|
DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COM
|
Facility
|
OP
|
$731.00
|
|
|
Service Code
|
HCPCS 93975 TC
|
| Hospital Charge Code |
4201024
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$109.65 |
| Max. Negotiated Rate |
$584.80 |
| Rate for Payer: Aetna of NY Commercial |
$475.15
|
| Rate for Payer: Aetna of NY Medicare |
$336.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$292.40
|
| Rate for Payer: Cash Price |
$548.25
|
| Rate for Payer: Cash Price |
$548.25
|
| Rate for Payer: CDPHP Medicare |
$270.47
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$511.70
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$584.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$584.80
|
| Rate for Payer: EmblemHealth Medicaid |
$584.80
|
| Rate for Payer: EmblemHealth Medicare |
$248.54
|
| Rate for Payer: EmblemHealth Select Care |
$475.15
|
| Rate for Payer: Fidelis Medicare |
$292.40
|
| Rate for Payer: Galaxy Health Commercial |
$475.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$292.40
|
| Rate for Payer: Humana Medicare |
$292.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$475.15
|
| Rate for Payer: Local 1199SEIU Medicare |
$336.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$548.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$411.55
|
| Rate for Payer: MVP Health Care of NY Medicare |
$307.02
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$287.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$109.65
|
| Rate for Payer: United Healthcare Commercial |
$287.00
|
| Rate for Payer: United Healthcare Medicare |
$292.40
|
| Rate for Payer: WellCare Medicare |
$402.05
|
|
|
DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMT
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
HCPCS 93976 26
|
| Hospital Charge Code |
5200051
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$76.05 |
| Max. Negotiated Rate |
$76.05 |
| Rate for Payer: Cash Price |
$87.75
|
| Rate for Payer: Galaxy Health Commercial |
$76.05
|
|
|
DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMT
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
HCPCS 93976 26
|
| Hospital Charge Code |
5200051
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$17.55 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of NY Commercial |
$76.05
|
| Rate for Payer: Aetna of NY Medicare |
$53.82
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$46.80
|
| Rate for Payer: Cash Price |
$87.75
|
| Rate for Payer: CDPHP Medicare |
$43.29
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$93.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$93.60
|
| Rate for Payer: EmblemHealth Medicaid |
$93.60
|
| Rate for Payer: EmblemHealth Medicare |
$39.78
|
| Rate for Payer: Fidelis Medicare |
$46.80
|
| Rate for Payer: Galaxy Health Commercial |
$76.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$46.80
|
| Rate for Payer: Humana Medicare |
$46.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$76.05
|
| Rate for Payer: Local 1199SEIU Medicare |
$53.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$87.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$65.87
|
| Rate for Payer: MVP Health Care of NY Medicare |
$49.14
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$17.55
|
| Rate for Payer: United Healthcare Medicare |
$46.80
|
| Rate for Payer: WellCare Medicare |
$64.35
|
|
|
DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMT
|
Facility
|
IP
|
$320.00
|
|
|
Service Code
|
HCPCS 93976 TC
|
| Hospital Charge Code |
4200051
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$208.00 |
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Galaxy Health Commercial |
$208.00
|
|
|
DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMT
|
Facility
|
OP
|
$320.00
|
|
|
Service Code
|
HCPCS 93976 TC
|
| Hospital Charge Code |
4200051
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$48.00 |
| Max. Negotiated Rate |
$287.00 |
| Rate for Payer: Aetna of NY Commercial |
$208.00
|
| Rate for Payer: Aetna of NY Medicare |
$147.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$128.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: CDPHP Medicare |
$118.40
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$224.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$256.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$256.00
|
| Rate for Payer: EmblemHealth Medicaid |
$256.00
|
| Rate for Payer: EmblemHealth Medicare |
$108.80
|
| Rate for Payer: EmblemHealth Select Care |
$208.00
|
| Rate for Payer: Fidelis Medicare |
$128.00
|
| Rate for Payer: Galaxy Health Commercial |
$208.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$128.00
