|
XR INTERSTIT APPL SIMP
|
Facility
OP
|
$371.65
|
|
|
Service Code
|
HCPCS 77799 TC
|
| Hospital Charge Code |
66542958
|
|
Hospital Revenue Code
|
342
|
| Min. Negotiated Rate |
$130.08 |
| Max. Negotiated Rate |
$297.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$204.41
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$185.82
|
| Rate for Payer: Aetna Government |
$185.82
|
| Rate for Payer: Cash Price |
$138.67
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$297.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$252.72
|
| Rate for Payer: Group Health Inc Commercial |
$185.82
|
| Rate for Payer: Group Health Inc Medicare |
$130.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$185.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$185.82
|
|
|
XR KNEE 1 VIEW
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73560 TC
|
| Hospital Charge Code |
41102856
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$29.54 |
| Max. Negotiated Rate |
$193.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$120.86
|
| Rate for Payer: Aetna Government |
$120.86
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$193.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$164.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$29.54
|
| Rate for Payer: Group Health Inc Commercial |
$120.86
|
| Rate for Payer: Group Health Inc Medicare |
$84.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$120.86
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$32.82
|
|
|
XR KNEE 2 VIEWS
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73560 TC
|
| Hospital Charge Code |
41102086
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$29.54 |
| Max. Negotiated Rate |
$193.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$120.86
|
| Rate for Payer: Aetna Government |
$120.86
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$193.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$164.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$29.54
|
| Rate for Payer: Group Health Inc Commercial |
$120.86
|
| Rate for Payer: Group Health Inc Medicare |
$84.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$120.86
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$32.82
|
|
|
XR KNEE 2 W/OBL-PAT-TUN
|
Facility
OP
|
$339.45
|
|
|
Service Code
|
HCPCS 73564 TC
|
| Hospital Charge Code |
41102484
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$39.89 |
| Max. Negotiated Rate |
$271.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$186.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$169.72
|
| Rate for Payer: Aetna Government |
$169.72
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$271.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$230.83
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$39.89
|
| Rate for Payer: Group Health Inc Commercial |
$169.72
|
| Rate for Payer: Group Health Inc Medicare |
$118.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$169.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$169.72
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$44.32
|
|
|
XR KNEE 3 VIEWS
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73562 TC
|
| Hospital Charge Code |
41102482
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$35.45 |
| Max. Negotiated Rate |
$193.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$120.86
|
| Rate for Payer: Aetna Government |
$120.86
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$193.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$164.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$35.45
|
| Rate for Payer: Group Health Inc Commercial |
$120.86
|
| Rate for Payer: Group Health Inc Medicare |
$84.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$120.86
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$39.39
|
|
|
XR LOCALIZE F.B. FOR CHILD
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 76010 TC
|
| Hospital Charge Code |
41102640
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$23.99 |
| Max. Negotiated Rate |
$193.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$120.86
|
| Rate for Payer: Aetna Government |
$120.86
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$193.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$164.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$23.99
|
| Rate for Payer: Group Health Inc Commercial |
$120.86
|
| Rate for Payer: Group Health Inc Medicare |
$84.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$120.86
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$26.66
|
|
|
XR LOWER EXTREMITY (INFANT)
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73592 TC
|
| Hospital Charge Code |
41102486
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$26.95 |
| Max. Negotiated Rate |
$193.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$120.86
|
| Rate for Payer: Aetna Government |
$120.86
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$193.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$164.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26.95
|
| Rate for Payer: Group Health Inc Commercial |
$120.86
|
| Rate for Payer: Group Health Inc Medicare |
$84.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$120.86
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$29.94
|
|
|
XR LOWER SPINE DISK LUMBAR
|
Facility
OP
|
$5,207.48
|
|
|
Service Code
|
HCPCS 72295 TC
|
| Hospital Charge Code |
41109980
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$4,165.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,864.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,603.74
|
| Rate for Payer: Aetna Government |
$2,603.74
|
| Rate for Payer: Cash Price |
$2,232.80
|
| Rate for Payer: Cash Price |
$2,232.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,165.98
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,541.09
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$79.80
|
| Rate for Payer: Group Health Inc Commercial |
$2,603.74
|
| Rate for Payer: Group Health Inc Medicare |
$1,822.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,603.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,603.74
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$88.67
|
|
|
XR LUMBAR SPINE AP/LATERAL
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 72110 TC
|
| Hospital Charge Code |
41102262
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$43.58 |
| Max. Negotiated Rate |
$261.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$163.50
|
| Rate for Payer: Aetna Government |
$163.50
