|
XR SPINE 1 VIEW
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 72020 TC
|
| Hospital Charge Code |
41102436
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$19.19 |
| 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 |
$19.19
|
| 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 |
$21.32
|
|
|
XR STERNO-CLAVICULAR JOINTS
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 71130 TC
|
| Hospital Charge Code |
41102050
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$34.71 |
| 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 |
$34.71
|
| 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 |
$38.57
|
|
|
XR STERNUM
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 71120 TC
|
| Hospital Charge Code |
41102048
|
|
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 TEMPOROMANDIBULAR JOINTS
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 70330 TC
|
| Hospital Charge Code |
41102196
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$46.54 |
| 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 |
$46.54
|
| 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 |
$51.71
|
|
|
XR THORACIC SPINE
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 72070 TC
|
| Hospital Charge Code |
41102438
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$26.21 |
| 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 |
$26.21
|
| 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 |
$29.12
|
|
|
XR THORACIC SPINE W/SWIMMERS
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 72072 TC
|
| Hospital Charge Code |
41102440
|
|
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 TIB/FIB 1 VIEW
|
Facility
OP
|
$766.16
|
|
|
Service Code
|
HCPCS 76499 TC
|
| Hospital Charge Code |
41107512
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$268.16 |
| Max. Negotiated Rate |
$612.93 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$421.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$383.08
|
| Rate for Payer: Aetna Government |
$383.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$612.93
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$520.99
|
| Rate for Payer: Group Health Inc Commercial |
$383.08
|
| Rate for Payer: Group Health Inc Medicare |
$268.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$383.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$383.08
|
|
|
XR TIB/FIB 1 VIEW
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73590 TC
|
| Hospital Charge Code |
41102858
|
|
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 TIBIA/FIBULA
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73590 TC
|
| Hospital Charge Code |
41102096
|
|
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 TOE(S)
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73660 TC
|
| Hospital Charge Code |
41102098
|
|
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 TOES 1 VIEW
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73660 TC
|
| Hospital Charge Code |
41102864
|
|
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 TOMO SINGLE PLANE
|
Facility
OP
|
$339.45
|
|
|
Service Code
|
HCPCS 76100 TC
|
| Hospital Charge Code |
41102182
|
|
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 TRANSHEPA PORTOGRAPHY W/O HEMO
|
Facility
OP
|
$4,940.28
|
|
|
Service Code
|
HCPCS 75887 TC
|
| Hospital Charge Code |
41107688
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.99 |
| 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 |
$3,686.08
|
| Rate for Payer: Cash Price |
$3,686.08
|
| 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: Fidelis CHP/HARP/Medicaid |
$81.99
|
| 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
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$91.10
|
|
|
XR TRANS/PORTABLE X-RAY
|
Facility
OP
|
$70.88
|
|
|
Service Code
|
HCPCS R0075
|
| Hospital Charge Code |
41107721
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$20.10 |
| Max. Negotiated Rate |
$56.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$38.98
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.10
|
| Rate for Payer: Aetna Government |
$20.10
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$56.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$48.20
|
| Rate for Payer: Group Health Inc Commercial |
$35.44
|
| Rate for Payer: Group Health Inc Medicare |
$24.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$35.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$35.44
|
|
|
XR TREAT DEVICE-COMPLEX
|
Facility
OP
|
$1,015.13
|
|
|
Service Code
|
HCPCS 77334 TC
|
| Hospital Charge Code |
66542943
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$80.05 |
| 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 |
$80.05
|
|
|
XR TREAT DEVICE INTERM
|
Facility
OP
|
$383.40
|
|
|
Service Code
|
HCPCS 77333 TC
|
| Hospital Charge Code |
66542942
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$121.12 |
| 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 |
$121.12
|
|
|
XR TREAT DEVICE SIMPLE
|
Facility
OP
|
$383.40
|
|
|
Service Code
|
HCPCS 77332 TC
|
| Hospital Charge Code |
66542941
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$18.03 |
| 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 |
$18.03
|
|
|
XR UPPER EXTREMITY (INFANT)
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 73092 TC
|
| Hospital Charge Code |
41102464
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$26.95 |
| 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 |
$26.95
|
| 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 |
$29.94
|
|
|
XR WRIST 1 VIEW
|
Facility
OP
|
$719.03
|
|
|
Service Code
|
HCPCS 76499 TC
|
| Hospital Charge Code |
41107498
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$251.66 |
| Max. Negotiated Rate |
$575.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$395.47
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$359.52
|
| Rate for Payer: Aetna Government |
$359.52
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$575.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$488.94
|
| Rate for Payer: Group Health Inc Commercial |
$359.52
|
| Rate for Payer: Group Health Inc Medicare |
$251.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$359.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$359.52
|
|
|
XR WRIST 1 VIEW
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73100 TC
|
| Hospital Charge Code |
41102844
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$29.17 |
| 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 |
$29.17
|
| 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 |
$32.41
|
|
|
XR WRIST 2 VIEWS
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73100 TC
|
| Hospital Charge Code |
41102466
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$29.17 |
| 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 |
$29.17
|
| 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 |
$32.41
|
|
|
XR WRIST COMPLETE
|
Facility
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73110 TC
|
| Hospital Charge Code |
41102100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$36.56 |
| 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 |
$36.56
|
| 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 |
$40.62
|
|
|
XR X-RAY EXAM OF SKULL
|
Facility
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 70250 TC
|
| Hospital Charge Code |
41102188
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$30.64 |
| 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 |
$30.64
|
| 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 |
$34.05
|
|
|
XR XRAY EXAM OF TEETH
|
Facility
OP
|
$705.83
|
|
|
Service Code
|
HCPCS 70310 TC
|
| Hospital Charge Code |
41109907
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$35.45 |
| Max. Negotiated Rate |
$564.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$388.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$352.92
|
| Rate for Payer: Aetna Government |
$352.92
|
| Rate for Payer: Cash Price |
$283.37
|
| Rate for Payer: Cash Price |
$283.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$564.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$479.96
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$35.45
|
| Rate for Payer: Group Health Inc Commercial |
$352.92
|
| Rate for Payer: Group Health Inc Medicare |
$247.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$352.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$352.92
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$39.39
|
|
|
XR X-RAY IAC'S(INTERNAL AUD CANAL
|
Facility
OP
|
$1,458.58
|
|
|
Service Code
|
HCPCS 70134 TC
|
| Hospital Charge Code |
41102868
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$49.87 |
| Max. Negotiated Rate |
$1,166.86 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$802.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$729.29
|
| Rate for Payer: Aetna Government |
$729.29
|
| Rate for Payer: Cash Price |
$637.97
|
| Rate for Payer: Cash Price |
$637.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,166.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$991.83
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$49.87
|
| Rate for Payer: Group Health Inc Commercial |
$729.29
|
| Rate for Payer: Group Health Inc Medicare |
$510.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$729.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$729.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$55.41
|
|
