|
DEXTROSE 10%-WATER IV SOLUTION 250 mL
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
4401427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.40 |
| Max. Negotiated Rate |
$5.20 |
| Rate for Payer: Aetna of NY Commercial |
$4.40
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Galaxy Health Commercial |
$5.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.40
|
| Rate for Payer: WellCare Medicare |
$4.40
|
|
|
DEXTROSE 10%-WATER IV SOLUTION 250 mL
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
4401427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: Aetna of NY Medicare |
$3.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.20
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: CDPHP Medicare |
$2.96
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$6.40
|
| Rate for Payer: EmblemHealth Medicaid |
$6.40
|
| Rate for Payer: EmblemHealth Medicare |
$2.72
|
| Rate for Payer: EmblemHealth Select Care |
$5.76
|
| Rate for Payer: Fidelis Medicare |
$3.20
|
| Rate for Payer: Galaxy Health Commercial |
$5.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$3.20
|
| Rate for Payer: Humana Medicare |
$3.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4.50
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.36
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.20
|
| Rate for Payer: United Healthcare Medicare |
$3.20
|
| Rate for Payer: WellCare Medicare |
$4.40
|
|
|
DEXTROSE 10%-WATER IV SOLUTION 500 mL, 500 mL
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 264752010
|
| Hospital Charge Code |
4401373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.40 |
| Max. Negotiated Rate |
$5.20 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Galaxy Health Commercial |
$5.20
|
| Rate for Payer: WellCare Medicare |
$4.40
|
|
|
DEXTROSE 10%-WATER IV SOLUTION 500 mL, 500 mL
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 264752010
|
| Hospital Charge Code |
4401373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: Aetna of NY Commercial |
$5.60
|
| Rate for Payer: Aetna of NY Medicare |
$3.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.20
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: CDPHP Medicare |
$2.96
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$6.40
|
| Rate for Payer: EmblemHealth Medicaid |
$6.40
|
| Rate for Payer: EmblemHealth Medicare |
$2.72
|
| Rate for Payer: EmblemHealth Select Care |
$5.76
|
| Rate for Payer: Fidelis Medicare |
$3.20
|
| Rate for Payer: Galaxy Health Commercial |
$5.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$3.20
|
| Rate for Payer: Humana Medicare |
$3.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4.50
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.36
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.20
|
| Rate for Payer: United Healthcare Medicare |
$3.20
|
| Rate for Payer: WellCare Medicare |
$4.40
|
|
|
DEXTROSE 25%/WATER 0.25 ANSY 10X10ML
|
Facility
|
OP
|
$27.04
|
|
|
Service Code
|
NDC 409177510
|
| Hospital Charge Code |
4400221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$21.63 |
| Rate for Payer: Aetna of NY Commercial |
$18.93
|
| Rate for Payer: Aetna of NY Medicare |
$12.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$10.82
|
| Rate for Payer: Cash Price |
$20.28
|
| Rate for Payer: CDPHP Medicare |
$10.00
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$21.63
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$21.63
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$21.63
|
| Rate for Payer: EmblemHealth Medicaid |
$21.63
|
| Rate for Payer: EmblemHealth Medicare |
$9.19
|
| Rate for Payer: EmblemHealth Select Care |
$19.47
|
| Rate for Payer: Fidelis Medicare |
$10.82
|
| Rate for Payer: Galaxy Health Commercial |
$17.58
|
| Rate for Payer: Hamaspik Choice Medicare |
$10.82
|
| Rate for Payer: Humana Medicare |
$10.82
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$18.93
|
| Rate for Payer: Local 1199SEIU Medicare |
$12.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$20.28
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$15.22
|
| Rate for Payer: MVP Health Care of NY Medicare |
$11.36
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4.06
|
| Rate for Payer: United Healthcare Medicare |
$10.82
|
| Rate for Payer: WellCare Medicare |
$14.87
|
|
|
DEXTROSE 25%/WATER 0.25 ANSY 10X10ML
|
Facility
|
IP
|
$27.04
|
|
|
Service Code
|
NDC 409177510
|
| Hospital Charge Code |
4400221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$17.58 |
| Rate for Payer: Cash Price |
$20.28
|
| Rate for Payer: Galaxy Health Commercial |
$17.58
|
| Rate for Payer: WellCare Medicare |
$14.87
|
|
|
DEXTROSE 50%/WATER 0.5 ANSY 10X50ML
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 409751716
|
