|
CYSTO/PYELOSCOPY BX&/FULGURATION PELIVC LESION
|
Facility
|
OP
|
$14,806.00
|
|
|
Service Code
|
HCPCS 52354
|
| Hospital Charge Code |
4002029
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$1,266.00 |
| Max. Negotiated Rate |
$11,918.83 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Aetna of NY Medicare |
$6,810.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,320.09
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,899.59
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5,478.22
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,266.00
|
| Rate for Payer: Cash Price |
$11,104.50
|
| Rate for Payer: Cash Price |
$11,104.50
|
| Rate for Payer: Cash Price |
$11,104.50
|
| Rate for Payer: CDPHP Commercial |
$11,918.83
|
| Rate for Payer: CDPHP Medicare |
$5,478.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$11,844.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$11,844.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$11,844.80
|
| Rate for Payer: EmblemHealth Medicaid |
$11,844.80
|
| Rate for Payer: EmblemHealth Medicare |
$5,034.04
|
| Rate for Payer: EmblemHealth Select Care |
$10,660.32
|
| Rate for Payer: Fidelis Medicare |
$5,642.57
|
| Rate for Payer: Galaxy Health Commercial |
$9,623.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$5,478.22
|
| Rate for Payer: Humana Medicare |
$5,478.22
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$6,810.76
|
| Rate for Payer: Multiplan Commercial |
$11,844.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11,104.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$8,335.78
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5,752.13
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4,930.08
|
| Rate for Payer: United Healthcare Commercial |
$2,036.00
|
| Rate for Payer: United Healthcare Medicare |
$5,478.22
|
| Rate for Payer: WellCare Medicare |
$8,143.30
|
|
|
CYSTO/PYELOSCOPY RESCJ PELVIC TUMOR
|
Facility
|
IP
|
$14,806.00
|
|
|
Service Code
|
HCPCS 52355
|
| Hospital Charge Code |
4002030
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$9,623.90 |
| Max. Negotiated Rate |
$9,623.90 |
| Rate for Payer: Cash Price |
$11,104.50
|
| Rate for Payer: Galaxy Health Commercial |
$9,623.90
|
|
|
CYSTO/PYELOSCOPY RESCJ PELVIC TUMOR
|
Facility
|
OP
|
$14,806.00
|
|
|
Service Code
|
HCPCS 52355
|
| Hospital Charge Code |
4002030
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$1,266.00 |
| Max. Negotiated Rate |
$11,918.83 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Aetna of NY Medicare |
$6,810.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,320.09
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,899.59
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5,478.22
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,266.00
|
| Rate for Payer: Cash Price |
$11,104.50
|
| Rate for Payer: Cash Price |
$11,104.50
|
| Rate for Payer: Cash Price |
$11,104.50
|
| Rate for Payer: CDPHP Commercial |
$11,918.83
|
| Rate for Payer: CDPHP Medicare |
$5,478.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$11,844.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$11,844.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$11,844.80
|
| Rate for Payer: EmblemHealth Medicaid |
$11,844.80
|
| Rate for Payer: EmblemHealth Medicare |
$5,034.04
|
| Rate for Payer: EmblemHealth Select Care |
$10,660.32
|
| Rate for Payer: Fidelis Medicare |
$5,642.57
|
| Rate for Payer: Galaxy Health Commercial |
$9,623.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$5,478.22
|
| Rate for Payer: Humana Medicare |
$5,478.22
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$6,810.76
|
| Rate for Payer: Multiplan Commercial |
$11,844.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11,104.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$8,335.78
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5,752.13
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4,930.08
|
| Rate for Payer: United Healthcare Commercial |
$2,036.00
|
| Rate for Payer: United Healthcare Medicare |
$5,478.22
|
| Rate for Payer: WellCare Medicare |
$8,143.30
|
|
|
CYSTOSCOPY PROSTATIC IMP 1-3
|
Facility
|
IP
|
$14,806.00
|
|
|
Service Code
|
HCPCS C9739
|
| Hospital Charge Code |
4002073
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$9,623.90 |
| Max. Negotiated Rate |
$9,623.90 |
| Rate for Payer: Cash Price |
$11,104.50
|
| Rate for Payer: Galaxy Health Commercial |
$9,623.90
|
|
|
