|
CSF CELL COUNT
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
HCPCS 89051
|
| Hospital Charge Code |
4304872
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$11.05 |
| Rate for Payer: Cash Price |
$12.75
|
| Rate for Payer: Galaxy Health Commercial |
$11.05
|
|
|
CT ABDOMEN W/ DYE
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
HCPCS 74160 26
|
| Hospital Charge Code |
5220004
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$120.90 |
| Max. Negotiated Rate |
$120.90 |
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Galaxy Health Commercial |
$120.90
|
|
|
CT ABDOMEN W/ DYE
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
HCPCS 74160 26
|
| Hospital Charge Code |
5220004
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$27.90 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$85.56
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$74.40
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: CDPHP Medicare |
$68.82
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$148.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$148.80
|
| Rate for Payer: EmblemHealth Medicaid |
$148.80
|
| Rate for Payer: EmblemHealth Medicare |
$63.24
|
| Rate for Payer: Fidelis Medicare |
$74.40
|
| Rate for Payer: Galaxy Health Commercial |
$120.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$74.40
|
| Rate for Payer: Humana Medicare |
$74.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$85.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$139.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$104.72
|
| Rate for Payer: MVP Health Care of NY Medicare |
$78.12
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$27.90
|
| Rate for Payer: United Healthcare Medicare |
$74.40
|
| Rate for Payer: WellCare Medicare |
$102.30
|
|
|
CT ABDOMEN W/DYE
|
Facility
|
OP
|
$1,505.00
|
|
|
Service Code
|
HCPCS 74160 TC
|
| Hospital Charge Code |
4220004
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$225.75 |
| Max. Negotiated Rate |
$1,204.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$692.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$602.00
|
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: CDPHP Medicare |
$556.85
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,053.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,204.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,204.00
|
| Rate for Payer: EmblemHealth Medicaid |
$1,204.00
|
| Rate for Payer: EmblemHealth Medicare |
$511.70
|
| Rate for Payer: EmblemHealth Select Care |
$978.25
|
| Rate for Payer: Fidelis Medicare |
$602.00
|
| Rate for Payer: Galaxy Health Commercial |
$978.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$602.00
|
| Rate for Payer: Humana Medicare |
$602.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$692.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,128.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$847.32
|
| Rate for Payer: MVP Health Care of NY Medicare |
$632.10
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$798.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$225.75
|
| Rate for Payer: United Healthcare Commercial |
$798.00
|
| Rate for Payer: United Healthcare Medicare |
$602.00
|
| Rate for Payer: WellCare Medicare |
$827.75
|
|
|
CT ABDOMEN W/DYE
|
Facility
|
IP
|
$1,505.00
|
|
|
Service Code
|
HCPCS 74160 TC
|
| Hospital Charge Code |
4220004
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$978.25 |
| Max. Negotiated Rate |
$978.25 |
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: Galaxy Health Commercial |
$978.25
|
|
|
CT ABDOMEN W/O DYE
|
Facility
|
OP
|
$1,398.00
|
|
|
Service Code
|
HCPCS 74150 TC
|
| Hospital Charge Code |
4220080
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$209.70 |
| Max. Negotiated Rate |
$1,118.40 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$643.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$559.20
|
| Rate for Payer: Cash Price |
$1,048.50
|
| Rate for Payer: Cash Price |
$1,048.50
|
| Rate for Payer: Cash Price |
$1,048.50
|
| Rate for Payer: CDPHP Medicare |
$517.26
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$978.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,118.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,118.40
|
| Rate for Payer: EmblemHealth Medicaid |
$1,118.40
|
| Rate for Payer: EmblemHealth Medicare |
$475.32
|
| Rate for Payer: EmblemHealth Select Care |
$908.70
|
| Rate for Payer: Fidelis Medicare |
$559.20
|
| Rate for Payer: Galaxy Health Commercial |
$908.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$559.20
|
| Rate for Payer: Humana Medicare |
$559.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$643.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,048.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$787.07
|
| Rate for Payer: MVP Health Care of NY Medicare |
$587.16
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$798.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$209.70
|
| Rate for Payer: United Healthcare Commercial |
$798.00
|
| Rate for Payer: United Healthcare Medicare |
$559.20
|
| Rate for Payer: WellCare Medicare |
