|
PT PET/CT LIMITED AREA
|
Facility
|
OP
|
$4,370.75
|
|
|
Service Code
|
HCPCS 78814 TC
|
| Hospital Charge Code |
41208732
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$833.59 |
| Max. Negotiated Rate |
$2,403.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,403.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,809.17
|
| Rate for Payer: Aetna Government |
$1,809.17
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,266.42
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,266.42
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,266.42
|
| Rate for Payer: Brighton Health Commercial |
$1,809.17
|
| Rate for Payer: Cash Price |
$1,809.17
|
| Rate for Payer: Cash Price |
$1,809.17
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,809.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,085.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,764.63
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,809.17
|
| Rate for Payer: EmblemHealth Commercial |
$1,266.42
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,537.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,537.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,610.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,809.17
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,610.16
|
| Rate for Payer: Group Health Inc Commercial |
$1,628.25
|
| Rate for Payer: Group Health Inc Medicare |
$1,628.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,185.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,809.17
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,628.25
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,809.17
|
| Rate for Payer: Healthfirst QHP |
$1,809.17
|
| Rate for Payer: Humana Medicare |
$1,845.35
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,809.17
|
| Rate for Payer: United Healthcare Commercial |
$833.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,809.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,809.17
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,447.34
|
| Rate for Payer: Wellcare Medicare |
$1,718.71
|
|
|
PT PET/CT SKULL BASE-MID THIGH
|
Facility
|
OP
|
$4,370.75
|
|
|
Service Code
|
HCPCS 78815 TC
|
| Hospital Charge Code |
41208733
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$833.59 |
| Max. Negotiated Rate |
$2,403.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,403.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,809.17
|
| Rate for Payer: Aetna Government |
$1,809.17
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,266.42
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,266.42
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,266.42
|
| Rate for Payer: Brighton Health Commercial |
$1,809.17
|
| Rate for Payer: Cash Price |
$1,809.17
|
| Rate for Payer: Cash Price |
$1,809.17
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,809.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,085.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,764.63
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,809.17
|
| Rate for Payer: EmblemHealth Commercial |
$1,266.42
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,537.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,537.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,610.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,809.17
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,610.16
|
| Rate for Payer: Group Health Inc Commercial |
$1,628.25
|
| Rate for Payer: Group Health Inc Medicare |
$1,628.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,185.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,809.17
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,628.25
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,809.17
|
| Rate for Payer: Healthfirst QHP |
$1,809.17
|
| Rate for Payer: Humana Medicare |
$1,845.35
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,809.17
|
| Rate for Payer: United Healthcare Commercial |
$833.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,809.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,809.17
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,447.34
|
| Rate for Payer: Wellcare Medicare |
$1,718.71
|
|
|
PT PET/CT SKULL BASE-MID THIGH
|
Facility
|
IP
|
$4,370.75
|
|
|
Service Code
|
HCPCS 78815 TC
|
| Hospital Charge Code |
41208733
|
|
Hospital Revenue Code
|
404
|
| Rate for Payer: Cash Price |
$1,809.17
|
|
|
PT PET/CT WHOLE BODY
|
Facility
|
IP
|
$4,370.75
|
|
|
Service Code
|
HCPCS 78816 TC
|
| Hospital Charge Code |
41208734
|
|
Hospital Revenue Code
|
404
|
| Rate for Payer: Cash Price |
$1,809.17
|
|
|
PT PET/CT WHOLE BODY
|
Facility
|
OP
|
$4,370.75
|
|
|
Service Code
|
HCPCS 78816 TC
|
| Hospital Charge Code |
41208734
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$833.59 |
| Max. Negotiated Rate |
$2,403.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,403.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,809.17
|
| Rate for Payer: Aetna Government |
$1,809.17
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,266.42
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,266.42
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,266.42
|
| Rate for Payer: Brighton Health Commercial |
$1,809.17
|
| Rate for Payer: Cash Price |
$1,809.17
|
| Rate for Payer: Cash Price |
$1,809.17
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,809.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,085.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,764.63
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,809.17
|
| Rate for Payer: EmblemHealth Commercial |
$1,266.42
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,537.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,537.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,610.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,809.17
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,610.16
|
| Rate for Payer: Group Health Inc Commercial |
$1,628.25
|
| Rate for Payer: Group Health Inc Medicare |
$1,628.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,185.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,809.17
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,628.25
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,809.17
|
| Rate for Payer: Healthfirst QHP |
$1,809.17
|
| Rate for Payer: Humana Medicare |
$1,845.35
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,809.17
|
| Rate for Payer: United Healthcare Commercial |
$833.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,809.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,809.17
