|
XR PORT FILMS
|
Facility
OP
|
$103.48
|
|
|
Service Code
|
HCPCS 77417
|
| Hospital Charge Code |
66542949
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$14.55 |
| Max. Negotiated Rate |
$294.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$56.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.55
|
| Rate for Payer: Aetna Government |
$14.55
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$82.78
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$70.37
|
| 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 Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$51.74
|
| Rate for Payer: Group Health Inc Medicare |
$36.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$51.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$51.74
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$17.21
|
|
|
XR REPL DISLODG G-J TUBE COMPLEX
|
Facility
OP
|
$697.79
|
|
|
Service Code
|
HCPCS 74355 TC
|
| Hospital Charge Code |
41107668
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$244.23 |
| Max. Negotiated Rate |
$558.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$383.78
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$348.90
|
| Rate for Payer: Aetna Government |
$348.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$558.23
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$474.50
|
| Rate for Payer: Group Health Inc Commercial |
$348.90
|
| Rate for Payer: Group Health Inc Medicare |
$244.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$348.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$348.90
|
|
|
XR RIBS BILATERAL
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 71110 TC
|
| Hospital Charge Code |
41102046
|
|
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 RIBS BI W/CHEST 1 VIEW
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 71111 TC
|
| Hospital Charge Code |
41102432
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$41.73 |
| 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 |
$41.73
|
| 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 |
$46.37
|
|
|
XR RIBS UNILATERAL
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 71100 TC
|
| Hospital Charge Code |
41102044
|
|
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 RIBS W/CHEST 1 VIEW
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 71101 TC
|
| Hospital Charge Code |
41102430
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$33.23 |
| 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 |
$33.23
|
| 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 |
$36.92
|
|
|
XR SACRO-ILIAC COMPLETE
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 72202 TC
|
| Hospital Charge Code |
41102216
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.12 |
| 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 |
$32.12
|
| 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 |
$35.69
|
|
|
XR SACRO-ILIAC LIMITED
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 72200 TC
|
| Hospital Charge Code |
41102634
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$28.05 |
| 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 |
$28.05
|
| 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 |
$31.17
|
|
|
XR SACRUM/COCCYX
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 72220 TC
|
| Hospital Charge Code |
41102210
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$27.32 |
| 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 |
$27.32
|
| 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 |
$30.35
|
|
|
XR SCAPULA
|
Facility
OP
|
$339.45
|
|
|
Service Code
|
HCPCS 73010 TC
|
| Hospital Charge Code |
41102092
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$16.96 |
| 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 |
$16.96
|
| 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 |
$18.85
|
|
|
XR SCOLIOSIS 1 VIEW ONLY
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 72081 TC
|
| Hospital Charge Code |
41102904
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$33.98 |
| 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 |
$33.98
|
| 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 |
$37.75
|
|
|
XR SCOLIOSIS 4 OR 5 VIEW ONLY
|
Facility
OP
|
$339.45
|
|
|
Service Code
|
HCPCS 72083 TC
|
| Hospital Charge Code |
41102905
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$69.08 |
| 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 |
$69.08
|
| 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 |
$76.76
|
|
|
XR SCOLIOSIS 6 OR MORE VIEWS
|
Facility
OP
|
$339.45
|
|
|
Service Code
|
HCPCS 72084 TC
|
| Hospital Charge Code |
41102906
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$88.64 |
| 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 |
$88.64
|
| 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 |
$98.49
|
|
|
XR SCOLIOSIS SERIES
|
Facility
OP
|
$339.45
|
|
|
Service Code
|
HCPCS 72082 TC
|
| Hospital Charge Code |
41102238
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$61.70 |
| 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 |
$61.70
|
| 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 |
$68.55
|
|
|
XR SELLA TURCICA
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 70240 TC
|
| Hospital Charge Code |
41102178
|
|
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 SHOULDER 1 VIEWS
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73020 TC
|
| Hospital Charge Code |
41102155
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$16.23 |
| 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 |
$16.23
|
| 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 |
$18.03
|
|
|
XR SHOULDER 2 VIEWS
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73030 TC
|
| Hospital Charge Code |
41102094
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$28.80 |
| 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 |
$28.80
|
| 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 |
$32.00
|
|
|
XR SHOULDER POST REDUCTION
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73030 TC
|
| Hospital Charge Code |
41103920
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$28.80 |
| 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 |
$28.80
|
| 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 |
$32.00
|
|
|
XR SINUSES COMPLETE
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 70220 TC
|
| Hospital Charge Code |
41102184
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$30.64 |
| 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 |
$30.64
|
| 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 |
$34.05
|
|
|
XR SINUSES LIMITED
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 70210 TC
|
| Hospital Charge Code |
41102404
|
|
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 SKULL COMPLETE
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 70260 TC
|
| Hospital Charge Code |
41102160
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$35.08 |
| 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 |
$35.08
|
| 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 |
$38.98
|
|
|
XR SOFT TISSUE NECK
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 70360 TC
|
| Hospital Charge Code |
41102038
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$25.84 |
| 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 |
$25.84
|
| 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 |
$28.71
|
|
|
XR SPECIAL DOSIMETRY
|
Facility
OP
|
$383.40
|
|
|
Service Code
|
HCPCS 77331 TC
|
| Hospital Charge Code |
66542940
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$23.78 |
| Max. Negotiated Rate |
$306.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$210.87
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$191.70
|
| Rate for Payer: Aetna Government |
$191.70
|
| Rate for Payer: Cash Price |
$156.91
|
| Rate for Payer: Cash Price |
$156.91
|
| Rate for Payer: Cash Price |
$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: 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 Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$191.70
|
| Rate for Payer: Group Health Inc Medicare |
$134.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$191.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$191.70
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$23.78
|
|
|
XR SPECIAL TELETHERAPY
|
Facility
OP
|
$1,015.13
|
|
|
Service Code
|
HCPCS 77321 TC
|
| Hospital Charge Code |
66542939
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$54.17 |
| Max. Negotiated Rate |
$812.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$558.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$507.56
|
| Rate for Payer: Aetna Government |
$507.56
|
| Rate for Payer: Cash Price |
$427.29
|
| Rate for Payer: Cash Price |
$427.29
|
| Rate for Payer: Cash Price |
$427.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$812.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$690.29
|
| 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 Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$507.56
|
| Rate for Payer: Group Health Inc Medicare |
$355.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$507.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$507.56
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$54.17
|
|
|
XR SPEC TRRMT PROC
|
Facility
OP
|
$1,631.98
|
|
|
Service Code
|
HCPCS 77470 TC
|
| Hospital Charge Code |
66542954
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$40.58 |
| Max. Negotiated Rate |
$1,305.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$897.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$815.99
|
| Rate for Payer: Aetna Government |
$815.99
|
| Rate for Payer: Cash Price |
$680.74
|
| Rate for Payer: Cash Price |
$680.74
|
| Rate for Payer: Cash Price |
$680.74
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,305.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,109.75
|
| 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 Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$815.99
|
| Rate for Payer: Group Health Inc Medicare |
$571.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$815.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$815.99
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40.58
|
|