$768.90
|
|
|
CT ABDOMEN W/O DYE
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
HCPCS 74150 26
|
| Hospital Charge Code |
5220080
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$113.10 |
| Max. Negotiated Rate |
$113.10 |
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Galaxy Health Commercial |
$113.10
|
|
|
CT ABDOMEN W/O DYE
|
Facility
|
IP
|
$1,398.00
|
|
|
Service Code
|
HCPCS 74150 TC
|
| Hospital Charge Code |
4220080
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$908.70 |
| Max. Negotiated Rate |
$908.70 |
| Rate for Payer: Cash Price |
$1,048.50
|
| Rate for Payer: Galaxy Health Commercial |
$908.70
|
|
|
CT ABDOMEN W/O DYE
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
HCPCS 74150 26
|
| Hospital Charge Code |
5220080
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$26.10 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$80.04
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$69.60
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: CDPHP Medicare |
$64.38
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$139.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$139.20
|
| Rate for Payer: EmblemHealth Medicaid |
$139.20
|
| Rate for Payer: EmblemHealth Medicare |
$59.16
|
| Rate for Payer: Fidelis Medicare |
$69.60
|
| Rate for Payer: Galaxy Health Commercial |
$113.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$69.60
|
| Rate for Payer: Humana Medicare |
$69.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$80.04
|
| Rate for Payer: MVP Health Care of NY Commercial |
$130.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$97.96
|
| Rate for Payer: MVP Health Care of NY Medicare |
$73.08
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$26.10
|
| Rate for Payer: United Healthcare Medicare |
$69.60
|
| Rate for Payer: WellCare Medicare |
$95.70
|
|
|
CT ABDOMEN W/O & W/DYE
|
Facility
|
IP
|
$204.00
|
|
|
Service Code
|
HCPCS 74170 26
|
| Hospital Charge Code |
5220003
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$132.60 |
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Galaxy Health Commercial |
$132.60
|
|
|
CT ABDOMEN W/O & W/DYE
|
Facility
|
OP
|
$204.00
|
|
|
Service Code
|
HCPCS 74170 26
|
| Hospital Charge Code |
5220003
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$30.60 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$93.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$81.60
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: CDPHP Medicare |
$75.48
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$163.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$163.20
|
| Rate for Payer: EmblemHealth Medicaid |
$163.20
|
| Rate for Payer: EmblemHealth Medicare |
$69.36
|
| Rate for Payer: Fidelis Medicare |
$81.60
|
| Rate for Payer: Galaxy Health Commercial |
$132.60
|
| Rate for Payer: Hamaspik Choice Medicare |
$81.60
|
| Rate for Payer: Humana Medicare |
$81.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$93.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$153.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$114.85
|
| Rate for Payer: MVP Health Care of NY Medicare |
$85.68
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$30.60
|
| Rate for Payer: United Healthcare Medicare |
$81.60
|
| Rate for Payer: WellCare Medicare |
$112.20
|
|
|
CT ABDOMEN W/O & W/DYE
|
Facility
|
IP
|
$2,448.00
|
|
|
Service Code
|
HCPCS 74170 TC
|
| Hospital Charge Code |
4220003
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,591.20 |
| Max. Negotiated Rate |
$1,591.20 |
| Rate for Payer: Cash Price |
$1,836.00
|
| Rate for Payer: Galaxy Health Commercial |
$1,591.20
|
|
|
CT ABDOMEN W/O & W/DYE
|
Facility
|
OP
|
$2,448.00
|
|
|
Service Code
|
HCPCS 74170 TC
|
| Hospital Charge Code |
4220003
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$367.20 |
| Max. Negotiated Rate |
$1,958.40 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$1,126.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$979.20
|
| Rate for Payer: Cash Price |
$1,836.00
|
| Rate for Payer: Cash Price |
$1,836.00
|
| Rate for Payer: Cash Price |
$1,836.00
|
| Rate for Payer: CDPHP Medicare |
$905.76
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,713.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,958.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,958.40
|
| Rate for Payer: EmblemHealth Medicaid |
$1,958.40
|
| Rate for Payer: EmblemHealth Medicare |
$832.32
|
| Rate for Payer: EmblemHealth Select Care |
$1,591.20
|
| Rate for Payer: Fidelis Medicare |
$979.20
|
| Rate for Payer: Galaxy Health Commercial |
$1,591.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$979.20
|
| Rate for Payer: Humana Medicare |
$979.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$1,126.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,836.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,378.22
|
| Rate for Payer: MVP Health Care of NY Medicare |
$1,028.16
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$798.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$367.20
|
| Rate for Payer: United Healthcare Commercial |
$798.00
|