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,447.34
|
| Rate for Payer: Wellcare Medicare |
$1,718.71
|
|
|
PT PET LIMITED AREA
|
Facility
|
IP
|
$3,853.15
|
|
|
Service Code
|
HCPCS 78811 TC
|
| Hospital Charge Code |
41208729
|
|
Hospital Revenue Code
|
404
|
| Rate for Payer: Cash Price |
$1,642.08
|
|
|
PT PET LIMITED AREA
|
Facility
|
OP
|
$3,853.15
|
|
|
Service Code
|
HCPCS 78811 TC
|
| Hospital Charge Code |
41208729
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$833.59 |
| 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 |
$2,085.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,764.63
|
| 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 |
$833.59
|
| 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
|
|
|
PT PET PERFUSION MULTIPLE
|
Facility
|
OP
|
$4,370.75
|
|
|
Service Code
|
HCPCS 78492 TC
|
| Hospital Charge Code |
41208738
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$342.00 |
| Max. Negotiated Rate |
$2,216.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,809.17
|
| Rate for Payer: Aetna Government |
$1,809.17
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,266.42
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,266.42
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,266.42
|
| Rate for Payer: Brighton Health Commercial |
$1,809.17
|
| Rate for Payer: Cash Price |
$1,809.17
|
| Rate for Payer: Cash Price |
$1,809.17
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,809.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,216.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,875.35
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,809.17
|
| Rate for Payer: EmblemHealth Commercial |
$1,266.42
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,537.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,537.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,610.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,809.17
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,610.16
|
| Rate for Payer: Group Health Inc Commercial |
$1,628.25
|
| Rate for Payer: Group Health Inc Medicare |
$1,628.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,185.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,809.17
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,628.25
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,809.17
|
| Rate for Payer: Healthfirst QHP |
$1,809.17
|
| Rate for Payer: Humana Medicare |
$1,845.35
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,809.17
|
| Rate for Payer: United Healthcare Commercial |
$885.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,809.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,809.17
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,447.34
|
| Rate for Payer: Wellcare Medicare |
$1,718.71
|
|
|
PT PET PERFUSION MULTIPLE
|
Facility
|
IP
|
$4,370.75
|
|
|
Service Code
|
HCPCS 78492 TC
|
| Hospital Charge Code |
41208738
|
|
Hospital Revenue Code
|
404
|
| Rate for Payer: Cash Price |
$1,809.17
|
|
|
PT PET PERFUSION SINGLE
|
Facility
|
OP
|
$4,370.75
|
|
|
Service Code
|
HCPCS 78491 TC
|
| Hospital Charge Code |
41208737
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$342.00 |
| Max. Negotiated Rate |
$2,216.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,809.17
|
| Rate for Payer: Aetna Government |
$1,809.17
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,266.42
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,266.42
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,266.42
|
| Rate for Payer: Brighton Health Commercial |
$1,809.17
|
| Rate for Payer: Cash Price |
$1,809.17
|
| Rate for Payer: Cash Price |
$1,809.17
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,809.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,216.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,875.35
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,809.17
|
| Rate for Payer: EmblemHealth Commercial |
$1,266.42
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,537.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,537.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,610.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,809.17
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,610.16
|
| Rate for Payer: Group Health Inc Commercial |
$1,628.25
|
| Rate for Payer: Group Health Inc Medicare |
$1,628.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,185.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,809.17
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,628.25
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,809.17
|
| Rate for Payer: Healthfirst QHP |
$1,809.17
|
| Rate for Payer: Humana Medicare |
$1,845.35
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,809.17
|
| Rate for Payer: United Healthcare Commercial |
$885.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,809.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,809.17
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,447.34
|
| Rate for Payer: Wellcare Medicare |
$1,718.71
|
|
|
PT PET PERFUSION SINGLE
|
Facility
|
IP
|
$4,370.75
|
|
|
Service Code
|
HCPCS 78491 TC
|
| Hospital Charge Code |
41208737
|
|
Hospital Revenue Code
|
404
|
| Rate for Payer: Cash Price |
$1,809.17
|
|
|
PT PET SKULL BASE - MID. THIGH
|
Facility
|
IP
|
$4,370.75
|
|
|
Service Code
|
HCPCS 78812 TC
|
| Hospital Charge Code |
41208730
|
|
Hospital Revenue Code
|
404
|
| Rate for Payer: Cash Price |
$1,809.17
|
|
|
PT PET SKULL BASE - MID. THIGH
|
Facility
|
OP
|
$4,370.75
|
|
|
Service Code
|
HCPCS 78812 TC
|
| Hospital Charge Code |
41208730
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$833.59 |
| Max. Negotiated Rate |
$2,403.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,403.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,809.17
|
| Rate for Payer: Aetna Government |
$1,809.17
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,266.42
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,266.42
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,266.42
|
| Rate for Payer: Brighton Health Commercial |
$1,809.17
|
| Rate for Payer: Cash Price |
$1,809.17
|
| Rate for Payer: Cash Price |
$1,809.17
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,809.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,085.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,764.63
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,809.17
|
| Rate for Payer: EmblemHealth Commercial |
$1,266.42
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,537.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,537.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,610.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,809.17