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$261.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$222.36
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$43.58
|
| Rate for Payer: Group Health Inc Commercial |
$163.50
|
| Rate for Payer: Group Health Inc Medicare |
$114.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$163.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$48.42
|
|
|
XR LUMBAR SPINE W/OBLIQUES
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 72110 TC
|
| Hospital Charge Code |
41102446
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$43.58 |
| Max. Negotiated Rate |
$261.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$163.50
|
| Rate for Payer: Aetna Government |
$163.50
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$261.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$222.36
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$43.58
|
| Rate for Payer: Group Health Inc Commercial |
$163.50
|
| Rate for Payer: Group Health Inc Medicare |
$114.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$163.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$48.42
|
|
|
XR LUMB. SPINE W/BEND VIEWS
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 72114 TC
|
| Hospital Charge Code |
41102230
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$52.82 |
| Max. Negotiated Rate |
$261.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$163.50
|
| Rate for Payer: Aetna Government |
$163.50
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$261.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$222.36
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$52.82
|
| Rate for Payer: Group Health Inc Commercial |
$163.50
|
| Rate for Payer: Group Health Inc Medicare |
$114.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$163.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$58.69
|
|
|
XR LYMPHANG,EXTREMITY ONLY, BIL
|
Facility
OP
|
$4,940.28
|
|
|
Service Code
|
HCPCS 75803 TC
|
| Hospital Charge Code |
41107633
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,729.10 |
| Max. Negotiated Rate |
$3,952.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,717.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,470.14
|
| Rate for Payer: Aetna Government |
$2,470.14
|
| Rate for Payer: Cash Price |
$1,852.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,952.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,359.39
|
| Rate for Payer: Group Health Inc Commercial |
$2,470.14
|
| Rate for Payer: Group Health Inc Medicare |
$1,729.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,470.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,470.14
|
|
|
XR LYMPHANG,PELVIC/ABD, BIL
|
Facility
OP
|
$8,393.53
|
|
|
Service Code
|
HCPCS 75807 TC
|
| Hospital Charge Code |
41107637
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$2,937.74 |
| Max. Negotiated Rate |
$6,714.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,616.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,196.76
|
| Rate for Payer: Aetna Government |
$4,196.76
|
| Rate for Payer: Cash Price |
$3,686.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6,714.82
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5,707.60
|
| Rate for Payer: Group Health Inc Commercial |
$4,196.76
|
| Rate for Payer: Group Health Inc Medicare |
$2,937.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,196.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,196.76
|
|
|
XR MANDIBLE COMPLETE
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 70110 TC
|
| Hospital Charge Code |
41102166
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$35.45 |
| Max. Negotiated Rate |
$261.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$163.50
|
| Rate for Payer: Aetna Government |
$163.50
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$261.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$222.36
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$35.45
|
| Rate for Payer: Group Health Inc Commercial |
$163.50
|
| Rate for Payer: Group Health Inc Medicare |
$114.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$163.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$39.39
|
|
|
XR MANDIBLE LIMITED
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 70100 TC
|
| Hospital Charge Code |
41102398
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$33.61 |
| Max. Negotiated Rate |
$193.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$120.86
|
| Rate for Payer: Aetna Government |
$120.86
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$193.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$164.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$33.61
|
| Rate for Payer: Group Health Inc Commercial |
$120.86
|
| Rate for Payer: Group Health Inc Medicare |
$84.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$120.86
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$37.34
|
|
|
XR MASTOIDS COMPLETE
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 70130 TC
|
| Hospital Charge Code |
41102168
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$51.71 |
| Max. Negotiated Rate |
$261.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$163.50
|
| Rate for Payer: Aetna Government |
$163.50
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$261.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$222.36
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$51.71
|
| Rate for Payer: Group Health Inc Commercial |
$163.50
|
| Rate for Payer: Group Health Inc Medicare |
$114.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$163.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$57.46
|
|
|
XR MASTOIDS LIMITED
|
Facility
OP
|
$339.45
|
|
|
Service Code
|
HCPCS 70120 TC
|
| Hospital Charge Code |
41102400
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$33.61 |
| Max. Negotiated Rate |
$271.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$186.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$169.72
|
| Rate for Payer: Aetna Government |
$169.72
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$271.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$230.83
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$33.61
|
| Rate for Payer: Group Health Inc Commercial |
$169.72
|
| Rate for Payer: Group Health Inc Medicare |
$118.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$169.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$169.72
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$37.34
|
|
|
XR NASAL BONES
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 70160 TC
|
| Hospital Charge Code |
41102172