| Rate for Payer: United Healthcare Medicare |
$979.20
|
| Rate for Payer: WellCare Medicare |
$1,346.40
|
|
|
CT ABD & PELV 1/> REGNS
|
Facility
|
IP
|
$1,595.00
|
|
|
Service Code
|
HCPCS 74178 TC
|
| Hospital Charge Code |
4220059
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,036.75 |
| Max. Negotiated Rate |
$1,036.75 |
| Rate for Payer: Cash Price |
$1,196.25
|
| Rate for Payer: Galaxy Health Commercial |
$1,036.75
|
|
|
CT ABD & PELV 1/> REGNS
|
Facility
|
OP
|
$1,595.00
|
|
|
Service Code
|
HCPCS 74178 TC
|
| Hospital Charge Code |
4220059
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$239.25 |
| Max. Negotiated Rate |
$1,276.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$733.70
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$638.00
|
| Rate for Payer: Cash Price |
$1,196.25
|
| Rate for Payer: Cash Price |
$1,196.25
|
| Rate for Payer: Cash Price |
$1,196.25
|
| Rate for Payer: CDPHP Medicare |
$590.15
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,116.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,276.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,276.00
|
| Rate for Payer: EmblemHealth Medicaid |
$1,276.00
|
| Rate for Payer: EmblemHealth Medicare |
$542.30
|
| Rate for Payer: EmblemHealth Select Care |
$1,036.75
|
| Rate for Payer: Fidelis Medicare |
$638.00
|
| Rate for Payer: Galaxy Health Commercial |
$1,036.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$638.00
|
| Rate for Payer: Humana Medicare |
$638.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$733.70
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,196.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$897.99
|
| Rate for Payer: MVP Health Care of NY Medicare |
$669.90
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$798.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$239.25
|
| Rate for Payer: United Healthcare Commercial |
$798.00
|
| Rate for Payer: United Healthcare Medicare |
$638.00
|
| Rate for Payer: WellCare Medicare |
$877.25
|
|
|
CT ABD & PELV 1> REGNS
|
Facility
|
IP
|
$294.00
|
|
|
Service Code
|
HCPCS 74178 26
|
| Hospital Charge Code |
5220059
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$191.10 |
| Max. Negotiated Rate |
$191.10 |
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Galaxy Health Commercial |
$191.10
|
|
|
CT ABD & PELV 1> REGNS
|
Facility
|
OP
|
$294.00
|
|
|
Service Code
|
HCPCS 74178 26
|
| Hospital Charge Code |
5220059
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$135.24
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$117.60
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: CDPHP Medicare |
$108.78
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$235.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$235.20
|
| Rate for Payer: EmblemHealth Medicaid |
$235.20
|
| Rate for Payer: EmblemHealth Medicare |
$99.96
|
| Rate for Payer: Fidelis Medicare |
$117.60
|
| Rate for Payer: Galaxy Health Commercial |
$191.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$117.60
|
| Rate for Payer: Humana Medicare |
$117.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$135.24
|
| Rate for Payer: MVP Health Care of NY Commercial |
$220.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$165.52
|
| Rate for Payer: MVP Health Care of NY Medicare |
$123.48
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$44.10
|
| Rate for Payer: United Healthcare Medicare |
$117.60
|
| Rate for Payer: WellCare Medicare |
$161.70
|
|
|
CT ABD & PELVIS W/ DYE
|
Facility
|
OP
|
$268.00
|
|
|
Service Code
|
HCPCS 74177 26
|
| Hospital Charge Code |
5220058
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$40.20 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$123.28
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$107.20
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: CDPHP Medicare |
$99.16
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$214.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$214.40
|
| Rate for Payer: EmblemHealth Medicaid |
$214.40
|
| Rate for Payer: EmblemHealth Medicare |
$91.12
|
| Rate for Payer: Fidelis Medicare |
$107.20
|
| Rate for Payer: Galaxy Health Commercial |
$174.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$107.20
|
| Rate for Payer: Humana Medicare |
$107.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$123.28
|
| Rate for Payer: MVP Health Care of NY Commercial |
$201.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$150.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$112.56
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$40.20
|
| Rate for Payer: United Healthcare Medicare |
$107.20
|
| Rate for Payer: WellCare Medicare |
$147.40
|
|
|
CT ABD & PELVIS W/ DYE
|
Facility
|
IP
|
$268.00
|
|
|
Service Code
|
HCPCS 74177 26
|
| Hospital Charge Code |
5220058
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$174.20 |
| Max. Negotiated Rate |
$174.20 |
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Galaxy Health Commercial |
$174.20
|
|
|
CT ABD & PELVIS W/O DYE
|
Facility
|
OP
|
$255.00
|
|
|
Service Code
|
HCPCS 74176 26
|
| Hospital Charge Code |
5220057
