|
US PREG UTERUS DETAIL FETAL ANAT EXAM EA GESTAT
|
Facility
|
OP
|
$260.00
|
|
|
Service Code
|
HCPCS 76812 26
|
| Hospital Charge Code |
5200087
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$39.00 |
| Max. Negotiated Rate |
$208.00 |
| Rate for Payer: Aetna of NY Commercial |
$182.00
|
| Rate for Payer: Aetna of NY Medicare |
$119.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$104.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: CDPHP Medicare |
$96.20
|
| 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: Fidelis Medicare |
$104.00
|
| Rate for Payer: Galaxy Health Commercial |
$169.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$104.00
|
| Rate for Payer: Humana Medicare |
$104.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$182.00
|
| 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 |
$109.20
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$39.00
|
| Rate for Payer: United Healthcare Medicare |
$104.00
|
| Rate for Payer: WellCare Medicare |
$143.00
|
|
|
US PREG UTERUS DETAIL FETAL ANAT EXAM EA GESTAT
|
Facility
|
IP
|
$807.00
|
|
|
Service Code
|
HCPCS 76812 TC
|
| Hospital Charge Code |
4200087
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$524.55 |
| Max. Negotiated Rate |
$524.55 |
| Rate for Payer: Cash Price |
$605.25
|
| Rate for Payer: Galaxy Health Commercial |
$524.55
|
|
|
US PREG UTERUS REAL TIME F/U TRANSABDL PER FETUS
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
HCPCS 76816 26
|
| Hospital Charge Code |
5200115
|
|
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
|
|
|
US PREG UTERUS REAL TIME F/U TRANSABDL PER FETUS
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
HCPCS 76816 26
|
| Hospital Charge Code |
5200115
|
|
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
|
|
|
US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS
|
Facility
|
IP
|
$320.00
|
|
|
Service Code
|
HCPCS 76816 TC
|
| Hospital Charge Code |
4200115
|
|
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
|
|
|
US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS
|
Facility
|
OP
|
$320.00
|
|
|
Service Code
|
HCPCS 76816 TC
|
| Hospital Charge Code |
4200115
|
|
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
|
|
|
US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG
|
Facility
|
IP
|
$320.00
|
|
|
Service Code
|
HCPCS 76817 TC
|
| Hospital Charge Code |
4200100
|
|
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
|
|
|
US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
HCPCS 76817 26
|
| Hospital Charge Code |
5200100
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$71.50 |
| Max. Negotiated Rate |
$71.50 |
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Galaxy Health Commercial |
$71.50
|
|
|
US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
HCPCS 76817 26
|
| Hospital Charge Code |
5200100
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$88.00 |
| Rate for Payer: Aetna of NY Commercial |
$77.00
|
| Rate for Payer: Aetna of NY Medicare |
$50.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$44.00
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: CDPHP Medicare |
$40.70
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$88.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$88.00
|
| Rate for Payer: EmblemHealth Medicaid |
$88.00
|
| Rate for Payer: EmblemHealth Medicare |
$37.40
|
| Rate for Payer: Fidelis Medicare |
$44.00
|
| Rate for Payer: Galaxy Health Commercial |
$71.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$44.00
|
| Rate for Payer: Humana Medicare |
$44.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$77.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$50.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$82.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$61.93
|
| Rate for Payer: MVP Health Care of NY Medicare |
$46.20
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$16.50
|
| Rate for Payer: United Healthcare Medicare |
$44.00
|
| Rate for Payer: WellCare Medicare |
$60.50
|
|
|
US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG
|
Facility
|
OP
|
$320.00
|
|
|
Service Code
|
HCPCS 76817 TC
|
| Hospital Charge Code |
4200100
|
|
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
|
|
|
US PREG UTERUS W/DETAIL FETAL ANAT 1ST GESTATION
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
HCPCS 76811 26
|
| Hospital Charge Code |
5200088
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$41.55 |
| Max. Negotiated Rate |
$221.60 |
| Rate for Payer: Aetna of NY Commercial |
$193.90
|
| Rate for Payer: Aetna of NY Medicare |
$127.42
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$110.80
|
| Rate for Payer: Cash Price |
$207.75
|
| Rate for Payer: CDPHP Medicare |
$102.49
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$221.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$221.60
|
| Rate for Payer: EmblemHealth Medicaid |
$221.60
|
| Rate for Payer: EmblemHealth Medicare |
$94.18
|
| Rate for Payer: Fidelis Medicare |
$110.80
|
| Rate for Payer: Galaxy Health Commercial |
$180.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$110.80
|
| Rate for Payer: Humana Medicare |
$110.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$193.90
|
| Rate for Payer: Local 1199SEIU Medicare |
$127.42
|
| Rate for Payer: MVP Health Care of NY Commercial |
$207.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$155.95
|
| Rate for Payer: MVP Health Care of NY Medicare |
$116.34
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$41.55
|
| Rate for Payer: United Healthcare Medicare |
$110.80
|
| Rate for Payer: WellCare Medicare |
$152.35
|
|
|
US PREG UTERUS W/DETAIL FETAL ANAT 1ST GESTATION