| Hospital Charge Code |
4400222
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna of NY Commercial |
$3.40
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.47
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.47
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.47
|
| Rate for Payer: Humana Medicare |
$2.47
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.63
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
DEXTROSE 50%/WATER 0.5 ANSY 10X50ML
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 409751716
|
| Hospital Charge Code |
4400222
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Aetna of NY Commercial |
$3.40
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.40
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
DEXTROSE 50%/WATER 0.5 LSSY 10X50ML
|
Facility
|
OP
|
$29.61
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4400223
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$23.69 |
| Rate for Payer: Aetna of NY Medicare |
$13.62
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$11.84
|
| Rate for Payer: Cash Price |
$22.21
|
| Rate for Payer: CDPHP Medicare |
$10.96
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$23.69
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$23.69
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$23.69
|
| Rate for Payer: EmblemHealth Medicaid |
$23.69
|
| Rate for Payer: EmblemHealth Medicare |
$10.07
|
| Rate for Payer: EmblemHealth Select Care |
$21.32
|
| Rate for Payer: Fidelis Medicare |
$11.84
|
| Rate for Payer: Galaxy Health Commercial |
$19.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$11.84
|
| Rate for Payer: Humana Medicare |
$11.84
|
| Rate for Payer: Local 1199SEIU Medicare |
$13.62
|
| Rate for Payer: MVP Health Care of NY Commercial |
$22.21
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$16.67
|
| Rate for Payer: MVP Health Care of NY Medicare |
$12.44
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4.44
|
| Rate for Payer: United Healthcare Medicare |
$11.84
|
| Rate for Payer: WellCare Medicare |
$16.29
|
|
|
DEXTROSE 50%/WATER 0.5 LSSY 10X50ML
|
Facility
|
IP
|
$29.61
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
4400223
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.29 |
| Max. Negotiated Rate |
$19.25 |
| Rate for Payer: Aetna of NY Commercial |
$16.29
|
| Rate for Payer: Cash Price |
$22.21
|
| Rate for Payer: Galaxy Health Commercial |
$19.25
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$16.29
|
| Rate for Payer: WellCare Medicare |
$16.29
|
|
|
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ BI
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
HCPCS 77066 26
|
| Hospital Charge Code |
5150401
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$116.80 |
| Rate for Payer: Aetna of NY Commercial |
$102.20
|
| 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: 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 |
$102.20
|
| 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
|
|
|
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ BI
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
HCPCS 77066 26
|
| Hospital Charge Code |
5150401
|
|
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
|
|
|
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ BI
|
Facility
|
IP
|
$599.00
|
|
|
Service Code
|
HCPCS 77066 TC
|
| Hospital Charge Code |
4150401
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$389.35 |
| Max. Negotiated Rate |
$389.35 |
| Rate for Payer: Cash Price |
$449.25
|
| Rate for Payer: Galaxy Health Commercial |
$389.35
|
|
|
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ BI
|
Facility
|
OP
|
$599.00
|
|
|
Service Code
|
HCPCS 77066 TC
|
| Hospital Charge Code |
4150401
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$89.85 |
| Max. Negotiated Rate |
$489.00 |
| Rate for Payer: Aetna of NY Commercial |
$419.30
|
| Rate for Payer: Aetna of NY Medicare |
$275.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$239.60
|
| Rate for Payer: Cash Price |
$449.25
|
| Rate for Payer: Cash Price |
$449.25
|
| Rate for Payer: CDPHP Medicare |
$221.63
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$419.30
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$479.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$479.20
|
| Rate for Payer: EmblemHealth Medicaid |
$479.20
|
| Rate for Payer: EmblemHealth Medicare |
$203.66
|
| Rate for Payer: EmblemHealth Select Care |
$389.35
|
| Rate for Payer: Fidelis Medicare |
$239.60
|
| Rate for Payer: Galaxy Health Commercial |
$389.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$239.60
|
| Rate for Payer: Humana Medicare |