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,610.16
|
| Rate for Payer: Group Health Inc Commercial |
$1,628.25
|
| Rate for Payer: Group Health Inc Medicare |
$1,628.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,185.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,809.17
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,628.25
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,809.17
|
| Rate for Payer: Healthfirst QHP |
$1,809.17
|
| Rate for Payer: Humana Medicare |
$1,845.35
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,809.17
|
| Rate for Payer: United Healthcare Commercial |
$833.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,809.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,809.17
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,447.34
|
| Rate for Payer: Wellcare Medicare |
$1,718.71
|
|
|
PT PET WHOLE BODY
|
Facility
|
IP
|
$4,370.75
|
|
|
Service Code
|
HCPCS 78813 TC
|
| Hospital Charge Code |
41208731
|
|
Hospital Revenue Code
|
404
|
| Rate for Payer: Cash Price |
$1,809.17
|
|
|
PT PET WHOLE BODY
|
Facility
|
OP
|
$4,370.75
|
|
|
Service Code
|
HCPCS 78813 TC
|
| Hospital Charge Code |
41208731
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$833.59 |
| Max. Negotiated Rate |
$2,403.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,403.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,809.17
|
| Rate for Payer: Aetna Government |
$1,809.17
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,266.42
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,266.42
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,266.42
|
| Rate for Payer: Brighton Health Commercial |
$1,809.17
|
| Rate for Payer: Cash Price |
$1,809.17
|
| Rate for Payer: Cash Price |
$1,809.17
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,809.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,085.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,764.63
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,809.17
|
| Rate for Payer: EmblemHealth Commercial |
$1,266.42
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,537.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,537.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,610.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,809.17
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,610.16
|
| Rate for Payer: Group Health Inc Commercial |
$1,628.25
|
| Rate for Payer: Group Health Inc Medicare |
$1,628.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,185.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,809.17
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,628.25
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,809.17
|
| Rate for Payer: Healthfirst QHP |
$1,809.17
|
| Rate for Payer: Humana Medicare |
$1,845.35
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,809.17
|
| Rate for Payer: United Healthcare Commercial |
$833.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,809.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,809.17
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,447.34
|
| Rate for Payer: Wellcare Medicare |
$1,718.71
|
|
|
PT PHYSICAL PERFORMANCE TEST 15MT
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
HCPCS 97750 GP
|
| Hospital Charge Code |
41701136
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$19.85 |
| Max. Negotiated Rate |
$4,788.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$56.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.85
|
| Rate for Payer: Aetna Government |
$19.85
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$107.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$107.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$47.88
|
| Rate for Payer: Amida Care Medicaid |
$47.88
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,788.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$47.88
|
| Rate for Payer: Fidelis Essential Plan QHP |
$47.88
|
| Rate for Payer: Fidelis Qualified Health Plan |
$50.27
|
| Rate for Payer: Group Health Inc Commercial |
$51.00
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$47.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$51.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$47.88
|
| Rate for Payer: Healthfirst Essential Plan |
$107.73
|
| Rate for Payer: Healthfirst QHP |
$47.88
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$47.88
|
| Rate for Payer: SOMOS Essential |
$107.73
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$107.73
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$52.67
|
| Rate for Payer: United Healthcare Medicaid |
$47.88
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$47.88
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
PT PLATFORM ATTACH-WALKER
|
Facility
|
OP
|
$453.48
|
|
|
Service Code
|
HCPCS E0154
|
| Hospital Charge Code |
41709422
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$37.48 |
| Max. Negotiated Rate |
$362.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$249.41
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$37.48
|
| Rate for Payer: Aetna Government |
$37.48
|
| Rate for Payer: Brighton Health Commercial |
$340.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$362.78
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$308.37
|
| Rate for Payer: Group Health Inc Commercial |
$226.74
|
| Rate for Payer: Group Health Inc Medicare |
$158.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$226.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$226.74
|
|
|
PT POST-OPERATIVE SHOE
|
Facility
|
OP
|
$10.10
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
41709500
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$10.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.51
|
| Rate for Payer: Aetna Government |
$8.51
|
| Rate for Payer: Brighton Health Commercial |
$6.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.05
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.81
|
| Rate for Payer: EmblemHealth Commercial |
$5.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$10.60
|
| Rate for Payer: Group Health Inc Commercial |
$5.05
|
| Rate for Payer: Group Health Inc Medicare |
$3.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.56
|
|
|
PT PROSTHETIC TRAINING -EXTRE 15M
|
Facility
|
OP
|
$122.90
|
|
|
Service Code
|
HCPCS 97761
|
| Hospital Charge Code |
41701128
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$19.85 |
| Max. Negotiated Rate |
$4,788.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$67.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.85
