|
XR TOE(S)
|
Facility
|
IP
|
$241.73
|
|
|
Service Code
|
HCPCS 73660 TC
|
| Hospital Charge Code |
41102098
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$105.08
|
|
|
XR TOES 1 VIEW
|
Facility
|
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73660 TC
|
| Hospital Charge Code |
41102864
|
|
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 TOES 1 VIEW
|
Facility
|
IP
|
$241.73
|
|
|
Service Code
|
HCPCS 73660 TC
|
| Hospital Charge Code |
41102864
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$105.08
|
|
|
XR TOMO SINGLE PLANE
|
Facility
|
IP
|
$339.45
|
|
|
Service Code
|
HCPCS 76100 TC
|
| Hospital Charge Code |
41102182
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
XR TOMO SINGLE PLANE
|
Facility
|
OP
|
$339.45
|
|
|
Service Code
|
HCPCS 76100 TC
|
| Hospital Charge Code |
41102182
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.00 |
| Max. Negotiated Rate |
$186.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$186.70
|
| 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 |
$169.72
|
| 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 TRANSHEPA PORTOGRAPHY W/O HEMO
|
Facility
|
IP
|
$4,940.28
|
|
|
Service Code
|
HCPCS 75887 TC
|
| Hospital Charge Code |
41107688
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$3,686.08
|
|
|
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 |
$1,217.14 |
| Max. Negotiated Rate |
$3,759.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,717.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,686.08
|
| Rate for Payer: Aetna Government |
$3,686.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,580.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,580.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,580.26
|
| Rate for Payer: Brighton Health Commercial |
$3,686.08
|
| Rate for Payer: Cash Price |
$3,686.08
|
| Rate for Payer: Cash Price |
$3,686.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,686.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,438.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,217.14
|
| Rate for Payer: Elderplan Medicare Advantage |
$3,686.08
|
| Rate for Payer: EmblemHealth Commercial |
$2,580.26
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3,133.17
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,133.17
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,280.61
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,686.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,280.61
|
| Rate for Payer: Group Health Inc Commercial |
$3,317.47
|
| Rate for Payer: Group Health Inc Medicare |
$3,317.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,470.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,686.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,317.47
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,686.08
|
| Rate for Payer: Healthfirst QHP |
$3,686.08
|
| Rate for Payer: Humana Medicare |
$3,759.80
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,686.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,686.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,686.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,948.86
|
| Rate for Payer: Wellcare Medicare |
$3,501.78
|
|
|
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: Brighton Health Commercial |
$53.16
|
| 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
|
IP
|
$1,015.13
|
|
|
Service Code
|
HCPCS 77334 TC
|
| Hospital Charge Code |
66542943
|
|
Hospital Revenue Code
|
333
|
| Rate for Payer: Cash Price |
$427.29
|
|
|
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 |
$279.92 |
| Max. Negotiated Rate |
$812.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$558.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$427.29
|
| Rate for Payer: Aetna Government |
$427.29
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$299.10
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$299.10
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$299.10
|
| Rate for Payer: Brighton Health Commercial |
$761.35
|
| Rate for Payer: Cash Price |
$427.29
|
| Rate for Payer: Cash Price |
$427.29
|
| Rate for Payer: Cash Price |
$427.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$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: Elderplan Medicare Advantage |
$427.29
|
| Rate for Payer: EmblemHealth Commercial |
$427.29
|
| 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 Medicare Advantage |
$427.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$427.29
|
| Rate for Payer: Group Health Inc Medicare |
$427.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$507.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$427.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$384.56
|
| Rate for Payer: Healthfirst Medicare Advantage |
$427.29
|
| Rate for Payer: Healthfirst QHP |
$427.29
|
| Rate for Payer: Humana Medicare |
$435.84
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$427.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$427.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$427.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$341.83
|
| Rate for Payer: Wellcare Medicare |
$405.93
|
|
|
XR TREAT DEVICE INTERM
|
Facility
|
IP
|
$383.40
|
|
|
Service Code
|
HCPCS 77333 TC
|
| Hospital Charge Code |
66542942
|
|
Hospital Revenue Code
|
333
|
| Rate for Payer: Cash Price |
$156.91
|
|
|
XR TREAT DEVICE INTERM
|
Facility
|
OP
|
$383.40
|
|
|
Service Code
|
HCPCS 77333 TC
|
| Hospital Charge Code |
66542942
|
|
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 TREAT DEVICE SIMPLE
|
Facility
|
OP
|
$383.40
|
|
|
Service Code
|
HCPCS 77332 TC
|
| Hospital Charge Code |
66542941
|
|
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 TREAT DEVICE SIMPLE
|
Facility
|
IP
|
$383.40
|
|
|
Service Code
|
HCPCS 77332 TC
|
| Hospital Charge Code |
66542941
|
|
Hospital Revenue Code
|
333
|
| Rate for Payer: Cash Price |
$156.91
|
|
|
XR UPPER EXTREMITY (INFANT)
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 73092 TC
|
| Hospital Charge Code |
41102464
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
XR UPPER EXTREMITY (INFANT)
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 73092 TC
|
| Hospital Charge Code |
41102464
|
|
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 WRIST 1 VIEW
|
Facility
|
IP
|
$241.73
|
|
|
Service Code
|
HCPCS 73100 TC
|
| Hospital Charge Code |
41102844
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$105.08
|
|
|
XR WRIST 1 VIEW
|
Facility
|
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73100 TC
|
| Hospital Charge Code |
41102844
|
|
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 WRIST 1 VIEW
|
Facility
|
OP
|
$719.03
|
|
|
Service Code
|
HCPCS 76499 TC
|
| Hospital Charge Code |
41107498
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$73.56 |
| Max. Negotiated Rate |
$395.47 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$395.47
|
| 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 |
$359.52
|
| 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 WRIST 1 VIEW
|
Facility
|
IP
|
$719.03
|
|
|
Service Code
|
HCPCS 76499 TC
|
| Hospital Charge Code |
41107498
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$105.08
|
|
|
XR WRIST 2 VIEWS
|
Facility
|
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73100 TC
|
| Hospital Charge Code |
41102466
|
|
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 WRIST 2 VIEWS
|
Facility
|
IP
|
$241.73
|
|
|
Service Code
|
HCPCS 73100 TC
|
| Hospital Charge Code |
41102466
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$105.08
|
|
|
XR WRIST COMPLETE
|
Facility
|
IP
|
$241.73
|
|
|
Service Code
|
HCPCS 73110 TC
|
| Hospital Charge Code |
41102100
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$105.08
|
|
|
XR WRIST COMPLETE
|
Facility
|
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73110 TC
|
| Hospital Charge Code |
41102100
|
|
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 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 |
$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
|
|
