|
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
|
|
|
XARELTO 20 MG TABLET
|
Facility
|
OP
|
$44.55
|
|
|
Service Code
|
NDC 50458057910
|
| Hospital Charge Code |
4409128
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$35.64 |
| Rate for Payer: Aetna of NY Commercial |
$31.18
|
| Rate for Payer: Aetna of NY Medicare |
$20.49
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$17.82
|
| Rate for Payer: Cash Price |
$33.41
|
| Rate for Payer: CDPHP Medicare |
$16.48
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$35.64
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$35.64
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$35.64
|
| Rate for Payer: EmblemHealth Medicaid |
$35.64
|
| Rate for Payer: EmblemHealth Medicare |
$15.15
|
| Rate for Payer: EmblemHealth Select Care |
$32.08
|
| Rate for Payer: Fidelis Medicare |
$17.82
|
| Rate for Payer: Galaxy Health Commercial |
$28.96
|
| Rate for Payer: Hamaspik Choice Medicare |
$17.82
|
| Rate for Payer: Humana Medicare |
$17.82
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$31.18
|
| Rate for Payer: Local 1199SEIU Medicare |
$20.49
|
| Rate for Payer: MVP Health Care of NY Commercial |
$33.41
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$25.08
|
| Rate for Payer: MVP Health Care of NY Medicare |
$18.71
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$6.68
|
| Rate for Payer: United Healthcare Medicare |
$17.82
|
| Rate for Payer: WellCare Medicare |
$24.50
|
|
|
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
|
|
|
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 |
$28.50 |
| Max. Negotiated Rate |
$152.00 |
| 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) Medicare |
$76.00
|
| Rate for Payer: Cash Price |
$142.50
|
| 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 |
$76.00
|
| Rate for Payer: Galaxy Health Commercial |
$123.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$76.00
|
| Rate for Payer: Humana Medicare |
$76.00
|
| 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 |
$79.80
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$28.50
|
| Rate for Payer: United Healthcare Medicare |
$76.00
|
| Rate for Payer: WellCare Medicare |
$104.50
|
|
|
XLARGE LEFT COMFORTFORM WRIST
|
Facility
|
IP
|
$27.81
|
|
| Hospital Charge Code |
4471573
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.08 |
| Max. Negotiated Rate |
$18.08 |
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: Galaxy Health Commercial |
$18.08
|
|
|
XLARGE LEFT COMFORTFORM WRIST
|
Facility
|
OP
|
$27.81
|
|
| Hospital Charge Code |
4471573
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.17 |
| Max. Negotiated Rate |
$22.25 |
| Rate for Payer: Aetna of NY Commercial |
$19.47
|
| Rate for Payer: Aetna of NY Medicare |
$12.79
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.12
|
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: CDPHP Medicare |
$10.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$22.25
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$22.25
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.25
|
| Rate for Payer: EmblemHealth Medicaid |
$22.25
|
| Rate for Payer: EmblemHealth Medicare |
$9.46
|
| Rate for Payer: EmblemHealth Select Care |
$20.02
|
| Rate for Payer: Fidelis Medicare |
$11.12
|
| Rate for Payer: Galaxy Health Commercial |
$18.08
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.12
|
| Rate for Payer: Humana Medicare |
$11.12
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$19.47
|
| Rate for Payer: Local 1199SEIU Medicare |
$12.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$20.86
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$15.66
|
| Rate for Payer: MVP Health Care of NY Medicare |
$11.68
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4.17
|
| Rate for Payer: United Healthcare Medicare |
$11.12
|
| Rate for Payer: WellCare Medicare |
$15.30
|
|
|
XLARGE RIGHT COMFORTFORM WRIST
|
Facility
|
OP
|
$27.81
|
|
| Hospital Charge Code |
4471568
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.17 |
| Max. Negotiated Rate |
$22.25 |
| Rate for Payer: Aetna of NY Commercial |
$19.47
|
| Rate for Payer: Aetna of NY Medicare |
$12.79
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.12
|
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: CDPHP Medicare |
$10.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$22.25
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$22.25
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$22.25
|
| Rate for Payer: EmblemHealth Medicaid |
$22.25
|
| Rate for Payer: EmblemHealth Medicare |
$9.46
|
| Rate for Payer: EmblemHealth Select Care |