$239.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$419.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$275.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$449.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$337.24
|
| Rate for Payer: MVP Health Care of NY Medicare |
$251.58
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$89.85
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$239.60
|
| Rate for Payer: WellCare Medicare |
$329.45
|
|
|
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS 77065 26
|
| Hospital Charge Code |
5150400
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Aetna of NY Commercial |
$83.30
|
| Rate for Payer: Aetna of NY Medicare |
$54.74
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$47.60
|
| Rate for Payer: Cash Price |
$89.25
|
| Rate for Payer: CDPHP Medicare |
$44.03
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$95.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$95.20
|
| Rate for Payer: EmblemHealth Medicaid |
$95.20
|
| Rate for Payer: EmblemHealth Medicare |
$40.46
|
| Rate for Payer: Fidelis Medicare |
$47.60
|
| Rate for Payer: Galaxy Health Commercial |
$77.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$47.60
|
| Rate for Payer: Humana Medicare |
$47.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$83.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$54.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$89.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$67.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$49.98
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$17.85
|
| Rate for Payer: United Healthcare Medicare |
$47.60
|
| Rate for Payer: WellCare Medicare |
$65.45
|
|
|
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI
|
Facility
|
IP
|
$475.00
|
|
|
Service Code
|
HCPCS 77065 TC
|
| Hospital Charge Code |
4150400
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$308.75 |
| Max. Negotiated Rate |
$308.75 |
| Rate for Payer: Cash Price |
$356.25
|
| Rate for Payer: Galaxy Health Commercial |
$308.75
|
|
|
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI
|
Facility
|
OP
|
$475.00
|
|
|
Service Code
|
HCPCS 77065 TC
|
| Hospital Charge Code |
4150400
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$71.25 |
| Max. Negotiated Rate |
$489.00 |
| Rate for Payer: Aetna of NY Commercial |
$332.50
|
| Rate for Payer: Aetna of NY Medicare |
$218.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$190.00
|
| Rate for Payer: Cash Price |
$356.25
|
| Rate for Payer: Cash Price |
$356.25
|
| Rate for Payer: CDPHP Medicare |
$175.75
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$332.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$380.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$380.00
|
| Rate for Payer: EmblemHealth Medicaid |
$380.00
|
| Rate for Payer: EmblemHealth Medicare |
$161.50
|
| Rate for Payer: EmblemHealth Select Care |
$308.75
|
| Rate for Payer: Fidelis Medicare |
$190.00
|
| Rate for Payer: Galaxy Health Commercial |
$308.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$190.00
|
| Rate for Payer: Humana Medicare |
$190.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$332.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$218.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$356.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$267.43
|
| Rate for Payer: MVP Health Care of NY Medicare |
$199.50
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$71.25
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$190.00
|
| Rate for Payer: WellCare Medicare |
$261.25
|
|
|
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
HCPCS 77065 26
|
| Hospital Charge Code |
5150400
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$77.35 |
| Max. Negotiated Rate |
$77.35 |
| Rate for Payer: Cash Price |
$89.25
|
| Rate for Payer: Galaxy Health Commercial |
$77.35
|
|
|
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI, LEFT
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS 77065 26,LT
|
| Hospital Charge Code |
5150409
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Aetna of NY Commercial |
$83.30
|
| Rate for Payer: Aetna of NY Medicare |
$54.74
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$47.60
|
| Rate for Payer: Cash Price |
$89.25
|
| Rate for Payer: CDPHP Medicare |
$44.03
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$95.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$95.20
|
| Rate for Payer: EmblemHealth Medicaid |
$95.20
|
| Rate for Payer: EmblemHealth Medicare |
$40.46
|
| Rate for Payer: Fidelis Medicare |
$47.60
|
| Rate for Payer: Galaxy Health Commercial |
$77.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$47.60
|
| Rate for Payer: Humana Medicare |
