|
NM GASTRIC EMPTYING SCAN
|
Facility
|
OP
|
$1,114.98
|
|
|
Service Code
|
HCPCS 78264 TC
|
| Hospital Charge Code |
41505048
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$191.44 |
| Max. Negotiated Rate |
$613.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$613.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$476.96
|
| Rate for Payer: Aetna Government |
$476.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$333.87
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$333.87
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$333.87
|
| Rate for Payer: Brighton Health Commercial |
$476.96
|
| Rate for Payer: Cash Price |
$476.96
|
| Rate for Payer: Cash Price |
$476.96
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$476.96
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$478.95
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$405.26
|
| Rate for Payer: Elderplan Medicare Advantage |
$476.96
|
| Rate for Payer: EmblemHealth Commercial |
$333.87
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$405.42
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$405.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$424.49
|
| Rate for Payer: Fidelis Medicare Advantage |
$476.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$424.49
|
| Rate for Payer: Group Health Inc Commercial |
$429.26
|
| Rate for Payer: Group Health Inc Medicare |
$429.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$557.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$476.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$429.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$476.96
|
| Rate for Payer: Healthfirst QHP |
$476.96
|
| Rate for Payer: Humana Medicare |
$486.50
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$476.96
|
| Rate for Payer: United Healthcare Commercial |
$191.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$476.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$476.96
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$381.57
|
| Rate for Payer: Wellcare Medicare |
$453.11
|
|
|
NM GASTRIC EMPTYING SCAN
|
Facility
|
IP
|
$1,114.98
|
|
|
Service Code
|
HCPCS 78264 TC
|
| Hospital Charge Code |
41505048
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$476.96
|
|
|
NM GASTRIC EMPTY/SMALL BOWL
|
Facility
|
OP
|
$1,114.98
|
|
|
Service Code
|
HCPCS 78265 TC
|
| Hospital Charge Code |
41502914
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$266.12 |
| Max. Negotiated Rate |
$891.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$613.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$476.96
|
| Rate for Payer: Aetna Government |
$476.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$333.87
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$333.87
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$333.87
|
| Rate for Payer: Brighton Health Commercial |
$476.96
|
| Rate for Payer: Cash Price |
$476.96
|
| Rate for Payer: Cash Price |
$476.96
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$476.96
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$891.98
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$758.19
|
| Rate for Payer: Elderplan Medicare Advantage |
$476.96
|
| Rate for Payer: EmblemHealth Commercial |
$333.87
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$405.42
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$405.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$424.49
|
| Rate for Payer: Fidelis Medicare Advantage |
$476.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$424.49
|
| Rate for Payer: Group Health Inc Commercial |
$429.26
|
| Rate for Payer: Group Health Inc Medicare |
$429.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$557.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$476.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$429.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$476.96
|
| Rate for Payer: Healthfirst QHP |
$476.96
|
| Rate for Payer: Humana Medicare |
$486.50
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$476.96
|
| Rate for Payer: United Healthcare Commercial |
$266.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$476.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$476.96
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$381.57
|
| Rate for Payer: Wellcare Medicare |
$453.11
|
|
|
NM GASTRIC EMPTY/SMALL BOWL
|
Facility
|
IP
|
$1,114.98
|
|
|
Service Code
|
HCPCS 78265 TC
|
| Hospital Charge Code |
41502914
|
|
Hospital Revenue Code
|
340
|
| Rate for Payer: Cash Price |
$476.96
|
|
|
NM GASTRIC EMPTY/SMALL&LARGE BOWL
|
Facility
|
OP
|
$1,429.50
|
|
|
Service Code
|
HCPCS 78266 TC
|
| Hospital Charge Code |
41502915
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$353.09 |
| Max. Negotiated Rate |
$1,143.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$786.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$625.05
|
| Rate for Payer: Aetna Government |
$625.05
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$437.54
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$437.54
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$437.54
|
| Rate for Payer: Brighton Health Commercial |
$625.05
|
| Rate for Payer: Cash Price |
$625.05
|
| Rate for Payer: Cash Price |
$625.05
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$625.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,143.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$972.06
|
| Rate for Payer: Elderplan Medicare Advantage |
