|
CT LUMBAR SPINE W/O & W/DYE
|
Facility
|
OP
|
$1,598.00
|
|
|
Service Code
|
HCPCS 72133 TC
|
| Hospital Charge Code |
4220029
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$239.70 |
| Max. Negotiated Rate |
$1,278.40 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$735.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$639.20
|
| Rate for Payer: Cash Price |
$1,198.50
|
| Rate for Payer: Cash Price |
$1,198.50
|
| Rate for Payer: Cash Price |
$1,198.50
|
| Rate for Payer: CDPHP Medicare |
$591.26
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,118.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,278.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,278.40
|
| Rate for Payer: EmblemHealth Medicaid |
$1,278.40
|
| Rate for Payer: EmblemHealth Medicare |
$543.32
|
| Rate for Payer: EmblemHealth Select Care |
$1,038.70
|
| Rate for Payer: Fidelis Medicare |
$639.20
|
| Rate for Payer: Galaxy Health Commercial |
$1,038.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$639.20
|
| Rate for Payer: Humana Medicare |
$639.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$735.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,198.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$899.67
|
| Rate for Payer: MVP Health Care of NY Medicare |
$671.16
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$798.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$239.70
|
| Rate for Payer: United Healthcare Commercial |
$798.00
|
| Rate for Payer: United Healthcare Medicare |
$639.20
|
| Rate for Payer: WellCare Medicare |
$878.90
|
|
|
CT LWR EXTREMITY W/O&W/DYE
|
Facility
|
IP
|
$1,505.00
|
|
|
Service Code
|
HCPCS 73702 TC
|
| Hospital Charge Code |
4220026
|
|
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 LWR EXTREMITY W/O&W/DYE
|
Facility
|
OP
|
$1,505.00
|
|
|
Service Code
|
HCPCS 73702 TC
|
| Hospital Charge Code |
4220026
|
|
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 MAXILLOFACIAL W/ DYE
|
Facility
|
IP
|
$165.00
|
|
|
Service Code
|
HCPCS 70487 26
|
| Hospital Charge Code |
5220033
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$107.25 |
| Max. Negotiated Rate |
$107.25 |
| Rate for Payer: Cash Price |
$123.75
|
| Rate for Payer: Galaxy Health Commercial |
$107.25
|
|
|
CT MAXILLOFACIAL W/ DYE
|
Facility
|
OP
|
$165.00
|
|
|
Service Code
|
HCPCS 70487 26
|
| Hospital Charge Code |
5220033
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$75.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$66.00
|
| Rate for Payer: Cash Price |
$123.75
|
| Rate for Payer: Cash Price |
$123.75
|
| Rate for Payer: CDPHP Medicare |
$61.05
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$132.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$132.00
|
| Rate for Payer: EmblemHealth Medicaid |
$132.00
|
| Rate for Payer: EmblemHealth Medicare |
$56.10
|
| Rate for Payer: Fidelis Medicare |
$66.00
|
| Rate for Payer: Galaxy Health Commercial |
$107.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$66.00
|
| Rate for Payer: Humana Medicare |
$66.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$75.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$123.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$92.89
|
| Rate for Payer: MVP Health Care of NY Medicare |
$69.30
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$24.75
|
| Rate for Payer: United Healthcare Medicare |
$66.00
|
| Rate for Payer: WellCare Medicare |
$90.75
|
|
|
CT MAXILLOFACIAL W/DYE
|
Facility
|
IP
|
$1,239.00
|
|
|
Service Code
|
HCPCS 70487 TC
|
| Hospital Charge Code |
4220033
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$805.35 |
| Max. Negotiated Rate |
$805.35 |
| Rate for Payer: Cash Price |
$929.25
|
| Rate for Payer: Galaxy Health Commercial |
$805.35
|
|
|
CT MAXILLOFACIAL W/DYE
|
Facility
|
OP
|
$1,239.00
|
|
|
Service Code
|
HCPCS 70487 TC
|
| Hospital Charge Code |
4220033
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$185.85 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$569.94
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$495.60
|
| Rate for Payer: Cash Price |
$929.25
|
| Rate for Payer: Cash Price |
$929.25
|
| Rate for Payer: Cash Price |
$929.25
|
| Rate for Payer: CDPHP Medicare |
$458.43
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$867.30
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$991.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$991.20
|
| Rate for Payer: EmblemHealth Medicaid |
$991.20
|
| Rate for Payer: EmblemHealth Medicare |
$421.26
|
| Rate for Payer: EmblemHealth Select Care |
$805.35
|
| Rate for Payer: Fidelis Medicare |
$495.60
|
| Rate for Payer: Galaxy Health Commercial |
$805.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$495.60
|
| Rate for Payer: Humana Medicare |
