|
XR PELVIS
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 72170 TC
|
| Hospital Charge Code |
41102214
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$76.27 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$89.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$114.43
|
| Rate for Payer: Group Health Inc Medicare |
$114.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$127.14
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
XR PELVIS
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 72170 TC
|
| Hospital Charge Code |
41102214
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
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 |
$76.27 |
| Max. Negotiated Rate |
$2,882.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,882.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$89.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$114.43
|
| Rate for Payer: Group Health Inc Medicare |
$114.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,620.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$127.14
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
XR PELVIS 3 VIEWS + (PLUS)
|
Facility
|
IP
|
$5,240.00
|
|
|
Service Code
|
HCPCS 72190 TC
|
| Hospital Charge Code |
41107520
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
XR PELVIS 3 VIEWS + (PLUS)
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 72190 TC
|
| Hospital Charge Code |
41102866
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
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 |
$76.27 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$89.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$114.43
|
| Rate for Payer: Group Health Inc Medicare |
$114.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$127.14
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
XR PHYSICS CONSULT
|
Facility
|
IP
|
$383.40
|
|
|
Service Code
|
HCPCS 77370
|
| Hospital Charge Code |
66542946
|
|
Hospital Revenue Code
|
333
|
| Rate for Payer: Cash Price |
$156.91
|
|
|
XR PHYSICS CONSULT
|
Facility
|
OP
|
$383.40
|
|
|
Service Code
|
HCPCS 77370
|
| Hospital Charge Code |
66542946
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$109.84 |
| 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: Affinity Essential Plan 1&2 |
$109.84
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$109.84
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$109.84
|
| Rate for Payer: Brighton Health Commercial |
$287.55
|
| 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: Humana Medicare |
$160.05
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$156.91
|
| Rate for Payer: United Healthcare 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
|
|
|
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: Brighton Health Commercial |
$77.61
|
| 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
|
|
|
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 |
$84.98 |
| Max. Negotiated Rate |
$558.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$383.78
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$84.98
|
| Rate for Payer: Aetna Government |
$84.98
|
| Rate for Payer: Brighton Health Commercial |
$523.34
|
| 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
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 71110 TC
|
| Hospital Charge Code |
41102046
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
XR RIBS BILATERAL
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 71110 TC
|
| Hospital Charge Code |
41102046
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$76.27 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$89.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$114.43
|
| Rate for Payer: Group Health Inc Medicare |
$114.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$127.14
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
XR RIBS BI W/CHEST 1 VIEW
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 71111 TC
|
| Hospital Charge Code |
41102432
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
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 |
$89.00 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$151.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$128.48
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$89.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$114.43
|
| Rate for Payer: Group Health Inc Medicare |
$114.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$127.14
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
XR RIBS UNILATERAL
|
Facility
|
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 71100 TC
|
| Hospital Charge Code |
41102044
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$73.56 |
| Max. Negotiated Rate |
$132.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$105.08
|
| Rate for Payer: Aetna Government |
$105.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$73.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$73.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$73.56
|
| Rate for Payer: Brighton Health Commercial |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$105.08
|
| Rate for Payer: EmblemHealth Commercial |
$73.56
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$89.32
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$89.32
|
| Rate for Payer: Fidelis Essential Plan QHP |
$93.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$105.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$93.52
|
| Rate for Payer: Group Health Inc Commercial |
$94.57
|
| Rate for Payer: Group Health Inc Medicare |
$94.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$105.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$94.57
|
| Rate for Payer: Healthfirst Medicare Advantage |
$105.08
|
| Rate for Payer: Healthfirst QHP |
$105.08
|
| Rate for Payer: Humana Medicare |
$107.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$105.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$105.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$105.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$84.06
|
| Rate for Payer: Wellcare Medicare |
$99.83
|
|
|
XR RIBS UNILATERAL
|
Facility
|
IP
|
$241.73
|
|
|
Service Code
|
HCPCS 71100 TC
|
| Hospital Charge Code |
41102044
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$105.08
|
|
|
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 |
$76.27 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$89.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$114.43
|
| Rate for Payer: Group Health Inc Medicare |
$114.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$127.14
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
XR RIBS W/CHEST 1 VIEW
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 71101 TC
|
| Hospital Charge Code |
41102430
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
XR SACRO-ILIAC COMPLETE
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 72202 TC
|
| Hospital Charge Code |
41102216
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$76.27 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$89.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$114.43
|
| Rate for Payer: Group Health Inc Medicare |
$114.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$127.14
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
XR SACRO-ILIAC COMPLETE
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 72202 TC
|
| Hospital Charge Code |
41102216
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
XR SACRO-ILIAC LIMITED
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 72200 TC
|
| Hospital Charge Code |
41102634
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
XR SACRO-ILIAC LIMITED
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 72200 TC
|
| Hospital Charge Code |
41102634
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$76.27 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$89.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$114.43
|
| Rate for Payer: Group Health Inc Medicare |
$114.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$127.14
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
XR SACRUM/COCCYX
|
Facility
|
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 72220 TC
|
| Hospital Charge Code |
41102210
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$73.56 |
| Max. Negotiated Rate |
$132.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$105.08
|
| Rate for Payer: Aetna Government |
$105.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$73.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$73.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$73.56
|
| Rate for Payer: Brighton Health Commercial |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$105.08
|
| Rate for Payer: EmblemHealth Commercial |
$73.56
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$89.32
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$89.32
|
| Rate for Payer: Fidelis Essential Plan QHP |
$93.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$105.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$93.52
|
| Rate for Payer: Group Health Inc Commercial |
$94.57
|
| Rate for Payer: Group Health Inc Medicare |
$94.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$105.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$94.57
|
| Rate for Payer: Healthfirst Medicare Advantage |
$105.08
|
| Rate for Payer: Healthfirst QHP |
$105.08
|
| Rate for Payer: Humana Medicare |
$107.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$105.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$105.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$105.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$84.06
|
| Rate for Payer: Wellcare Medicare |
$99.83
|
|
|
XR SACRUM/COCCYX
|
Facility
|
IP
|
$241.73
|
|
|
Service Code
|
HCPCS 72220 TC
|
| Hospital Charge Code |
41102210
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$105.08
|
|
|
XR SCAPULA
|
Facility
|
IP
|
$339.45
|
|
|
Service Code
|
HCPCS 73010 TC
|
| Hospital Charge Code |
41102092
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