$625.05
|
| Rate for Payer: EmblemHealth Commercial |
$437.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$531.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$531.29
|
| Rate for Payer: Fidelis Essential Plan QHP |
$556.29
|
| Rate for Payer: Fidelis Medicare Advantage |
$625.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$556.29
|
| Rate for Payer: Group Health Inc Commercial |
$562.54
|
| Rate for Payer: Group Health Inc Medicare |
$562.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$714.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$625.05
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$562.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$625.05
|
| Rate for Payer: Healthfirst QHP |
$625.05
|
| Rate for Payer: Humana Medicare |
$637.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$625.05
|
| Rate for Payer: United Healthcare Commercial |
$353.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$625.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$625.05
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$500.04
|
| Rate for Payer: Wellcare Medicare |
$593.80
|
|
|
NM GASTRIC EMPTY/SMALL&LARGE BOWL
|
Facility
|
IP
|
$1,429.50
|
|
|
Service Code
|
HCPCS 78266 TC
|
| Hospital Charge Code |
41502915
|
|
Hospital Revenue Code
|
340
|
| Rate for Payer: Cash Price |
$625.05
|
|
|
NM HEPATOBILIARY SCAN
|
Facility
|
OP
|
$1,114.98
|
|
|
Service Code
|
HCPCS 78226 TC
|
| Hospital Charge Code |
41505034
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$234.74 |
| Max. Negotiated Rate |
$891.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$613.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$476.96
|
| Rate for Payer: Aetna Government |
$476.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$333.87
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$333.87
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$333.87
|
| Rate for Payer: Brighton Health Commercial |
$476.96
|
| Rate for Payer: Cash Price |
$476.96
|
| Rate for Payer: Cash Price |
$476.96
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$476.96
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$891.98
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$758.19
|
| Rate for Payer: Elderplan Medicare Advantage |
$476.96
|
| Rate for Payer: EmblemHealth Commercial |
$333.87
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$405.42
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$405.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$424.49
|
| Rate for Payer: Fidelis Medicare Advantage |
$476.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$424.49
|
| Rate for Payer: Group Health Inc Commercial |
$429.26
|
| Rate for Payer: Group Health Inc Medicare |
$429.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$557.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$476.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$429.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$476.96
|
| Rate for Payer: Healthfirst QHP |
$476.96
|
| Rate for Payer: Humana Medicare |
$486.50
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$476.96
|
| Rate for Payer: United Healthcare Commercial |
$234.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$476.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$476.96
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$381.57
|
| Rate for Payer: Wellcare Medicare |
$453.11
|
|
|
NM HEPATOBILIARY SCAN
|
Facility
|
IP
|
$1,114.98
|
|
|
Service Code
|
HCPCS 78226 TC
|
| Hospital Charge Code |
41505034
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$476.96
|
|
|
NM LIVER/SPLEEN SCAN
|
Facility
|
IP
|
$1,114.98
|
|
|
Service Code
|
HCPCS 78215 TC
|
| Hospital Charge Code |
41505030
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$476.96
|
|
|
NM LIVER/SPLEEN SCAN
|
Facility
|
OP
|
$1,114.98
|
|
|
Service Code
|
HCPCS 78215 TC
|
| Hospital Charge Code |
41505030
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$212.10 |
| Max. Negotiated Rate |
$613.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$613.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$476.96
|
| Rate for Payer: Aetna Government |
$476.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$333.87
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$333.87
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$333.87
|
| Rate for Payer: Brighton Health Commercial |
$476.96
|
| Rate for Payer: Cash Price |
$476.96
|
| Rate for Payer: Cash Price |
$476.96
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$476.96
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$530.63
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$449.00
|
| Rate for Payer: Elderplan Medicare Advantage |
$476.96
|
| Rate for Payer: EmblemHealth Commercial |
$333.87
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$405.42
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$405.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$424.49
|
| Rate for Payer: Fidelis Medicare Advantage |
$476.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$424.49
|
| Rate for Payer: Group Health Inc Commercial |
$429.26
|
| Rate for Payer: Group Health Inc Medicare |
$429.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$557.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$476.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$429.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$476.96
|
| Rate for Payer: Healthfirst QHP |
$476.96
|
| Rate for Payer: Humana Medicare |