$495.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$569.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$929.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$697.56
|
| Rate for Payer: MVP Health Care of NY Medicare |
$520.38
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$798.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$185.85
|
| Rate for Payer: United Healthcare Commercial |
$798.00
|
| Rate for Payer: United Healthcare Medicare |
$495.60
|
| Rate for Payer: WellCare Medicare |
$681.45
|
|
|
CT MAXILLOFACIAL W/O DYE
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
HCPCS 70486 TC
|
| Hospital Charge Code |
4220031
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$748.15 |
| Max. Negotiated Rate |
$748.15 |
| Rate for Payer: Cash Price |
$863.25
|
| Rate for Payer: Galaxy Health Commercial |
$748.15
|
|
|
CT MAXILLOFACIAL W/O DYE
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
HCPCS 70486 26
|
| Hospital Charge Code |
5220031
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$57.96
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$50.40
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: CDPHP Medicare |
$46.62
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$100.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$100.80
|
| Rate for Payer: EmblemHealth Medicaid |
$100.80
|
| Rate for Payer: EmblemHealth Medicare |
$42.84
|
| Rate for Payer: Fidelis Medicare |
$50.40
|
| Rate for Payer: Galaxy Health Commercial |
$81.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$50.40
|
| Rate for Payer: Humana Medicare |
$50.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$57.96
|
| Rate for Payer: MVP Health Care of NY Commercial |
$94.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$70.94
|
| Rate for Payer: MVP Health Care of NY Medicare |
$52.92
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$18.90
|
| Rate for Payer: United Healthcare Medicare |
$50.40
|
| Rate for Payer: WellCare Medicare |
$69.30
|
|
|
CT MAXILLOFACIAL W/O DYE
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
HCPCS 70486 TC
|
| Hospital Charge Code |
4220031
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$172.65 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$529.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$460.40
|
| Rate for Payer: Cash Price |
$863.25
|
| Rate for Payer: Cash Price |
$863.25
|
| Rate for Payer: Cash Price |
$863.25
|
| Rate for Payer: CDPHP Medicare |
$425.87
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$805.70
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$920.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$920.80
|
| Rate for Payer: EmblemHealth Medicaid |
$920.80
|
| Rate for Payer: EmblemHealth Medicare |
$391.34
|
| Rate for Payer: EmblemHealth Select Care |
$748.15
|
| Rate for Payer: Fidelis Medicare |
$460.40
|
| Rate for Payer: Galaxy Health Commercial |
$748.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$460.40
|
| Rate for Payer: Humana Medicare |
$460.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$529.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$863.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$648.01
|
| Rate for Payer: MVP Health Care of NY Medicare |
$483.42
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$798.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$172.65
|
| Rate for Payer: United Healthcare Commercial |
$798.00
|
| Rate for Payer: United Healthcare Medicare |
$460.40
|
| Rate for Payer: WellCare Medicare |
$633.05
|
|
|
CT MAXILLOFACIAL W/O DYE
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS 70486 26
|
| Hospital Charge Code |
5220031
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$81.90 |
| Max. Negotiated Rate |
$81.90 |
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Galaxy Health Commercial |
$81.90
|
|
|
CT MAXILLOFACIAL W/O & W/ DYE
|
Facility
|
OP
|
$185.00
|
|
|
Service Code
|
HCPCS 70488 26
|
| Hospital Charge Code |
5220032
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$27.75 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$85.10
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$74.00
|
| Rate for Payer: Cash Price |
$138.75
|
| Rate for Payer: Cash Price |
$138.75
|
| Rate for Payer: CDPHP Medicare |
$68.45
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$148.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$148.00
|
| Rate for Payer: EmblemHealth Medicaid |
$148.00
|
| Rate for Payer: EmblemHealth Medicare |
$62.90
|
| Rate for Payer: Fidelis Medicare |
$74.00
|
| Rate for Payer: Galaxy Health Commercial |
$120.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$74.00
|
| Rate for Payer: Humana Medicare |