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$38.25 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$117.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$102.00
|
| Rate for Payer: Cash Price |
$191.25
|
| Rate for Payer: Cash Price |
$191.25
|
| Rate for Payer: CDPHP Medicare |
$94.35
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$204.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$204.00
|
| Rate for Payer: EmblemHealth Medicaid |
$204.00
|
| Rate for Payer: EmblemHealth Medicare |
$86.70
|
| Rate for Payer: Fidelis Medicare |
$102.00
|
| Rate for Payer: Galaxy Health Commercial |
$165.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$102.00
|
| Rate for Payer: Humana Medicare |
$102.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$117.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$191.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$143.56
|
| Rate for Payer: MVP Health Care of NY Medicare |
$107.10
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$38.25
|
| Rate for Payer: United Healthcare Medicare |
$102.00
|
| Rate for Payer: WellCare Medicare |
$140.25
|
|
|
CT ABD & PELVIS W/O DYE
|
Facility
|
OP
|
$1,413.00
|
|
|
Service Code
|
HCPCS 74176 TC
|
| Hospital Charge Code |
4220057
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$211.95 |
| Max. Negotiated Rate |
$1,130.40 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$649.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$565.20
|
| Rate for Payer: Cash Price |
$1,059.75
|
| Rate for Payer: Cash Price |
$1,059.75
|
| Rate for Payer: Cash Price |
$1,059.75
|
| Rate for Payer: CDPHP Medicare |
$522.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$989.10
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,130.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,130.40
|
| Rate for Payer: EmblemHealth Medicaid |
$1,130.40
|
| Rate for Payer: EmblemHealth Medicare |
$480.42
|
| Rate for Payer: EmblemHealth Select Care |
$918.45
|
| Rate for Payer: Fidelis Medicare |
$565.20
|
| Rate for Payer: Galaxy Health Commercial |
$918.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$565.20
|
| Rate for Payer: Humana Medicare |
$565.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$649.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,059.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$795.52
|
| Rate for Payer: MVP Health Care of NY Medicare |
$593.46
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$798.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$211.95
|
| Rate for Payer: United Healthcare Commercial |
$798.00
|
| Rate for Payer: United Healthcare Medicare |
$565.20
|
| Rate for Payer: WellCare Medicare |
$777.15
|
|
|
CT ABD & PELVIS W/O DYE
|
Facility
|
IP
|
$255.00
|
|
|
Service Code
|
HCPCS 74176 26
|
| Hospital Charge Code |
5220057
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$165.75 |
| Max. Negotiated Rate |
$165.75 |
| Rate for Payer: Cash Price |
$191.25
|
| Rate for Payer: Galaxy Health Commercial |
$165.75
|
|
|
CT ABD & PELVIS W/O DYE
|
Facility
|
IP
|
$1,413.00
|
|
|
Service Code
|
HCPCS 74176 TC
|
| Hospital Charge Code |
4220057
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$918.45 |
| Max. Negotiated Rate |
$918.45 |
| Rate for Payer: Cash Price |
$1,059.75
|
| Rate for Payer: Galaxy Health Commercial |
$918.45
|
|
|
CT ABD & PELV W/ DYE
|
Facility
|
OP
|
$1,505.00
|
|
|
Service Code
|
HCPCS 74177 TC
|
| Hospital Charge Code |
4220058
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$225.75 |
| Max. Negotiated Rate |
$1,204.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$692.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$602.00
|
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: CDPHP Medicare |
$556.85
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,053.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,204.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,204.00
|
| Rate for Payer: EmblemHealth Medicaid |
$1,204.00
|
| Rate for Payer: EmblemHealth Medicare |
$511.70
|
| Rate for Payer: EmblemHealth Select Care |
$978.25
|
| Rate for Payer: Fidelis Medicare |
$602.00
|
| Rate for Payer: Galaxy Health Commercial |
$978.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$602.00
|
| Rate for Payer: Humana Medicare |
$602.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$692.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,128.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$847.32
|
| Rate for Payer: MVP Health Care of NY Medicare |
$632.10
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$798.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$225.75
|
| Rate for Payer: United Healthcare Commercial |
$798.00
|
| Rate for Payer: United Healthcare Medicare |
$602.00
|
| Rate for Payer: WellCare Medicare |
$827.75
|
|
|
CT ABD & PELV W/ DYE
|
Facility
|
IP
|
$1,505.00
|
|
|
Service Code
|
HCPCS 74177 TC
|
| Hospital Charge Code |
4220058
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$978.25 |
| Max. Negotiated Rate |
$978.25 |
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: Galaxy Health Commercial |
$978.25
|
|