$486.50
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$476.96
|
| Rate for Payer: United Healthcare Commercial |
$212.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$476.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$476.96
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$381.57
|
| Rate for Payer: Wellcare Medicare |
$453.11
|
|
|
NM LIVER (STATIC)
|
Facility
|
OP
|
$3,853.15
|
|
|
Service Code
|
HCPCS 78201 TC
|
| Hospital Charge Code |
41509989
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$212.10 |
| Max. Negotiated Rate |
$2,119.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,119.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$625.05
|
| Rate for Payer: Aetna Government |
$625.05
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$437.54
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$437.54
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$437.54
|
| Rate for Payer: Brighton Health Commercial |
$625.05
|
| Rate for Payer: Cash Price |
$625.05
|
| Rate for Payer: Cash Price |
$625.05
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$625.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$530.63
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$449.00
|
| Rate for Payer: Elderplan Medicare Advantage |
$625.05
|
| Rate for Payer: EmblemHealth Commercial |
$437.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$531.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$531.29
|
| Rate for Payer: Fidelis Essential Plan QHP |
$556.29
|
| Rate for Payer: Fidelis Medicare Advantage |
$625.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$556.29
|
| Rate for Payer: Group Health Inc Commercial |
$562.54
|
| Rate for Payer: Group Health Inc Medicare |
$562.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,926.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$625.05
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$562.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$625.05
|
| Rate for Payer: Healthfirst QHP |
$625.05
|
| Rate for Payer: Humana Medicare |
$637.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$625.05
|
| Rate for Payer: United Healthcare Commercial |
$212.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$625.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$625.05
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$500.04
|
| Rate for Payer: Wellcare Medicare |
$593.80
|
|
|
NM LIVER (STATIC)
|
Facility
|
IP
|
$3,853.15
|
|
|
Service Code
|
HCPCS 78201 TC
|
| Hospital Charge Code |
41509989
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$625.05
|
|
|
NM LIVER W/VASC. FLOW
|
Facility
|
OP
|
$3,853.15
|
|
|
Service Code
|
HCPCS 78202 TC
|
| Hospital Charge Code |
41505026
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$212.10 |
| Max. Negotiated Rate |
$2,119.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,119.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$625.05
|
| Rate for Payer: Aetna Government |
$625.05
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$437.54
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$437.54
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$437.54
|
| Rate for Payer: Brighton Health Commercial |
$625.05
|
| Rate for Payer: Cash Price |
$625.05
|
| Rate for Payer: Cash Price |
$625.05
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$625.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$530.63
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$449.00
|
| Rate for Payer: Elderplan Medicare Advantage |
$625.05
|
| Rate for Payer: EmblemHealth Commercial |
$437.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$531.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$531.29
|
| Rate for Payer: Fidelis Essential Plan QHP |
$556.29
|
| Rate for Payer: Fidelis Medicare Advantage |
$625.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$556.29
|
| Rate for Payer: Group Health Inc Commercial |
$562.54
|
| Rate for Payer: Group Health Inc Medicare |
$562.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,926.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$625.05
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$562.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$625.05
|
| Rate for Payer: Healthfirst QHP |
$625.05
|
| Rate for Payer: Humana Medicare |
$637.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$625.05
|
| Rate for Payer: United Healthcare Commercial |
$212.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$625.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$625.05
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$500.04
|
| Rate for Payer: Wellcare Medicare |
$593.80
|
|
|
NM LIVER W/VASC. FLOW
|
Facility
|
IP
|
$3,853.15
|
|
|
Service Code
|
HCPCS 78202 TC
|
| Hospital Charge Code |
41505026
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$625.05
|
|
|
NM LYMPH/NODES SCAN
|
Facility
|
IP
|
$1,429.50
|
|
|
Service Code
|
HCPCS 78195 TC
|
| Hospital Charge Code |
41509985
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$625.05
|
|
|
NM LYMPH/NODES SCAN
|
Facility
|
OP
|
$1,429.50
|
|
|
Service Code
|
HCPCS 78195 TC
|
| Hospital Charge Code |
41509985
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$205.62 |
| Max. Negotiated Rate |
$786.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$786.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$625.05
|
| Rate for Payer: Aetna Government |
$625.05
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$437.54