CYSTOSCOPY PROSTATIC IMP 1-3
|
Facility
|
OP
|
$14,806.00
|
|
|
Service Code
|
HCPCS C9739
|
| Hospital Charge Code |
4002073
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$1,266.00 |
| Max. Negotiated Rate |
$11,918.83 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Aetna of NY Medicare |
$6,810.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,320.09
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,899.59
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5,478.22
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,266.00
|
| Rate for Payer: Cash Price |
$11,104.50
|
| Rate for Payer: Cash Price |
$11,104.50
|
| Rate for Payer: Cash Price |
$11,104.50
|
| Rate for Payer: CDPHP Commercial |
$11,918.83
|
| Rate for Payer: CDPHP Medicare |
$5,478.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$11,844.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$11,844.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$11,844.80
|
| Rate for Payer: EmblemHealth Medicaid |
$11,844.80
|
| Rate for Payer: EmblemHealth Medicare |
$5,034.04
|
| Rate for Payer: EmblemHealth Select Care |
$10,660.32
|
| Rate for Payer: Fidelis Medicare |
$5,642.57
|
| Rate for Payer: Galaxy Health Commercial |
$9,623.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$5,478.22
|
| Rate for Payer: Humana Medicare |
$5,478.22
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$6,810.76
|
| Rate for Payer: Multiplan Commercial |
$11,844.80
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11,104.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$8,335.78
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5,752.13
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4,930.08
|
| Rate for Payer: United Healthcare Commercial |
$2,036.00
|
| Rate for Payer: United Healthcare Medicare |
$5,478.22
|
| Rate for Payer: WellCare Medicare |
$8,143.30
|
|
|
CYSTOSCOPY PROSTATIC IMP 4 OR MORE
|
Facility
|
IP
|
$26,360.00
|
|
|
Service Code
|
HCPCS C9740
|
| Hospital Charge Code |
4002074
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$17,134.00 |
| Max. Negotiated Rate |
$17,134.00 |
| Rate for Payer: Cash Price |
$19,770.00
|
| Rate for Payer: Galaxy Health Commercial |
$17,134.00
|
|
|
CYSTOSCOPY PROSTATIC IMP 4 OR MORE
|
Facility
|
OP
|
$26,360.00
|
|
|
Service Code
|
HCPCS C9740
|
| Hospital Charge Code |
4002074
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$1,421.00 |
| Max. Negotiated Rate |
$21,219.80 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Aetna of NY Medicare |
$12,125.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,973.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$3,716.31
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9,753.20
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,421.00
|
| Rate for Payer: Cash Price |
$19,770.00
|
| Rate for Payer: Cash Price |
$19,770.00
|
| Rate for Payer: Cash Price |
$19,770.00
|
| Rate for Payer: CDPHP Commercial |
$21,219.80
|
| Rate for Payer: CDPHP Medicare |
$9,753.20
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$21,088.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$21,088.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$21,088.00
|
| Rate for Payer: EmblemHealth Medicaid |
$21,088.00
|
| Rate for Payer: EmblemHealth Medicare |
$8,962.40
|
| Rate for Payer: EmblemHealth Select Care |
$18,979.20
|
| Rate for Payer: Fidelis Medicare |
$10,045.80
|
| Rate for Payer: Galaxy Health Commercial |
$17,134.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$9,753.20
|
| Rate for Payer: Humana Medicare |
$9,753.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$12,125.60
|
| Rate for Payer: Multiplan Commercial |
$21,088.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$19,770.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$14,840.68
|
| Rate for Payer: MVP Health Care of NY Medicare |
$10,240.86
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$8,777.41
|
| Rate for Payer: United Healthcare Commercial |
$2,304.00
|
| Rate for Payer: United Healthcare Medicare |
$9,753.20
|
| Rate for Payer: WellCare Medicare |
$14,498.00
|
|
|
CYSTOSTOMY CYSTOTOMY W/DRAINAGE
|
Facility
|
IP
|
$5,828.00
|
|
|
Service Code
|
HCPCS 51040
|
| Hospital Charge Code |
4002004
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$3,788.20 |
| Max. Negotiated Rate |
$3,788.20 |
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: Galaxy Health Commercial |
$3,788.20
|
|
|
CYSTOSTOMY CYSTOTOMY W/DRAINAGE
|
Facility