|
| Rate for Payer: Humana Medicare |
$128.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$208.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$147.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$240.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$180.16
|
| Rate for Payer: MVP Health Care of NY Medicare |
$134.40
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$287.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$48.00
|
| Rate for Payer: United Healthcare Commercial |
$287.00
|
| Rate for Payer: United Healthcare Medicare |
$128.00
|
| Rate for Payer: WellCare Medicare |
$176.00
|
|
|
DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
HCPCS 93925 26
|
| Hospital Charge Code |
5200043
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$74.75 |
| Max. Negotiated Rate |
$74.75 |
| Rate for Payer: Cash Price |
$86.25
|
| Rate for Payer: Galaxy Health Commercial |
$74.75
|
|
|
DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY
|
Facility
|
OP
|
$731.00
|
|
|
Service Code
|
HCPCS 93925 TC
|
| Hospital Charge Code |
4200043
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$109.65 |
| Max. Negotiated Rate |
$584.80 |
| Rate for Payer: Aetna of NY Commercial |
$475.15
|
| Rate for Payer: Aetna of NY Medicare |
$336.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$292.40
|
| Rate for Payer: Cash Price |
$548.25
|
| Rate for Payer: Cash Price |
$548.25
|
| Rate for Payer: CDPHP Medicare |
$270.47
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$511.70
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$584.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$584.80
|
| Rate for Payer: EmblemHealth Medicaid |
$584.80
|
| Rate for Payer: EmblemHealth Medicare |
$248.54
|
| Rate for Payer: EmblemHealth Select Care |
$475.15
|
| Rate for Payer: Fidelis Medicare |
$292.40
|
| Rate for Payer: Galaxy Health Commercial |
$475.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$292.40
|
| Rate for Payer: Humana Medicare |
$292.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$475.15
|
| Rate for Payer: Local 1199SEIU Medicare |
$336.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$548.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$411.55
|
| Rate for Payer: MVP Health Care of NY Medicare |
$307.02
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$287.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$109.65
|
| Rate for Payer: United Healthcare Commercial |
$287.00
|
| Rate for Payer: United Healthcare Medicare |
$292.40
|
| Rate for Payer: WellCare Medicare |
$402.05
|
|
|
DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS 93925 26
|
| Hospital Charge Code |
5200043
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$17.25 |
| Max. Negotiated Rate |
$92.00 |
| Rate for Payer: Aetna of NY Commercial |
$74.75
|
| Rate for Payer: Aetna of NY Medicare |
$52.90
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$46.00
|
| Rate for Payer: Cash Price |
$86.25
|
| Rate for Payer: CDPHP Medicare |
$42.55
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$92.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$92.00
|
| Rate for Payer: EmblemHealth Medicaid |
$92.00
|
| Rate for Payer: EmblemHealth Medicare |
$39.10
|
| Rate for Payer: Fidelis Medicare |
$46.00
|
| Rate for Payer: Galaxy Health Commercial |
$74.75
|
| Rate for Payer: Hamaspik Choice Medicare |
$46.00
|
| Rate for Payer: Humana Medicare |
$46.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$74.75
|
| Rate for Payer: Local 1199SEIU Medicare |
$52.90
|
| Rate for Payer: MVP Health Care of NY Commercial |
$86.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$64.75
|
| Rate for Payer: MVP Health Care of NY Medicare |
$48.30
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$17.25
|
| Rate for Payer: United Healthcare Medicare |
$46.00
|
| Rate for Payer: WellCare Medicare |
$63.25
|
|
|
DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY
|
Facility
|
IP
|
$731.00
|
|
|
Service Code
|
HCPCS 93925 TC
|
| Hospital Charge Code |
4200043
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$475.15 |
| Max. Negotiated Rate |
$475.15 |
| Rate for Payer: Cash Price |
$548.25
|
| Rate for Payer: Galaxy Health Commercial |
$475.15
|
|
|
DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY, LEFT
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
HCPCS 93926 26,LT
|
| Hospital Charge Code |
5200044
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Galaxy Health Commercial |
$45.50
|
|
|
DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY, LEFT
|
Facility
|
OP
|
$442.00
|
|
|
Service Code
|
HCPCS 93926 LT,TC