|
Facility
|
IP
|
$1,004.00
|
|
|
Service Code
|
HCPCS 76811 TC
|
| Hospital Charge Code |
4200088
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$652.60 |
| Max. Negotiated Rate |
$652.60 |
| Rate for Payer: Cash Price |
$753.00
|
| Rate for Payer: Galaxy Health Commercial |
$652.60
|
|
|
US PREG UTERUS W/DETAIL FETAL ANAT 1ST GESTATION
|
Facility
|
OP
|
$1,004.00
|
|
|
Service Code
|
HCPCS 76811 TC
|
| Hospital Charge Code |
4200088
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$150.60 |
| Max. Negotiated Rate |
$803.20 |
| Rate for Payer: Aetna of NY Commercial |
$702.80
|
| Rate for Payer: Aetna of NY Medicare |
$461.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$401.60
|
| Rate for Payer: Cash Price |
$753.00
|
| Rate for Payer: Cash Price |
$753.00
|
| Rate for Payer: CDPHP Medicare |
$371.48
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$702.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$803.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$803.20
|
| Rate for Payer: EmblemHealth Medicaid |
$803.20
|
| Rate for Payer: EmblemHealth Medicare |
$341.36
|
| Rate for Payer: EmblemHealth Select Care |
$652.60
|
| Rate for Payer: Fidelis Medicare |
$401.60
|
| Rate for Payer: Galaxy Health Commercial |
$652.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$401.60
|
| Rate for Payer: Humana Medicare |
$401.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$702.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$461.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$753.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$565.25
|
| Rate for Payer: MVP Health Care of NY Medicare |
$421.68
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$150.60
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$401.60
|
| Rate for Payer: WellCare Medicare |
$552.20
|
|
|
US PREG UTERUS W/DETAIL FETAL ANAT 1ST GESTATION
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
HCPCS 76811 26
|
| Hospital Charge Code |
5200088
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$180.05 |
| Max. Negotiated Rate |
$180.05 |
| Rate for Payer: Cash Price |
$207.75
|
| Rate for Payer: Galaxy Health Commercial |
$180.05
|
|
|
US RETOPERITONEAL REAL TIME W/ IMAGE LIMITED
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
HCPCS 76775 26
|
| Hospital Charge Code |
5200055
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$55.90 |
| Max. Negotiated Rate |
$55.90 |
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Galaxy Health Commercial |
$55.90
|
|
|
US RETOPERITONEAL REAL TIME W/ IMAGE LIMITED
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
HCPCS 76775 26
|
| Hospital Charge Code |
5200055
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$12.90 |
| Max. Negotiated Rate |
$68.80 |
| Rate for Payer: Aetna of NY Commercial |
$60.20
|
| Rate for Payer: Aetna of NY Medicare |
$39.56
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$34.40
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: CDPHP Medicare |
$31.82
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$68.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$68.80
|
| Rate for Payer: EmblemHealth Medicaid |
$68.80
|
| Rate for Payer: EmblemHealth Medicare |
$29.24
|
| Rate for Payer: Fidelis Medicare |
$34.40
|
| Rate for Payer: Galaxy Health Commercial |
$55.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$34.40
|
| Rate for Payer: Humana Medicare |
$34.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$60.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$39.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$64.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$48.42
|
| Rate for Payer: MVP Health Care of NY Medicare |
$36.12
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$12.90
|
| Rate for Payer: United Healthcare Medicare |
$34.40
|
| Rate for Payer: WellCare Medicare |
$47.30
|
|
|
US RETROPERITONEAL REAL TIME W/IMAGE COMPLETE
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
HCPCS 76770 26
|
| Hospital Charge Code |
5200001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$70.20 |
| Max. Negotiated Rate |
$70.20 |
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Galaxy Health Commercial |
$70.20
|
|
|
US RETROPERITONEAL REAL TIME W/IMAGE COMPLETE
|
Facility
|
OP
|
$631.00
|
|
|
Service Code
|
HCPCS 76770 TC
|
| Hospital Charge Code |
4200001
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$94.65 |
| Max. Negotiated Rate |
$504.80 |
| Rate for Payer: Aetna of NY Commercial |
$441.70
|
| Rate for Payer: Aetna of NY Medicare |
$290.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$252.40
|
| Rate for Payer: Cash Price |
$473.25
|
| Rate for Payer: Cash Price |
$473.25
|
| Rate for Payer: CDPHP Medicare |
$233.47
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$441.70
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$504.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$504.80
|
| Rate for Payer: EmblemHealth Medicaid |
$504.80
|
| Rate for Payer: EmblemHealth Medicare |
$214.54
|
| Rate for Payer: EmblemHealth Select Care |
$410.15
|
| Rate for Payer: Fidelis Medicare |
$252.40
|
| Rate for Payer: Galaxy Health Commercial |
$410.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$252.40
|
| Rate for Payer: Humana Medicare |
$252.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$441.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$290.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$473.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$355.25
|
| Rate for Payer: MVP Health Care of NY Medicare |
$265.02
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$94.65
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$252.40