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$33.61 |
| Max. Negotiated Rate |
$193.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$120.86
|
| Rate for Payer: Aetna Government |
$120.86
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$193.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$164.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$33.61
|
| Rate for Payer: Group Health Inc Commercial |
$120.86
|
| Rate for Payer: Group Health Inc Medicare |
$84.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$120.86
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$37.34
|
|
|
XR OPTIC FERAMINA
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 70190 TC
|
| Hospital Charge Code |
41102176
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$30.28 |
| Max. Negotiated Rate |
$193.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$120.86
|
| Rate for Payer: Aetna Government |
$120.86
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$193.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$164.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$30.28
|
| Rate for Payer: Group Health Inc Commercial |
$120.86
|
| Rate for Payer: Group Health Inc Medicare |
$84.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$120.86
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$33.64
|
|
|
XR ORBITS
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 70200 TC
|
| Hospital Charge Code |
41102174
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$38.78 |
| Max. Negotiated Rate |
$261.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$163.50
|
| Rate for Payer: Aetna Government |
$163.50
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$261.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$222.36
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$38.78
|
| Rate for Payer: Group Health Inc Commercial |
$163.50
|
| Rate for Payer: Group Health Inc Medicare |
$114.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$163.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$43.09
|
|
|
XR OS CALCIS
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73650 TC
|
| Hospital Charge Code |
41102084
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$23.62 |
| Max. Negotiated Rate |
$193.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$120.86
|
| Rate for Payer: Aetna Government |
$120.86
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$193.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$164.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$23.62
|
| Rate for Payer: Group Health Inc Commercial |
$120.86
|
| Rate for Payer: Group Health Inc Medicare |
$84.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$120.86
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$26.25
|
|
|
XR PELVIS
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 72170 TC
|
| Hospital Charge Code |
41102214
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$22.14 |
| Max. Negotiated Rate |
$261.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$163.50
|
| Rate for Payer: Aetna Government |
$163.50
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$261.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$222.36
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$22.14
|
| Rate for Payer: Group Health Inc Commercial |
$163.50
|
| Rate for Payer: Group Health Inc Medicare |
$114.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$163.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$24.60
|
|
|
XR PELVIS 3 VIEWS + (PLUS)
|
Facility
OP
|
$5,240.00
|
|
|
Service Code
|
HCPCS 72190 TC
|
| Hospital Charge Code |
41107520
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$33.98 |
| Max. Negotiated Rate |
$4,192.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,882.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,620.00
|
| Rate for Payer: Aetna Government |
$2,620.00
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,192.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,563.20
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$33.98
|
| Rate for Payer: Group Health Inc Commercial |
$2,620.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,834.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,620.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,620.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$37.75
|
|
|
XR PELVIS 3 VIEWS + (PLUS)
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 72190 TC
|
| Hospital Charge Code |
41102866
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$33.98 |
| Max. Negotiated Rate |
$261.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$163.50
|
| Rate for Payer: Aetna Government |
$163.50
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$261.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$222.36
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$33.98
|
| Rate for Payer: Group Health Inc Commercial |
$163.50
|
| Rate for Payer: Group Health Inc Medicare |
$114.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$163.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$37.75
|
|
|
XR PHYSICS CONSULT
|
Facility
OP
|
$383.40
|
|
|
Service Code
|
HCPCS 77370
|
| Hospital Charge Code |
66542946
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$125.53 |
| Max. Negotiated Rate |
$306.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$210.87
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$156.91
|
| Rate for Payer: Aetna Government |
$156.91
|
| Rate for Payer: Cash Price |
$156.91
|
| Rate for Payer: Cash Price |
$156.91
|
| Rate for Payer: Cash Price |
$156.91
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$156.91
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$306.72
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$260.71
|
| Rate for Payer: Elderplan Medicare Advantage |
$156.91
|
| Rate for Payer: EmblemHealth Commercial |
$156.91
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$156.91
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$156.91
|
| Rate for Payer: Group Health Inc Medicare |
$156.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$191.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$156.91
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$141.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$156.91
|
| Rate for Payer: Healthfirst QHP |
$156.91
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$156.91
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$156.91
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$125.53
|
| Rate for Payer: Wellcare Medicare |
$149.06
|
|