|
| Hospital Charge Code |
4200044
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$66.30 |
| Max. Negotiated Rate |
$353.60 |
| Rate for Payer: Aetna of NY Commercial |
$287.30
|
| Rate for Payer: Aetna of NY Medicare |
$203.32
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$176.80
|
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: CDPHP Medicare |
$163.54
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$309.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$353.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$353.60
|
| Rate for Payer: EmblemHealth Medicaid |
$353.60
|
| Rate for Payer: EmblemHealth Medicare |
$150.28
|
| Rate for Payer: EmblemHealth Select Care |
$287.30
|
| Rate for Payer: Fidelis Medicare |
$176.80
|
| Rate for Payer: Galaxy Health Commercial |
$287.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$176.80
|
| Rate for Payer: Humana Medicare |
$176.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$287.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$203.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$331.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$248.85
|
| Rate for Payer: MVP Health Care of NY Medicare |
$185.64
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$287.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$66.30
|
| Rate for Payer: United Healthcare Commercial |
$287.00
|
| Rate for Payer: United Healthcare Medicare |
$176.80
|
| Rate for Payer: WellCare Medicare |
$243.10
|
|
|
DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY, LEFT
|
Facility
|
IP
|
$442.00
|
|
|
Service Code
|
HCPCS 93926 LT,TC
|
| Hospital Charge Code |
4200044
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$287.30 |
| Max. Negotiated Rate |
$287.30 |
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Galaxy Health Commercial |
$287.30
|
|
|
DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY, LEFT
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
HCPCS 93926 26,LT
|
| Hospital Charge Code |
5200044
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna of NY Commercial |
$45.50
|
| Rate for Payer: Aetna of NY Medicare |
$32.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$28.00
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: CDPHP Medicare |
$25.90
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$56.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$56.00
|
| Rate for Payer: EmblemHealth Medicaid |
$56.00
|
| Rate for Payer: EmblemHealth Medicare |
$23.80
|
| Rate for Payer: Fidelis Medicare |
$28.00
|
| Rate for Payer: Galaxy Health Commercial |
$45.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$28.00
|
| Rate for Payer: Humana Medicare |
$28.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$45.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$32.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$52.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$39.41
|
| Rate for Payer: MVP Health Care of NY Medicare |
$29.40
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.50
|
| Rate for Payer: United Healthcare Medicare |
$28.00
|
| Rate for Payer: WellCare Medicare |
$38.50
|
|
|
DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY, RIGHT
|
Facility
|
OP
|
$442.00
|
|
|
Service Code
|
HCPCS 93926 RT,TC
|
| Hospital Charge Code |
4201036
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$66.30 |
| Max. Negotiated Rate |
$353.60 |
| Rate for Payer: Aetna of NY Commercial |
$287.30
|
| Rate for Payer: Aetna of NY Medicare |
$203.32
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$176.80
|
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: CDPHP Medicare |
$163.54
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$309.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$353.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$353.60
|
| Rate for Payer: EmblemHealth Medicaid |
$353.60
|
| Rate for Payer: EmblemHealth Medicare |
$150.28
|
| Rate for Payer: EmblemHealth Select Care |
$287.30
|
| Rate for Payer: Fidelis Medicare |
$176.80
|
| Rate for Payer: Galaxy Health Commercial |
$287.30
|
| Rate for Payer: Hamaspik Choice Medicare |
$176.80
|
| Rate for Payer: Humana Medicare |
$176.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$287.30
|
| Rate for Payer: Local 1199SEIU Medicare |
$203.32
|
| Rate for Payer: MVP Health Care of NY Commercial |
$331.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$248.85
|
| Rate for Payer: MVP Health Care of NY Medicare |
$185.64
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$287.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$66.30
|
| Rate for Payer: United Healthcare Commercial |