|
| Rate for Payer: WellCare Medicare |
$347.05
|
|
|
US RETROPERITONEAL REAL TIME W/IMAGE COMPLETE
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
HCPCS 76770 26
|
| Hospital Charge Code |
5200001
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$16.20 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna of NY Commercial |
$75.60
|
| Rate for Payer: Aetna of NY Medicare |
$49.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$43.20
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: CDPHP Medicare |
$39.96
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$86.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$86.40
|
| Rate for Payer: EmblemHealth Medicaid |
$86.40
|
| Rate for Payer: EmblemHealth Medicare |
$36.72
|
| Rate for Payer: Fidelis Medicare |
$43.20
|
| Rate for Payer: Galaxy Health Commercial |
$70.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$43.20
|
| Rate for Payer: Humana Medicare |
$43.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$75.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$49.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$81.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$60.80
|
| Rate for Payer: MVP Health Care of NY Medicare |
$45.36
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$16.20
|
| Rate for Payer: United Healthcare Medicare |
$43.20
|
| Rate for Payer: WellCare Medicare |
$59.40
|
|
|
US RETROPERITONEAL REAL TIME W/IMAGE COMPLETE
|
Facility
|
IP
|
$631.00
|
|
|
Service Code
|
HCPCS 76770 TC
|
| Hospital Charge Code |
4200001
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$410.15 |
| Max. Negotiated Rate |
$410.15 |
| Rate for Payer: Cash Price |
$473.25
|
| Rate for Payer: Galaxy Health Commercial |
$410.15
|
|
|
US RETROPERITONEAL REAL TIME W/IMAGE LIMITED
|
Facility
|
OP
|
$500.00
|
|
|
Service Code
|
HCPCS 76775 TC
|
| Hospital Charge Code |
4200055
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$489.00 |
| Rate for Payer: Aetna of NY Commercial |
$350.00
|
| Rate for Payer: Aetna of NY Medicare |
$230.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$200.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: CDPHP Medicare |
$185.00
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$350.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$400.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$400.00
|
| Rate for Payer: EmblemHealth Medicaid |
$400.00
|
| Rate for Payer: EmblemHealth Medicare |
$170.00
|
| Rate for Payer: EmblemHealth Select Care |
$325.00
|
| Rate for Payer: Fidelis Medicare |
$200.00
|
| Rate for Payer: Galaxy Health Commercial |
$325.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$200.00
|
| Rate for Payer: Humana Medicare |
$200.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$350.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$230.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$375.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$281.50
|
| Rate for Payer: MVP Health Care of NY Medicare |
$210.00
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$75.00
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$200.00
|
| Rate for Payer: WellCare Medicare |
$275.00
|
|
|
US RETROPERITONEAL REAL TIME W/IMAGE LIMITED
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
HCPCS 76775 TC
|
| Hospital Charge Code |
4200055
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$325.00 |
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Galaxy Health Commercial |
$325.00
|
|
|
US SCROTUM & CONTENTS
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
HCPCS 76870 26
|
| Hospital Charge Code |
5200016
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$61.10 |
| Max. Negotiated Rate |
$61.10 |
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Galaxy Health Commercial |
$61.10
|
|
|
US SCROTUM & CONTENTS
|
Facility
|
IP
|
$653.00
|
|
|
Service Code
|
HCPCS 76870 TC
|
| Hospital Charge Code |
4200016
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$424.45 |
| Max. Negotiated Rate |
$424.45 |
| Rate for Payer: Cash Price |
$489.75
|
| Rate for Payer: Galaxy Health Commercial |
$424.45
|
|
|
US SCROTUM & CONTENTS
|
Facility
|
OP
|
$653.00
|
|
|
Service Code
|
HCPCS 76870 TC
|
| Hospital Charge Code |
4200016
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$97.95 |
| Max. Negotiated Rate |
$522.40 |
| Rate for Payer: Aetna of NY Commercial |
$457.10
|
| Rate for Payer: Aetna of NY Medicare |
$300.38
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$261.20
|
| Rate for Payer: Cash Price |
$489.75
|
| Rate for Payer: Cash Price |
$489.75
|
| Rate for Payer: CDPHP Medicare |
$241.61
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$457.10
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$522.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$522.40
|
| Rate for Payer: EmblemHealth Medicaid |
$522.40
|
| Rate for Payer: EmblemHealth Medicare |
$222.02
|
| Rate for Payer: EmblemHealth Select Care |
$424.45
|
| Rate for Payer: Fidelis Medicare |
$261.20
|
| Rate for Payer: Galaxy Health Commercial |
$424.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$261.20
|
| Rate for Payer: Humana Medicare |
$261.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$457.10
|
| Rate for Payer: Local 1199SEIU Medicare |
$300.38
|
| Rate for Payer: MVP Health Care of NY Commercial |
$489.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$367.64
|
| Rate for Payer: MVP Health Care of NY Medicare |
$274.26
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$97.95
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$261.20
|
| Rate for Payer: WellCare Medicare |
$359.15
|
|