$20.02
|
| Rate for Payer: Fidelis Medicare |
$11.12
|
| Rate for Payer: Galaxy Health Commercial |
$18.08
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.12
|
| Rate for Payer: Humana Medicare |
$11.12
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$19.47
|
| Rate for Payer: Local 1199SEIU Medicare |
$12.79
|
| Rate for Payer: MVP Health Care of NY Commercial |
$20.86
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$15.66
|
| Rate for Payer: MVP Health Care of NY Medicare |
$11.68
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4.17
|
| Rate for Payer: United Healthcare Medicare |
$11.12
|
| Rate for Payer: WellCare Medicare |
$15.30
|
|
|
XLARGE RIGHT COMFORTFORM WRIST
|
Facility
|
IP
|
$27.81
|
|
| Hospital Charge Code |
4471568
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.08 |
| Max. Negotiated Rate |
$18.08 |
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: Galaxy Health Commercial |
$18.08
|
|
|
XLARGE SPECIALTY ARM SLING
|
Facility
|
IP
|
$14.42
|
|
| Hospital Charge Code |
4471559
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.37 |
| Max. Negotiated Rate |
$9.37 |
| Rate for Payer: Cash Price |
$10.82
|
| Rate for Payer: Galaxy Health Commercial |
$9.37
|
|
|
XLARGE SPECIALTY ARM SLING
|
Facility
|
OP
|
$14.42
|
|
| Hospital Charge Code |
4471559
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$11.54 |
| Rate for Payer: Aetna of NY Commercial |
$10.09
|
| Rate for Payer: Aetna of NY Medicare |
$6.63
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.77
|
| Rate for Payer: Cash Price |
$10.82
|
| Rate for Payer: CDPHP Medicare |
$5.34
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$11.54
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$11.54
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$11.54
|
| Rate for Payer: EmblemHealth Medicaid |
$11.54
|
| Rate for Payer: EmblemHealth Medicare |
$4.90
|
| Rate for Payer: EmblemHealth Select Care |
$10.38
|
| Rate for Payer: Fidelis Medicare |
$5.77
|
| Rate for Payer: Galaxy Health Commercial |
$9.37
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.77
|
| Rate for Payer: Humana Medicare |
$5.77
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10.09
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.63
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.81
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$8.12
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.06
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.16
|
| Rate for Payer: United Healthcare Medicare |
$5.77
|
| Rate for Payer: WellCare Medicare |
$7.93
|
|
|
XL HEELBO
|
Facility
|
OP
|
$24.72
|
|
| Hospital Charge Code |
4471291
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$19.78 |
| Rate for Payer: Aetna of NY Commercial |
$17.30
|
| Rate for Payer: Aetna of NY Medicare |
$11.37
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.89
|
| Rate for Payer: Cash Price |
$18.54
|
| Rate for Payer: CDPHP Medicare |
$9.15
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$19.78
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$19.78
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$19.78
|
| Rate for Payer: EmblemHealth Medicaid |
$19.78
|
| Rate for Payer: EmblemHealth Medicare |
$8.40
|
| Rate for Payer: EmblemHealth Select Care |
$17.80
|
| Rate for Payer: Fidelis Medicare |
$9.89
|
| Rate for Payer: Galaxy Health Commercial |
$16.07
|
| Rate for Payer: Hamaspik Choice Medicare |
$9.89
|
| Rate for Payer: Humana Medicare |
$9.89
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$17.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$11.37
|
| Rate for Payer: MVP Health Care of NY Commercial |
$18.54
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$13.92
|
| Rate for Payer: MVP Health Care of NY Medicare |
$10.38
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3.71
|
| Rate for Payer: United Healthcare Medicare |
$9.89
|
| Rate for Payer: WellCare Medicare |
$13.60
|
|
|
XL HEELBO
|
Facility
|
IP
|
$24.72
|
|
| Hospital Charge Code |
4471291
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$16.07 |
| Max. Negotiated Rate |
$16.07 |
| Rate for Payer: Cash Price |
$18.54
|
| Rate for Payer: Galaxy Health Commercial |
$16.07
|
|
|
XL STOCKING ANTI-EMB THIGH
|
Facility
|
IP
|
$19.57
|
|
| Hospital Charge Code |
4471190
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.72 |
| Max. Negotiated Rate |
$12.72 |
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: Galaxy Health Commercial |
$12.72
|
|
|
XL STOCKING ANTI-EMB THIGH
|
Facility
|
OP
|
$19.57
|
|
| Hospital Charge Code |
4471190