|
OP
|
$5,828.00
|
|
|
Service Code
|
HCPCS 51040
|
| Hospital Charge Code |
4002004
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$1,266.00 |
| Max. Negotiated Rate |
$4,691.54 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Aetna of NY Medicare |
$2,680.88
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2,156.36
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,266.00
|
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: CDPHP Commercial |
$4,691.54
|
| Rate for Payer: CDPHP Medicare |
$2,156.36
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4,662.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4,662.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4,662.40
|
| Rate for Payer: EmblemHealth Medicaid |
$4,662.40
|
| Rate for Payer: EmblemHealth Medicare |
$1,981.52
|
| Rate for Payer: EmblemHealth Select Care |
$4,196.16
|
| Rate for Payer: Fidelis Medicare |
$2,221.05
|
| Rate for Payer: Galaxy Health Commercial |
$3,788.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$2,156.36
|
| Rate for Payer: Humana Medicare |
$2,156.36
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$2,680.88
|
| Rate for Payer: Multiplan Commercial |
$4,662.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,371.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3,281.16
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2,264.18
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1,940.66
|
| Rate for Payer: United Healthcare Commercial |
$2,036.00
|
| Rate for Payer: United Healthcare Medicare |
$2,156.36
|
| Rate for Payer: WellCare Medicare |
$3,205.40
|
|
|
CYSTOURETHROSCOPY
|
Facility
|
OP
|
$1,955.00
|
|
|
Service Code
|
HCPCS 52000
|
| Hospital Charge Code |
4002013
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$636.00 |
| Max. Negotiated Rate |
$2,521.93 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Aetna of NY Medicare |
$899.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$723.35
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$636.00
|
| Rate for Payer: Cash Price |
$1,466.25
|
| Rate for Payer: Cash Price |
$1,466.25
|
| Rate for Payer: Cash Price |
$1,466.25
|
| Rate for Payer: CDPHP Commercial |
$1,573.78
|
| Rate for Payer: CDPHP Medicare |
$723.35
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,564.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,564.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,564.00
|
| Rate for Payer: EmblemHealth Medicaid |
$1,564.00
|
| Rate for Payer: EmblemHealth Medicare |
$664.70
|
| Rate for Payer: EmblemHealth Select Care |
$1,407.60
|
| Rate for Payer: Fidelis Medicare |
$745.05
|
| Rate for Payer: Galaxy Health Commercial |
$1,270.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$723.35
|
| Rate for Payer: Humana Medicare |
$723.35
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$899.30
|
| Rate for Payer: Multiplan Commercial |
$1,564.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,466.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$1,100.66
|
| Rate for Payer: MVP Health Care of NY Medicare |
$759.52
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$650.86
|
| Rate for Payer: United Healthcare Commercial |
$1,775.00
|
| Rate for Payer: United Healthcare Medicare |
$723.35
|
| Rate for Payer: WellCare Medicare |
$1,075.25
|
|
|
CYSTOURETHROSCOPY
|
Facility
|
IP
|
$1,955.00
|
|
|
Service Code
|
HCPCS 52000
|
| Hospital Charge Code |
4002013
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$1,270.75 |
| Max. Negotiated Rate |
$1,270.75 |
| Rate for Payer: Cash Price |
$1,466.25
|
| Rate for Payer: Galaxy Health Commercial |
$1,270.75
|
|
|
CYSTOURETHROSCOPY W/DIL BLADDER GENERAL ANESTH
|
Facility
|
OP
|
$5,828.00
|
|
|
Service Code
|
HCPCS 52260
|
| Hospital Charge Code |
4002018
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$897.00 |
| Max. Negotiated Rate |
$4,691.54 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Aetna of NY Medicare |
$2,680.88
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2,156.36
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$897.00
|
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: CDPHP Commercial |
$4,691.54
|
| Rate for Payer: CDPHP Medicare |
$2,156.36
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4,662.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4,662.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4,662.40
|
| Rate for Payer: EmblemHealth Medicaid |
$4,662.40
|