$47.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$83.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$54.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$89.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$67.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$49.98
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$17.85
|
| Rate for Payer: United Healthcare Medicare |
$47.60
|
| Rate for Payer: WellCare Medicare |
$65.45
|
|
|
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI, LEFT
|
Facility
|
OP
|
$475.00
|
|
|
Service Code
|
HCPCS 77065 LT,TC
|
| Hospital Charge Code |
4150409
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$71.25 |
| Max. Negotiated Rate |
$489.00 |
| Rate for Payer: Aetna of NY Commercial |
$332.50
|
| Rate for Payer: Aetna of NY Medicare |
$218.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$190.00
|
| Rate for Payer: Cash Price |
$356.25
|
| Rate for Payer: Cash Price |
$356.25
|
| Rate for Payer: CDPHP Medicare |
$175.75
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$332.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$380.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$380.00
|
| Rate for Payer: EmblemHealth Medicaid |
$380.00
|
| Rate for Payer: EmblemHealth Medicare |
$161.50
|
| Rate for Payer: EmblemHealth Select Care |
$308.75
|
| Rate for Payer: Fidelis Medicare |
$190.00
|
| Rate for Payer: Galaxy Health Commercial |
$308.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$190.00
|
| Rate for Payer: Humana Medicare |
$190.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$332.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$218.50
|
| Rate for Payer: MVP Health Care of NY Commercial |
$356.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$267.43
|
| Rate for Payer: MVP Health Care of NY Medicare |
$199.50
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$489.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$71.25
|
| Rate for Payer: United Healthcare Commercial |
$489.00
|
| Rate for Payer: United Healthcare Medicare |
$190.00
|
| Rate for Payer: WellCare Medicare |
$261.25
|
|
|
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI, LEFT
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
HCPCS 77065 26,LT
|
| Hospital Charge Code |
5150409
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$77.35 |
| Max. Negotiated Rate |
$77.35 |
| Rate for Payer: Cash Price |
$89.25
|
| Rate for Payer: Galaxy Health Commercial |
$77.35
|
|
|
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI, LEFT
|
Facility
|
IP
|
$475.00
|
|
|
Service Code
|
HCPCS 77065 LT,TC
|
| Hospital Charge Code |
4150409
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$308.75 |
| Max. Negotiated Rate |
$308.75 |
| Rate for Payer: Cash Price |
$356.25
|
| Rate for Payer: Galaxy Health Commercial |
$308.75
|
|
|
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI, RIGHT
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS 77065 26,RT
|
| Hospital Charge Code |
5150408
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Aetna of NY Commercial |
$83.30
|
| Rate for Payer: Aetna of NY Medicare |
$54.74
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$47.60
|
| Rate for Payer: Cash Price |
$89.25
|
| Rate for Payer: CDPHP Medicare |
$44.03
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$95.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$95.20
|
| Rate for Payer: EmblemHealth Medicaid |
$95.20
|
| Rate for Payer: EmblemHealth Medicare |
$40.46
|
| Rate for Payer: Fidelis Medicare |
$47.60
|
| Rate for Payer: Galaxy Health Commercial |
$77.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$47.60
|
| Rate for Payer: Humana Medicare |
$47.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$83.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$54.74
|
| Rate for Payer: MVP Health Care of NY Commercial |
$89.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$67.00
|
| Rate for Payer: MVP Health Care of NY Medicare |
$49.98
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$17.85
|
| Rate for Payer: United Healthcare Medicare |
$47.60
|
| Rate for Payer: WellCare Medicare |
$65.45
|
|
|
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI, RIGHT
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
HCPCS 77065 26,RT
|
| Hospital Charge Code |
5150408
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$77.35 |
| Max. Negotiated Rate |
$77.35 |
| Rate for Payer: Cash Price |
$89.25
|
| Rate for Payer: Galaxy Health Commercial |
$77.35
|
|
|
DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI, RIGHT
|
Facility
|
IP
|
$475.00
|
|
|
Service Code
|
HCPCS 77065 RT,TC
|
| Hospital Charge Code |
4150408
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$308.75 |
| Max. Negotiated Rate |
$308.75 |
| Rate for Payer: Cash Price |
$356.25
|
| Rate for Payer: Galaxy Health Commercial |
$308.75
|
|