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$437.54
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$437.54
|
| Rate for Payer: Brighton Health Commercial |
$625.05
|
| Rate for Payer: Cash Price |
$625.05
|
| Rate for Payer: Cash Price |
$625.05
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$625.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$514.41
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$435.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$625.05
|
| Rate for Payer: EmblemHealth Commercial |
$437.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$531.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$531.29
|
| Rate for Payer: Fidelis Essential Plan QHP |
$556.29
|
| Rate for Payer: Fidelis Medicare Advantage |
$625.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$556.29
|
| Rate for Payer: Group Health Inc Commercial |
$562.54
|
| Rate for Payer: Group Health Inc Medicare |
$562.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$714.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$625.05
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$562.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$625.05
|
| Rate for Payer: Healthfirst QHP |
$625.05
|
| Rate for Payer: Humana Medicare |
$637.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$625.05
|
| Rate for Payer: United Healthcare Commercial |
$205.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$625.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$625.05
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$500.04
|
| Rate for Payer: Wellcare Medicare |
$593.80
|
|
|
NM MECKEL'S SCAN
|
Facility
|
OP
|
$1,114.98
|
|
|
Service Code
|
HCPCS 78290 TC
|
| Hospital Charge Code |
41505050
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$191.44 |
| Max. Negotiated Rate |
$613.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$613.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$476.96
|
| Rate for Payer: Aetna Government |
$476.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$333.87
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$333.87
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$333.87
|
| Rate for Payer: Brighton Health Commercial |
$476.96
|
| Rate for Payer: Cash Price |
$476.96
|
| Rate for Payer: Cash Price |
$476.96
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$476.96
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$478.95
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$405.26
|
| Rate for Payer: Elderplan Medicare Advantage |
$476.96
|
| Rate for Payer: EmblemHealth Commercial |
$333.87
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$405.42
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$405.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$424.49
|
| Rate for Payer: Fidelis Medicare Advantage |
$476.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$424.49
|
| Rate for Payer: Group Health Inc Commercial |
$429.26
|
| Rate for Payer: Group Health Inc Medicare |
$429.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$557.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$476.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$429.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$476.96
|
| Rate for Payer: Healthfirst QHP |
$476.96
|
| Rate for Payer: Humana Medicare |
$486.50
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$476.96
|
| Rate for Payer: United Healthcare Commercial |
$191.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$476.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$476.96
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$381.57
|
| Rate for Payer: Wellcare Medicare |
$453.11
|
|
|
NM MECKEL'S SCAN
|
Facility
|
IP
|
$1,114.98
|
|
|
Service Code
|
HCPCS 78290 TC
|
| Hospital Charge Code |
41505050
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$476.96
|
|
|
NM MISC. PROC. (FOLLOW UP) NO-INJ
|
Facility
|
OP
|
$1,114.98
|
|
|
Service Code
|
HCPCS 78999 TC
|
| Hospital Charge Code |
41509998
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$80.62 |
| Max. Negotiated Rate |
$613.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$613.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$476.96
|
| Rate for Payer: Aetna Government |
$476.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$333.87
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$333.87
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$333.87
|
| Rate for Payer: Brighton Health Commercial |
$476.96
|
| Rate for Payer: Cash Price |
$476.96
|
| Rate for Payer: Cash Price |
$476.96
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$476.96
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$201.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$170.65
|
| Rate for Payer: Elderplan Medicare Advantage |
$476.96
|
| Rate for Payer: EmblemHealth Commercial |
$333.87
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$405.42
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$405.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$424.49
|
| Rate for Payer: Fidelis Medicare Advantage |
$476.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$424.49
|
| Rate for Payer: Group Health Inc Commercial |
$429.26
|
| Rate for Payer: Group Health Inc Medicare |
$429.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$557.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$476.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$429.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$476.96