| Rate for Payer: EmblemHealth Medicare |
$1,981.52
|
| Rate for Payer: EmblemHealth Select Care |
$4,196.16
|
| Rate for Payer: Fidelis Medicare |
$2,221.05
|
| Rate for Payer: Galaxy Health Commercial |
$3,788.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$2,156.36
|
| Rate for Payer: Humana Medicare |
$2,156.36
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$2,680.88
|
| Rate for Payer: Multiplan Commercial |
$4,662.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,371.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3,281.16
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2,264.18
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1,940.66
|
| Rate for Payer: United Healthcare Commercial |
$1,775.00
|
| Rate for Payer: United Healthcare Medicare |
$2,156.36
|
| Rate for Payer: WellCare Medicare |
$3,205.40
|
|
|
CYSTOURETHROSCOPY W/DIL BLADDER GENERAL ANESTH
|
Facility
|
IP
|
$5,828.00
|
|
|
Service Code
|
HCPCS 52260
|
| Hospital Charge Code |
4002018
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$3,788.20 |
| Max. Negotiated Rate |
$3,788.20 |
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: Galaxy Health Commercial |
$3,788.20
|
|
|
CYSTOURETHROSCOPY WITH BIOPSY
|
Facility
|
IP
|
$5,828.00
|
|
|
Service Code
|
HCPCS 52204
|
| Hospital Charge Code |
4002016
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$3,788.20 |
| Max. Negotiated Rate |
$3,788.20 |
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: Galaxy Health Commercial |
$3,788.20
|
|
|
CYSTOURETHROSCOPY WITH BIOPSY
|
Facility
|
OP
|
$5,828.00
|
|
|
Service Code
|
HCPCS 52204
|
| Hospital Charge Code |
4002016
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$1,266.00 |
| Max. Negotiated Rate |
$4,691.54 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Aetna of NY Medicare |
$2,680.88
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2,156.36
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,266.00
|
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: CDPHP Commercial |
$4,691.54
|
| Rate for Payer: CDPHP Medicare |
$2,156.36
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4,662.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4,662.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4,662.40
|
| Rate for Payer: EmblemHealth Medicaid |
$4,662.40
|
| Rate for Payer: EmblemHealth Medicare |
$1,981.52
|
| Rate for Payer: EmblemHealth Select Care |
$4,196.16
|
| Rate for Payer: Fidelis Medicare |
$2,221.05
|
| Rate for Payer: Galaxy Health Commercial |
$3,788.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$2,156.36
|
| Rate for Payer: Humana Medicare |
$2,156.36
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$2,680.88
|
| Rate for Payer: Multiplan Commercial |
$4,662.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,371.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3,281.16
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2,264.18
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1,940.66
|
| Rate for Payer: United Healthcare Commercial |
$2,036.00
|
| Rate for Payer: United Healthcare Medicare |
$2,156.36
|
| Rate for Payer: WellCare Medicare |
$3,205.40
|
|
|
CYSTOURETHROSCOPY W/RMVL URETERAL CALCULUS
|
Facility
|
IP
|
$9,975.00
|
|
|
Service Code
|
HCPCS 52320
|
| Hospital Charge Code |
4002023
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$6,483.75 |
| Max. Negotiated Rate |
$6,483.75 |
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: Galaxy Health Commercial |
$6,483.75
|
|
|
CYSTOURETHROSCOPY W/RMVL URETERAL CALCULUS
|
Facility
|
OP
|
$9,975.00
|
|
|
Service Code
|
HCPCS 52320
|
| Hospital Charge Code |
4002023
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$1,266.00 |
| Max. Negotiated Rate |
$8,029.88 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Aetna of NY Medicare |
$4,588.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3,690.75
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,266.00
|
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: CDPHP Commercial |
$8,029.88
|
| Rate for Payer: CDPHP Medicare |
$3,690.75
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7,980.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7,980.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7,980.00
|
| Rate for Payer: EmblemHealth Medicaid |
$7,980.00
|
| Rate for Payer: EmblemHealth Medicare |
$3,391.50
|
| Rate for Payer: EmblemHealth Select Care |
$7,182.00
|
| Rate for Payer: Fidelis Medicare |
$3,801.47