$74.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$85.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$138.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$104.16
|
| Rate for Payer: MVP Health Care of NY Medicare |
$77.70
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$27.75
|
| Rate for Payer: United Healthcare Medicare |
$74.00
|
| Rate for Payer: WellCare Medicare |
$101.75
|
|
|
CT MAXILLOFACIAL W/O & W/ DYE
|
Facility
|
IP
|
$185.00
|
|
|
Service Code
|
HCPCS 70488 26
|
| Hospital Charge Code |
5220032
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$120.25 |
| Max. Negotiated Rate |
$120.25 |
| Rate for Payer: Cash Price |
$138.75
|
| Rate for Payer: Galaxy Health Commercial |
$120.25
|
|
|
CT MAXILLOFACIAL W/O & W/DYE
|
Facility
|
OP
|
$1,332.00
|
|
|
Service Code
|
HCPCS 70488 TC
|
| Hospital Charge Code |
4220032
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$199.80 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$612.72
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$532.80
|
| Rate for Payer: Cash Price |
$999.00
|
| Rate for Payer: Cash Price |
$999.00
|
| Rate for Payer: Cash Price |
$999.00
|
| Rate for Payer: CDPHP Medicare |
$492.84
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$932.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,065.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,065.60
|
| Rate for Payer: EmblemHealth Medicaid |
$1,065.60
|
| Rate for Payer: EmblemHealth Medicare |
$452.88
|
| Rate for Payer: EmblemHealth Select Care |
$865.80
|
| Rate for Payer: Fidelis Medicare |
$532.80
|
| Rate for Payer: Galaxy Health Commercial |
$865.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$532.80
|
| Rate for Payer: Humana Medicare |
$532.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$612.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$999.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$749.92
|
| Rate for Payer: MVP Health Care of NY Medicare |
$559.44
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$798.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$199.80
|
| Rate for Payer: United Healthcare Commercial |
$798.00
|
| Rate for Payer: United Healthcare Medicare |
$532.80
|
| Rate for Payer: WellCare Medicare |
$732.60
|
|
|
CT MAXILLOFACIAL W/O & W/DYE
|
Facility
|
IP
|
$1,332.00
|
|
|
Service Code
|
HCPCS 70488 TC
|
| Hospital Charge Code |
4220032
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$865.80 |
| Max. Negotiated Rate |
$865.80 |
| Rate for Payer: Cash Price |
$999.00
|
| Rate for Payer: Galaxy Health Commercial |
$865.80
|
|
|
CT NECK SPINE W/ DYE
|
Facility
|
OP
|
$178.00
|
|
|
Service Code
|
HCPCS 72126 26
|
| Hospital Charge Code |
5220009
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$26.70 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$81.88
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$71.20
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: CDPHP Medicare |
$65.86
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$142.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$142.40
|
| Rate for Payer: EmblemHealth Medicaid |
$142.40
|
| Rate for Payer: EmblemHealth Medicare |
$60.52
|
| Rate for Payer: Fidelis Medicare |
$71.20
|
| Rate for Payer: Galaxy Health Commercial |
$115.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$71.20
|
| Rate for Payer: Humana Medicare |
$71.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$81.88
|
| Rate for Payer: MVP Health Care of NY Commercial |
$133.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$100.21
|
| Rate for Payer: MVP Health Care of NY Medicare |
$74.76
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$26.70
|
| Rate for Payer: United Healthcare Medicare |
$71.20
|
| Rate for Payer: WellCare Medicare |
$97.90
|
|
|
CT NECK SPINE W/ DYE
|
Facility
|
IP
|
$178.00
|
|
|
Service Code
|
HCPCS 72126 26
|
| Hospital Charge Code |
5220009
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$115.70 |
| Max. Negotiated Rate |
$115.70 |
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Galaxy Health Commercial |
$115.70
|
|
|
CT NECK SPINE W/DYE
|
Facility
|
OP
|
$1,505.00
|
|
|
Service Code
|
HCPCS 72126 TC
|
| Hospital Charge Code |
4220009
|
|
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 NECK SPINE W/DYE
|
Facility
|
IP
|
$1,505.00
|
|
|
Service Code
|
HCPCS 72126 TC
|
| Hospital Charge Code |
4220009
|
|
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 NECK SPINE W/O DYE
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
HCPCS 72125 26
|
| Hospital Charge Code |
5220020
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$67.16
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$58.40
|
| Rate for Payer: Cash Price |
$109.50
|
| Rate for Payer: Cash Price |
$109.50
|
