicare |
$15.41
|
| Rate for Payer: EmblemHealth Select Care |
$32.63
|
| Rate for Payer: Fidelis Medicare |
$18.13
|
| Rate for Payer: Galaxy Health Commercial |
$29.46
|
| Rate for Payer: Hamaspik Choice Medicare |
$18.13
|
| Rate for Payer: Humana Medicare |
$18.13
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$31.72
|
| Rate for Payer: Local 1199SEIU Medicare |
$20.85
|
| Rate for Payer: MVP Health Care of NY Commercial |
$33.99
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$25.52
|
| Rate for Payer: MVP Health Care of NY Medicare |
$19.03
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$6.80
|
| Rate for Payer: United Healthcare Medicare |
$18.13
|
| Rate for Payer: WellCare Medicare |
$24.93
|
|
|
UNIVERSAL ANKLE BRACE
|
Facility
|
IP
|
$45.32
|
|
| Hospital Charge Code |
4471168
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$29.46 |
| Max. Negotiated Rate |
$29.46 |
| Rate for Payer: Cash Price |
$33.99
|
| Rate for Payer: Galaxy Health Commercial |
$29.46
|
|
|
UNIVERSAL BLOCK TRAY
|
Facility
|
OP
|
$53.56
|
|
| Hospital Charge Code |
4473037
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.03 |
| Max. Negotiated Rate |
$42.85 |
| Rate for Payer: Aetna of NY Commercial |
$37.49
|
| Rate for Payer: Aetna of NY Medicare |
$24.64
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$21.42
|
| Rate for Payer: Cash Price |
$40.17
|
| Rate for Payer: CDPHP Medicare |
$19.82
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$42.85
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$42.85
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$42.85
|
| Rate for Payer: EmblemHealth Medicaid |
$42.85
|
| Rate for Payer: EmblemHealth Medicare |
$18.21
|
| Rate for Payer: EmblemHealth Select Care |
$38.56
|
| Rate for Payer: Fidelis Medicare |
$21.42
|
| Rate for Payer: Galaxy Health Commercial |
$34.81
|
| Rate for Payer: Hamaspik Choice Medicare |
$21.42
|
| Rate for Payer: Humana Medicare |
$21.42
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$37.49
|
| Rate for Payer: Local 1199SEIU Medicare |
$24.64
|
| Rate for Payer: MVP Health Care of NY Commercial |
$40.17
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$30.15
|
| Rate for Payer: MVP Health Care of NY Medicare |
$22.50
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$8.03
|
| Rate for Payer: United Healthcare Medicare |
$21.42
|
| Rate for Payer: WellCare Medicare |
$29.46
|
|
|
UNIVERSAL BLOCK TRAY
|
Facility
|
IP
|
$53.56
|
|
| Hospital Charge Code |
4473037
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.81 |
| Max. Negotiated Rate |
$34.81 |
| Rate for Payer: Cash Price |
$40.17
|
| Rate for Payer: Galaxy Health Commercial |
$34.81
|
|
|
UNIVERSAL STRYKER SAW BLADE
|
Facility
|
OP
|
$147.29
|
|
| Hospital Charge Code |
4471625
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.09 |
| Max. Negotiated Rate |
$117.83 |
| Rate for Payer: Aetna of NY Commercial |
$103.10
|
| Rate for Payer: Aetna of NY Medicare |
$67.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$58.92
|
| Rate for Payer: Cash Price |
$110.47
|
| Rate for Payer: CDPHP Medicare |
$54.50
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$117.83
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$117.83
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$117.83
|
| Rate for Payer: EmblemHealth Medicaid |
$117.83
|
| Rate for Payer: EmblemHealth Medicare |
$50.08
|
| Rate for Payer: EmblemHealth Select Care |
$106.05
|
| Rate for Payer: Fidelis Medicare |
$58.92
|
| Rate for Payer: Galaxy Health Commercial |
$95.74
|
| Rate for Payer: Hamaspik Choice Medicare |
$58.92
|
| Rate for Payer: Humana Medicare |
$58.92
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$103.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$67.75
|
| Rate for Payer: MVP Health Care of NY Commercial |
$110.47
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$82.92
|
| Rate for Payer: MVP Health Care of NY Medicare |
$61.86
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$22.09
|
| Rate for Payer: United Healthcare Medicare |
$58.92
|
| Rate for Payer: WellCare Medicare |
$81.01
|
|