$287.00
|
| Rate for Payer: United Healthcare Medicare |
$176.80
|
| Rate for Payer: WellCare Medicare |
$243.10
|
|
|
DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY, RIGHT
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
HCPCS 93926 26,RT
|
| Hospital Charge Code |
5201036
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna of NY Commercial |
$45.50
|
| Rate for Payer: Aetna of NY Medicare |
$32.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$28.00
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: CDPHP Medicare |
$25.90
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$56.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$56.00
|
| Rate for Payer: EmblemHealth Medicaid |
$56.00
|
| Rate for Payer: EmblemHealth Medicare |
$23.80
|
| Rate for Payer: Fidelis Medicare |
$28.00
|
| Rate for Payer: Galaxy Health Commercial |
$45.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$28.00
|
| Rate for Payer: Humana Medicare |
$28.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$45.50
|
| Rate for Payer: Local 1199SEIU Medicare |
$32.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$52.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$39.41
|
| Rate for Payer: MVP Health Care of NY Medicare |
$29.40
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.50
|
| Rate for Payer: United Healthcare Medicare |
$28.00
|
| Rate for Payer: WellCare Medicare |
$38.50
|
|
|
DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY, RIGHT
|
Facility
|
IP
|
$442.00
|
|
|
Service Code
|
HCPCS 93926 RT,TC
|
| Hospital Charge Code |
4201036
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$287.30 |
| Max. Negotiated Rate |
$287.30 |
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Galaxy Health Commercial |
$287.30
|
|
|
DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY, RIGHT
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
HCPCS 93926 26,RT
|
| Hospital Charge Code |
5201036
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Galaxy Health Commercial |
$45.50
|
|
|
DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
HCPCS 93930 26
|
| Hospital Charge Code |
5200045
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$76.05 |
| Max. Negotiated Rate |
$76.05 |
| Rate for Payer: Cash Price |
$87.75
|
| Rate for Payer: Galaxy Health Commercial |
$76.05
|
|
|
DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY
|
Facility
|
OP
|
$731.00
|
|
|
Service Code
|
HCPCS 93930 TC
|
| Hospital Charge Code |
4200045
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$109.65 |
| Max. Negotiated Rate |
$584.80 |
| Rate for Payer: Aetna of NY Commercial |
$475.15
|
| Rate for Payer: Aetna of NY Medicare |
$336.26
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$292.40
|
| Rate for Payer: Cash Price |
$548.25
|
| Rate for Payer: Cash Price |
$548.25
|
| Rate for Payer: CDPHP Medicare |
$270.47
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$511.70
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$584.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$584.80
|
| Rate for Payer: EmblemHealth Medicaid |
$584.80
|
| Rate for Payer: EmblemHealth Medicare |
$248.54
|
| Rate for Payer: EmblemHealth Select Care |
$475.15
|
| Rate for Payer: Fidelis Medicare |
$292.40
|
| Rate for Payer: Galaxy Health Commercial |
$475.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$292.40
|
| Rate for Payer: Humana Medicare |
$292.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$475.15
|
| Rate for Payer: Local 1199SEIU Medicare |
$336.26
|
| Rate for Payer: MVP Health Care of NY Commercial |
$548.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$411.55
|
| Rate for Payer: MVP Health Care of NY Medicare |
$307.02
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$287.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$109.65
|
| Rate for Payer: United Healthcare Commercial |
$287.00
|
| Rate for Payer: United Healthcare Medicare |
$292.40
|
| Rate for Payer: WellCare Medicare |
$402.05
|
|
|
DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
HCPCS 93930 26
|
| Hospital Charge Code |
5200045
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$17.55 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of NY Commercial |
$76.05
|
| Rate for Payer: Aetna of NY Medicare |
$53.82
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$46.80
|
| Rate for Payer: Cash Price |
$87.75
|
| Rate for Payer: CDPHP Medicare |
$43.29
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$93.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$93.60
|
| Rate for Payer: EmblemHealth Medicaid |
$93.60
|
| Rate for Payer: EmblemHealth Medicare |