|
| Rate for Payer: Galaxy Health Commercial |
$6,483.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$3,690.75
|
| Rate for Payer: Humana Medicare |
$3,690.75
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$4,588.50
|
| Rate for Payer: Multiplan Commercial |
$7,980.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7,481.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5,615.92
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3,875.29
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3,321.58
|
| Rate for Payer: United Healthcare Commercial |
$2,036.00
|
| Rate for Payer: United Healthcare Medicare |
$3,690.75
|
| Rate for Payer: WellCare Medicare |
$5,486.25
|
|
|
CYSTO W/DESTRUCTION OF LESIONS
|
Facility
|
OP
|
$9,975.00
|
|
|
Service Code
|
HCPCS 52214
|
| Hospital Charge Code |
4002017
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$1,266.00 |
| Max. Negotiated Rate |
$8,029.88 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Aetna of NY Medicare |
$4,588.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3,690.75
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,266.00
|
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: CDPHP Commercial |
$8,029.88
|
| Rate for Payer: CDPHP Medicare |
$3,690.75
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7,980.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7,980.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7,980.00
|
| Rate for Payer: EmblemHealth Medicaid |
$7,980.00
|
| Rate for Payer: EmblemHealth Medicare |
$3,391.50
|
| Rate for Payer: EmblemHealth Select Care |
$7,182.00
|
| Rate for Payer: Fidelis Medicare |
$3,801.47
|
| Rate for Payer: Galaxy Health Commercial |
$6,483.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$3,690.75
|
| Rate for Payer: Humana Medicare |
$3,690.75
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$4,588.50
|
| Rate for Payer: Multiplan Commercial |
$7,980.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7,481.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5,615.92
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3,875.29
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3,321.58
|
| Rate for Payer: United Healthcare Commercial |
$2,036.00
|
| Rate for Payer: United Healthcare Medicare |
$3,690.75
|
| Rate for Payer: WellCare Medicare |
$5,486.25
|
|
|
CYSTO W/DESTRUCTION OF LESIONS
|
Facility
|
IP
|
$9,975.00
|
|
|
Service Code
|
HCPCS 52214
|
| Hospital Charge Code |
4002017
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$6,483.75 |
| Max. Negotiated Rate |
$6,483.75 |
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: Galaxy Health Commercial |
$6,483.75
|
|
|
CYSTO W/INSERT URETERAL STENT
|
Facility
|
IP
|
$9,975.00
|
|
|
Service Code
|
HCPCS 52332
|
| Hospital Charge Code |
4002025
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$6,483.75 |
| Max. Negotiated Rate |
$6,483.75 |
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: Galaxy Health Commercial |
$6,483.75
|
|
|
CYSTO W/INSERT URETERAL STENT
|
Facility
|
OP
|
$9,975.00
|
|
|
Service Code
|
HCPCS 52332
|
| Hospital Charge Code |
4002025
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$1,266.00 |
| Max. Negotiated Rate |
$8,029.88 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Aetna of NY Medicare |
$4,588.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3,690.75
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$1,266.00
|
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: CDPHP Commercial |
$8,029.88
|
| Rate for Payer: CDPHP Medicare |
$3,690.75
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7,980.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7,980.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7,980.00
|
| Rate for Payer: EmblemHealth Medicaid |
$7,980.00
|
| Rate for Payer: EmblemHealth Medicare |
$3,391.50
|
| Rate for Payer: EmblemHealth Select Care |
$7,182.00
|
| Rate for Payer: Fidelis Medicare |
$3,801.47
|
| Rate for Payer: Galaxy Health Commercial |
$6,483.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$3,690.75
|
| Rate for Payer: Humana Medicare |
$3,690.75
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$4,588.50
|
| Rate for Payer: Multiplan Commercial |
$7,980.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7,481.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5,615.92
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3,875.29
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3,321.58