|
| Rate for Payer: Healthfirst QHP |
$476.96
|
| Rate for Payer: Humana Medicare |
$486.50
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$476.96
|
| Rate for Payer: United Healthcare Commercial |
$80.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$476.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$476.96
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$381.57
|
| Rate for Payer: Wellcare Medicare |
$453.11
|
|
|
NM MISC. PROC. (FOLLOW UP) NO-INJ
|
Facility
|
IP
|
$1,114.98
|
|
|
Service Code
|
HCPCS 78999 TC
|
| Hospital Charge Code |
41509998
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$476.96
|
|
|
NM MYOCARDIAC PERF (PLANAR) SINGL
|
Facility
|
IP
|
$3,853.15
|
|
|
Service Code
|
HCPCS 78453 TC
|
| Hospital Charge Code |
41509999
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$1,642.08
|
|
|
NM MYOCARDIAC PERF (PLANAR) SINGL
|
Facility
|
OP
|
$3,853.15
|
|
|
Service Code
|
HCPCS 78453 TC
|
| Hospital Charge Code |
41509999
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$607.92 |
| Max. Negotiated Rate |
$2,119.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,119.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,642.08
|
| Rate for Payer: Aetna Government |
$1,642.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,149.46
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,149.46
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,149.46
|
| Rate for Payer: Brighton Health Commercial |
$1,642.08
|
| Rate for Payer: Cash Price |
$1,642.08
|
| Rate for Payer: Cash Price |
$1,642.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,642.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,520.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,286.91
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,642.08
|
| Rate for Payer: EmblemHealth Commercial |
$1,149.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,395.77
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,395.77
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,461.45
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,642.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,461.45
|
| Rate for Payer: Group Health Inc Commercial |
$1,477.87
|
| Rate for Payer: Group Health Inc Medicare |
$1,477.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,926.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,642.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,477.87
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,642.08
|
| Rate for Payer: Healthfirst QHP |
$1,642.08
|
| Rate for Payer: Humana Medicare |
$1,674.92
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,642.08
|
| Rate for Payer: United Healthcare Commercial |
$607.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,642.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,642.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,313.66
|
| Rate for Payer: Wellcare Medicare |
$1,559.98
|
|
|
NM MYOCARDIAC PERF (SPECT) SINGLE
|
Facility
|
OP
|
$3,853.15
|
|
|
Service Code
|
HCPCS 78451 TC
|
| Hospital Charge Code |
41501408
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$607.92 |
| Max. Negotiated Rate |
$2,119.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,119.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,642.08
|
| Rate for Payer: Aetna Government |
$1,642.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,149.46
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,149.46
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,149.46
|
| Rate for Payer: Brighton Health Commercial |
$1,642.08
|
| Rate for Payer: Cash Price |
$1,642.08
|
| Rate for Payer: Cash Price |
$1,642.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,642.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,520.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,286.91
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,642.08
|
| Rate for Payer: EmblemHealth Commercial |
$1,149.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,395.77
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,395.77
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,461.45
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,642.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,461.45
|
| Rate for Payer: Group Health Inc Commercial |
$1,477.87
|
| Rate for Payer: Group Health Inc Medicare |
$1,477.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,926.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,642.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,477.87
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,642.08
|
| Rate for Payer: Healthfirst QHP |
$1,642.08
|
| Rate for Payer: Humana Medicare |
$1,674.92
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,642.08
|
| Rate for Payer: United Healthcare Commercial |
$607.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,642.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,642.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,313.66
|
| Rate for Payer: Wellcare Medicare |
$1,559.98
|
|
|
NM MYOCARDIAC PERF (SPECT) SINGLE
|
Facility
|
IP
|
$3,853.15
|
|
|
Service Code
|
HCPCS 78451 TC
|
| Hospital Charge Code |
41501408
|
|
Hospital Revenue Code
|
341
|
| Rate for Payer: Cash Price |
$1,642.08
|
|
|
NM MYOCARDIAC (REST) SPECT.
|
Facility
|
IP
|
$3,853.15
|
|
|
Service Code
|
HCPCS 78469 TC
|
| Hospital Charge Code |
41509994
|
|
Hospital Revenue Code
|
340
|
| Rate for Payer: Cash Price |
$625.05
|
|