| Rate for Payer: CDPHP Medicare |
$54.02
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$116.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$116.80
|
| Rate for Payer: EmblemHealth Medicaid |
$116.80
|
| Rate for Payer: EmblemHealth Medicare |
$49.64
|
| Rate for Payer: Fidelis Medicare |
$58.40
|
| Rate for Payer: Galaxy Health Commercial |
$94.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$58.40
|
| Rate for Payer: Humana Medicare |
$58.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$67.16
|
| Rate for Payer: MVP Health Care of NY Commercial |
$109.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$82.20
|
| Rate for Payer: MVP Health Care of NY Medicare |
$61.32
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$21.90
|
| Rate for Payer: United Healthcare Medicare |
$58.40
|
| Rate for Payer: WellCare Medicare |
$80.30
|
|
|
CT NECK SPINE W/O DYE
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
HCPCS 72125 26
|
| Hospital Charge Code |
5220020
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$94.90 |
| Max. Negotiated Rate |
$94.90 |
| Rate for Payer: Cash Price |
$109.50
|
| Rate for Payer: Galaxy Health Commercial |
$94.90
|
|
|
CT NECK SPINE W/O DYE
|
Facility
|
IP
|
$1,506.00
|
|
|
Service Code
|
HCPCS 72125 TC
|
| Hospital Charge Code |
4220020
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$978.90 |
| Max. Negotiated Rate |
$978.90 |
| Rate for Payer: Cash Price |
$1,129.50
|
| Rate for Payer: Galaxy Health Commercial |
$978.90
|
|
|
CT NECK SPINE W/O DYE
|
Facility
|
OP
|
$1,506.00
|
|
|
Service Code
|
HCPCS 72125 TC
|
| Hospital Charge Code |
4220020
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$225.90 |
| Max. Negotiated Rate |
$1,204.80 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$692.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$602.40
|
| Rate for Payer: Cash Price |
$1,129.50
|
| Rate for Payer: Cash Price |
$1,129.50
|
| Rate for Payer: Cash Price |
$1,129.50
|
| Rate for Payer: CDPHP Medicare |
$557.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,054.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,204.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,204.80
|
| Rate for Payer: EmblemHealth Medicaid |
$1,204.80
|
| Rate for Payer: EmblemHealth Medicare |
$512.04
|
| Rate for Payer: EmblemHealth Select Care |
$978.90
|
| Rate for Payer: Fidelis Medicare |
$602.40
|
| Rate for Payer: Galaxy Health Commercial |
$978.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$602.40
|
| Rate for Payer: Humana Medicare |
$602.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$692.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,129.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$847.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$632.52
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$798.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$225.90
|
| Rate for Payer: United Healthcare Commercial |
$798.00
|
| Rate for Payer: United Healthcare Medicare |
$602.40
|
| Rate for Payer: WellCare Medicare |
$828.30
|
|
|
CT NECK SPINE W/O & W/ DYE
|
Facility
|
IP
|
$185.00
|
|
|
Service Code
|
HCPCS 72127 26
|
| Hospital Charge Code |
5220008
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$120.25 |
| Max. Negotiated Rate |
$120.25 |
| Rate for Payer: Cash Price |
$138.75
|
| Rate for Payer: Galaxy Health Commercial |
$120.25
|
|
|
CT NECK SPINE W/O & W/ DYE
|
Facility
|
OP
|
$185.00
|
|
|
Service Code
|
HCPCS 72127 26
|
| Hospital Charge Code |
5220008
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$27.75 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,076.00
|
| Rate for Payer: Aetna of NY Medicare |
$85.10
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$74.00
|
| Rate for Payer: Cash Price |
$138.75
|
| Rate for Payer: Cash Price |
$138.75
|
| Rate for Payer: CDPHP Medicare |
$68.45
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$148.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$148.00
|
| Rate for Payer: EmblemHealth Medicaid |
$148.00
|
| Rate for Payer: EmblemHealth Medicare |
$62.90
|
| Rate for Payer: Fidelis Medicare |
$74.00
|
| Rate for Payer: Galaxy Health Commercial |
$120.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$74.00
|
| Rate for Payer: Humana Medicare |
$74.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,076.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$85.10
|
| Rate for Payer: MVP Health Care of NY Commercial |
$138.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$104.16
|
| Rate for Payer: MVP Health Care of NY Medicare |
$77.70
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$27.75
|
| Rate for Payer: United Healthcare Medicare |
$74.00
|
| Rate for Payer: WellCare Medicare |
$101.75
|
|