|
| Rate for Payer: Aetna Government |
$19.85
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$107.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$107.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$47.88
|
| Rate for Payer: Amida Care Medicaid |
$47.88
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4,788.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$47.88
|
| Rate for Payer: Fidelis Essential Plan QHP |
$47.88
|
| Rate for Payer: Fidelis Qualified Health Plan |
$50.27
|
| Rate for Payer: Group Health Inc Commercial |
$61.45
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$47.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$61.45
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$47.88
|
| Rate for Payer: Healthfirst Essential Plan |
$107.73
|
| Rate for Payer: Healthfirst QHP |
$47.88
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$47.88
|
| Rate for Payer: SOMOS Essential |
$107.73
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$107.73
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$52.67
|
| Rate for Payer: United Healthcare Medicaid |
$47.88
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$47.88
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
PT RECV >=1 WELL-CHLD VISIT
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS G9964
|
| Hospital Charge Code |
30300374
|
|
Hospital Revenue Code
|
969
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
PT RECV TBCO CESS INTERV
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS G9906
|
| Hospital Charge Code |
30307879
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
PT RE-EVALUATION
|
Facility
|
OP
|
$171.98
|
|
|
Service Code
|
HCPCS 97164 GP
|
| Hospital Charge Code |
41709554
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$33.56 |
| Max. Negotiated Rate |
$11,418.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$94.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$33.56
|
| Rate for Payer: Aetna Government |
$33.56
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$256.90
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$256.90
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$114.18
|
| Rate for Payer: Amida Care Medicaid |
$114.18
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$11,418.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$114.18
|
| Rate for Payer: Fidelis Essential Plan QHP |
$114.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$119.89
|
| Rate for Payer: Group Health Inc Commercial |
$85.99
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$114.18
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$85.99
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.18
|
| Rate for Payer: Healthfirst Essential Plan |
$256.90
|
| Rate for Payer: Healthfirst QHP |
$114.18
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$114.18
|
| Rate for Payer: SOMOS Essential |
$256.90
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$256.90
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$125.60
|
| Rate for Payer: United Healthcare Medicaid |
$114.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$114.18
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
PT REEVALUATION
|
Facility
|
OP
|
$171.98
|
|
|
Service Code
|
HCPCS 97164 GP
|
| Hospital Charge Code |
41701102
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$33.56 |
| Max. Negotiated Rate |
$11,418.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$94.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$33.56
|
| Rate for Payer: Aetna Government |
$33.56
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$256.90
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$256.90
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$114.18
|
| Rate for Payer: Amida Care Medicaid |
$114.18
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$11,418.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$114.18
|
| Rate for Payer: Fidelis Essential Plan QHP |
$114.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$119.89
|
| Rate for Payer: Group Health Inc Commercial |
$85.99
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$114.18
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$85.99
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.18
|
| Rate for Payer: Healthfirst Essential Plan |
$256.90
|
| Rate for Payer: Healthfirst QHP |
$114.18
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$114.18
|
| Rate for Payer: SOMOS Essential |
$256.90
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$256.90
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$125.60
|
| Rate for Payer: United Healthcare Medicaid |
$114.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$114.18
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
PT REF APP RSRCS
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS G2186
|
| Hospital Charge Code |
30300314
|
|
Hospital Revenue Code
|
929
|
| Max. Negotiated Rate |
$94.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$94.00
|
|
|
PT REMOVAL/REVISION CAST
|
Facility
|
OP
|
$696.08
|
|
|
Service Code
|
HCPCS 29700
|
| Hospital Charge Code |
41709447
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$55.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$310.57
|
| Rate for Payer: Aetna Government |
$310.57
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$217.40
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$217.40
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$217.40
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$310.57
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$310.57
|
| Rate for Payer: EmblemHealth Commercial |
$310.57
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$310.57
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$263.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$276.41
|
| Rate for Payer: Fidelis Medicare Advantage |
$310.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$276.41
|
| Rate for Payer: Group Health Inc Commercial |
$310.57
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$348.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$310.57
|
| Rate for Payer: Healthfirst Medicare Advantage |
$263.98
|
| Rate for Payer: Healthfirst QHP |
$310.57
|
| Rate for Payer: Humana Medicare |
$316.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$310.57
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$310.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$310.57
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$248.46
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