$39.78
|
| Rate for Payer: Fidelis Medicare |
$46.80
|
| Rate for Payer: Galaxy Health Commercial |
$76.05
|
| Rate for Payer: Hamaspik Choice Medicare |
$46.80
|
| Rate for Payer: Humana Medicare |
$46.80
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$76.05
|
| Rate for Payer: Local 1199SEIU Medicare |
$53.82
|
| Rate for Payer: MVP Health Care of NY Commercial |
$87.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$65.87
|
| Rate for Payer: MVP Health Care of NY Medicare |
$49.14
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$17.55
|
| Rate for Payer: United Healthcare Medicare |
$46.80
|
| Rate for Payer: WellCare Medicare |
$64.35
|
|
|
DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY
|
Facility
|
IP
|
$731.00
|
|
|
Service Code
|
HCPCS 93930 TC
|
| Hospital Charge Code |
4200045
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$475.15 |
| Max. Negotiated Rate |
$475.15 |
| Rate for Payer: Cash Price |
$548.25
|
| Rate for Payer: Galaxy Health Commercial |
$475.15
|
|
|
DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STUDY
|
Facility
|
OP
|
$320.00
|
|
|
Service Code
|
HCPCS 93931 TC
|
| Hospital Charge Code |
4201026
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$48.00 |
| Max. Negotiated Rate |
$287.00 |
| Rate for Payer: Aetna of NY Commercial |
$208.00
|
| Rate for Payer: Aetna of NY Medicare |
$147.20
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$128.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: CDPHP Medicare |
$118.40
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$224.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$256.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$256.00
|
| Rate for Payer: EmblemHealth Medicaid |
$256.00
|
| Rate for Payer: EmblemHealth Medicare |
$108.80
|
| Rate for Payer: EmblemHealth Select Care |
$208.00
|
| Rate for Payer: Fidelis Medicare |
$128.00
|
| Rate for Payer: Galaxy Health Commercial |
$208.00
|
| Rate for Payer: Hamaspik Choice Medicare |
$128.00
|
| Rate for Payer: Humana Medicare |
$128.00
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$208.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$147.20
|
| Rate for Payer: MVP Health Care of NY Commercial |
$240.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$180.16
|
| Rate for Payer: MVP Health Care of NY Medicare |
$134.40
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$287.00
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$48.00
|
| Rate for Payer: United Healthcare Commercial |
$287.00
|
| Rate for Payer: United Healthcare Medicare |
$128.00
|
| Rate for Payer: WellCare Medicare |
$176.00
|
|
|
DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STUDY
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
HCPCS 93931 26
|
| Hospital Charge Code |
5201026
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$56.80 |
| Rate for Payer: Aetna of NY Commercial |
$46.15
|
| Rate for Payer: Aetna of NY Medicare |
$32.66
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$28.40
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: CDPHP Medicare |
$26.27
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$56.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$56.80
|
| Rate for Payer: EmblemHealth Medicaid |
$56.80
|
| Rate for Payer: EmblemHealth Medicare |
$24.14
|
| Rate for Payer: Fidelis Medicare |
$28.40
|
| Rate for Payer: Galaxy Health Commercial |
$46.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$28.40
|
| Rate for Payer: Humana Medicare |
$28.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$46.15
|
| Rate for Payer: Local 1199SEIU Medicare |
$32.66
|
| Rate for Payer: MVP Health Care of NY Commercial |
$53.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$39.97
|
| Rate for Payer: MVP Health Care of NY Medicare |
$29.82
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$10.65
|
| Rate for Payer: United Healthcare Medicare |
$28.40
|
| Rate for Payer: WellCare Medicare |
$39.05
|
|
|
DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STUDY
|
Facility
|
IP
|
$320.00
|
|
|
Service Code
|
HCPCS 93931 TC
|
| Hospital Charge Code |
4201026
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$208.00 |
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Galaxy Health Commercial |
$208.00
|
|
|
DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STUDY
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
HCPCS 93931 26
|
| Hospital Charge Code |
5201026
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$46.15 |
| Max. Negotiated Rate |
$46.15 |
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: Galaxy Health Commercial |
$46.15
|
|