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$15.66 |
| Rate for Payer: Aetna of NY Commercial |
$13.70
|
| Rate for Payer: Aetna of NY Medicare |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7.83
|
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: CDPHP Medicare |
$7.24
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$15.66
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$15.66
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$15.66
|
| Rate for Payer: EmblemHealth Medicaid |
$15.66
|
| Rate for Payer: EmblemHealth Medicare |
$6.65
|
| Rate for Payer: EmblemHealth Select Care |
$14.09
|
| Rate for Payer: Fidelis Medicare |
$7.83
|
| Rate for Payer: Galaxy Health Commercial |
$12.72
|
| Rate for Payer: Hamaspik Choice Medicare |
$7.83
|
| Rate for Payer: Humana Medicare |
$7.83
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$13.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$9.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$14.68
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$11.02
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.22
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.94
|
| Rate for Payer: United Healthcare Medicare |
$7.83
|
| Rate for Payer: WellCare Medicare |
$10.76
|
|
|
XL UNIVER KNEE WRAP W/CLOSED P
|
Facility
|
IP
|
$35.02
|
|
| Hospital Charge Code |
4471544
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$22.76 |
| Max. Negotiated Rate |
$22.76 |
| Rate for Payer: Cash Price |
$26.26
|
| Rate for Payer: Galaxy Health Commercial |
$22.76
|
|
|
XL UNIVER KNEE WRAP W/CLOSED P
|
Facility
|
OP
|
$35.02
|
|
| Hospital Charge Code |
4471544
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$28.02 |
| Rate for Payer: Aetna of NY Commercial |
$24.51
|
| Rate for Payer: Aetna of NY Medicare |
$16.11
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$14.01
|
| Rate for Payer: Cash Price |
$26.26
|
| Rate for Payer: CDPHP Medicare |
$12.96
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$28.02
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$28.02
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$28.02
|
| Rate for Payer: EmblemHealth Medicaid |
$28.02
|
| Rate for Payer: EmblemHealth Medicare |
$11.91
|
| Rate for Payer: EmblemHealth Select Care |
$25.21
|
| Rate for Payer: Fidelis Medicare |
$14.01
|
| Rate for Payer: Galaxy Health Commercial |
$22.76
|
| Rate for Payer: Hamaspik Choice Medicare |
$14.01
|
| Rate for Payer: Humana Medicare |
$14.01
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$24.51
|
| Rate for Payer: Local 1199SEIU Medicare |
$16.11
|
| Rate for Payer: MVP Health Care of NY Commercial |
$26.27
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$19.72
|
| Rate for Payer: MVP Health Care of NY Medicare |
$14.71
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$5.25
|
| Rate for Payer: United Healthcare Medicare |
$14.01
|
| Rate for Payer: WellCare Medicare |
$19.26
|
|
|
X-RAY BONE LENGTH STUDIES
|
Facility
|
OP
|
$320.00
|
|
|
Service Code
|
HCPCS 77073 TC
|
| Hospital Charge Code |
4150026
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$48.00 |
| Max. Negotiated Rate |
$402.00 |
| Rate for Payer: Aetna of NY Commercial |
$192.00
|
| 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 |
$192.00
|
| 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 |
$402.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$48.00
|
| Rate for Payer: United Healthcare Commercial |
$402.00
|
| Rate for Payer: United Healthcare Medicare |
$128.00
|
| Rate for Payer: WellCare Medicare |
$176.00
|
|
|
X-RAY BONE LENGTH STUDIES
|
Facility
|
IP
|
$320.00
|
|
|
Service Code
|
HCPCS 77073 TC
|
| Hospital Charge Code |
4150026
|
|
Hospital Revenue Code
|
320
|
| 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
|
|
|
X-RAY BONE LENGTH STUDIES
|
Facility
|
IP
|
$41.00
|
|
|
Service Code
|
HCPCS 77073 26
|
| Hospital Charge Code |
5150026
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$26.65 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Cash Price |
$30.75
|
| Rate for Payer: Galaxy Health Commercial |
$26.65
|
|
|
X-RAY BONE LENGTH STUDIES
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
HCPCS 77073 26
|
| Hospital Charge Code |
5150026
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$6.15 |
| Max. Negotiated Rate |
$32.80 |
| Rate for Payer: Aetna of NY Commercial |
$28.70
|
| Rate for Payer: Aetna of NY Medicare |
$18.86
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$16.40
|
| Rate for Payer: Cash Price |
$30.75
|
| Rate for Payer: CDPHP Medicare |
$15.17