|
| Rate for Payer: United Healthcare Commercial |
$2,036.00
|
| Rate for Payer: United Healthcare Medicare |
$3,690.75
|
| Rate for Payer: WellCare Medicare |
$5,486.25
|
|
|
CYSTO W/IRRIG & EVAC MULTPLE OBSTRUCTING CLOTS
|
Facility
|
OP
|
$9,975.00
|
|
|
Service Code
|
HCPCS 52001
|
| Hospital Charge Code |
4002014
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$897.00 |
| Max. Negotiated Rate |
$8,029.88 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Aetna of NY Medicare |
$4,588.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3,690.75
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$897.00
|
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: CDPHP Commercial |
$8,029.88
|
| Rate for Payer: CDPHP Medicare |
$3,690.75
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7,980.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7,980.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7,980.00
|
| Rate for Payer: EmblemHealth Medicaid |
$7,980.00
|
| Rate for Payer: EmblemHealth Medicare |
$3,391.50
|
| Rate for Payer: EmblemHealth Select Care |
$7,182.00
|
| Rate for Payer: Fidelis Medicare |
$3,801.47
|
| Rate for Payer: Galaxy Health Commercial |
$6,483.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$3,690.75
|
| Rate for Payer: Humana Medicare |
$3,690.75
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$4,588.50
|
| Rate for Payer: Multiplan Commercial |
$7,980.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$7,481.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$5,615.92
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3,875.29
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$3,321.58
|
| Rate for Payer: United Healthcare Commercial |
$1,775.00
|
| Rate for Payer: United Healthcare Medicare |
$3,690.75
|
| Rate for Payer: WellCare Medicare |
$5,486.25
|
|
|
CYSTO W/IRRIG & EVAC MULTPLE OBSTRUCTING CLOTS
|
Facility
|
IP
|
$9,975.00
|
|
|
Service Code
|
HCPCS 52001
|
| Hospital Charge Code |
4002014
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$6,483.75 |
| Max. Negotiated Rate |
$6,483.75 |
| Rate for Payer: Cash Price |
$7,481.25
|
| Rate for Payer: Galaxy Health Commercial |
$6,483.75
|
|
|
CYSTO W/SIMPLE REMOVAL STONE & STENT
|
Facility
|
OP
|
$5,828.00
|
|
|
Service Code
|
HCPCS 52310
|
| Hospital Charge Code |
4002020
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$897.00 |
| Max. Negotiated Rate |
$4,691.54 |
| Rate for Payer: Aetna of NY Commercial |
$1,857.00
|
| Rate for Payer: Aetna of NY Medicare |
$2,680.88
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$2,017.33
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$2,521.93
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2,156.36
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$897.00
|
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: CDPHP Commercial |
$4,691.54
|
| Rate for Payer: CDPHP Medicare |
$2,156.36
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4,662.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4,662.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4,662.40
|
| Rate for Payer: EmblemHealth Medicaid |
$4,662.40
|
| Rate for Payer: EmblemHealth Medicare |
$1,981.52
|
| Rate for Payer: EmblemHealth Select Care |
$4,196.16
|
| Rate for Payer: Fidelis Medicare |
$2,221.05
|
| Rate for Payer: Galaxy Health Commercial |
$3,788.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$2,156.36
|
| Rate for Payer: Humana Medicare |
$2,156.36
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,857.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$2,680.88
|
| Rate for Payer: Multiplan Commercial |
$4,662.40
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4,371.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3,281.16
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2,264.18
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1,775.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1,940.66
|
| Rate for Payer: United Healthcare Commercial |
$1,775.00
|
| Rate for Payer: United Healthcare Medicare |
$2,156.36
|
| Rate for Payer: WellCare Medicare |
$3,205.40
|
|
|
CYSTO W/SIMPLE REMOVAL STONE & STENT
|
Facility
|
IP
|
$5,828.00
|
|
|
Service Code
|
HCPCS 52310
|
| Hospital Charge Code |
4002020
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$3,788.20 |
| Max. Negotiated Rate |
$3,788.20 |
| Rate for Payer: Cash Price |
$4,371.00
|
| Rate for Payer: Galaxy Health Commercial |
$3,788.20
|
|