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$32.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$32.80
|
| Rate for Payer: EmblemHealth Medicaid |
$32.80
|
| Rate for Payer: EmblemHealth Medicare |
$13.94
|
| Rate for Payer: Fidelis Medicare |
$16.40
|
| Rate for Payer: Galaxy Health Commercial |
$26.65
|
| Rate for Payer: Hamaspik Choice Medicare |
$16.40
|
| Rate for Payer: Humana Medicare |
$16.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$28.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$18.86
|
| Rate for Payer: MVP Health Care of NY Commercial |
$30.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$23.08
|
| Rate for Payer: MVP Health Care of NY Medicare |
$17.22
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$6.15
|
| Rate for Payer: United Healthcare Medicare |
$16.40
|
| Rate for Payer: WellCare Medicare |
$22.55
|
|
|
X-RAY BONE SURVEY COMPLETE
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
HCPCS 77075 26
|
| Hospital Charge Code |
5150325
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$12.15 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Aetna of NY Commercial |
$56.70
|
| Rate for Payer: Aetna of NY Medicare |
$37.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$32.40
|
| Rate for Payer: Cash Price |
$60.75
|
| Rate for Payer: CDPHP Medicare |
$29.97
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$64.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$64.80
|
| Rate for Payer: EmblemHealth Medicaid |
$64.80
|
| Rate for Payer: EmblemHealth Medicare |
$27.54
|
| Rate for Payer: Fidelis Medicare |
$32.40
|
| Rate for Payer: Galaxy Health Commercial |
$52.65
|
| Rate for Payer: Hamaspik Choice Medicare |
$32.40
|
| Rate for Payer: Humana Medicare |
$32.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$56.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$37.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$60.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$45.60
|
| Rate for Payer: MVP Health Care of NY Medicare |
$34.02
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$12.15
|
| Rate for Payer: United Healthcare Medicare |
$32.40
|
| Rate for Payer: WellCare Medicare |
$44.55
|
|
|
X-RAY BONE SURVEY COMPLETE
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
HCPCS 77075 26
|
| Hospital Charge Code |
5150325
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$52.65 |
| Max. Negotiated Rate |
$52.65 |
| Rate for Payer: Cash Price |
$60.75
|
| Rate for Payer: Galaxy Health Commercial |
$52.65
|
|
|
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 |
$111.30 |
| Max. Negotiated Rate |
$593.60 |
| 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) Medicare |
$296.80
|
| Rate for Payer: Cash Price |
$556.50
|
| Rate for Payer: Cash Price |
$556.50
|
| 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 |
$296.80
|
| Rate for Payer: Galaxy Health Commercial |
$482.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$296.80
|
| Rate for Payer: Humana Medicare |
$296.80
|
| 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 |
$311.64
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$402.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$111.30
|
| Rate for Payer: United Healthcare Commercial |
$402.00
|
| Rate for Payer: United Healthcare Medicare |
$296.80
|
| Rate for Payer: WellCare Medicare |
$408.10
|
|
|
X-RAY BONE SURVEY INFANT
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS 77076 26
|
| Hospital Charge Code |
5150522
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$83.20 |
| Rate for Payer: Aetna of NY Commercial |
$72.80
|
| Rate for Payer: Aetna of NY Medicare |
$47.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$41.60
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: CDPHP Medicare |
$38.48
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$83.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$83.20
|
| Rate for Payer: EmblemHealth Medicaid |
$83.20
|
| Rate for Payer: EmblemHealth Medicare |
$35.36
|
| Rate for Payer: Fidelis Medicare |
$41.60
|
| Rate for Payer: Galaxy Health Commercial |
$67.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$41.60
|
| Rate for Payer: Humana Medicare |
$41.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$72.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$47.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$78.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$58.55
|
| Rate for Payer: MVP Health Care of NY Medicare |
$43.68
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$15.60
|
| Rate for Payer: United Healthcare Medicare |
$41.60
|
| Rate for Payer: WellCare Medicare |
$57.20
|
|
