045% SODIUM CHLORIDE- 1000CC
|
Facility
OP
|
$9.92
|
|
Hospital Charge Code |
40504020
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$3.47 |
Max. Negotiated Rate |
$7.94 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.46
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.96
|
Rate for Payer: Aetna Government |
$4.96
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.94
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.75
|
Rate for Payer: Group Health Inc Commercial |
$4.96
|
Rate for Payer: Group Health Inc Medicare |
$3.47
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.96
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$4.96
|
|
045% SODIUM CHLORIDE -500CC
|
Facility
OP
|
$8.15
|
|
Hospital Charge Code |
40504021
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$2.85 |
Max. Negotiated Rate |
$6.52 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.48
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.08
|
Rate for Payer: Aetna Government |
$4.08
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.52
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.54
|
Rate for Payer: Group Health Inc Commercial |
$4.08
|
Rate for Payer: Group Health Inc Medicare |
$2.85
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.08
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$4.08
|
|
10% ALCOL-5% DEXTRS WAT 1000CC
|
Facility
OP
|
$20.20
|
|
Hospital Charge Code |
40509780
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$7.07 |
Max. Negotiated Rate |
$16.16 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.11
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.10
|
Rate for Payer: Aetna Government |
$10.10
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.16
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.74
|
Rate for Payer: Group Health Inc Commercial |
$10.10
|
Rate for Payer: Group Health Inc Medicare |
$7.07
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.10
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$10.10
|
|
10% DEX IN .9 NS 1000CC
|
Facility
OP
|
$10.64
|
|
Hospital Charge Code |
40509786
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$3.72 |
Max. Negotiated Rate |
$8.51 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.85
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.32
|
Rate for Payer: Aetna Government |
$5.32
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.51
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.24
|
Rate for Payer: Group Health Inc Commercial |
$5.32
|
Rate for Payer: Group Health Inc Medicare |
$3.72
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.32
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$5.32
|
|
10% DEX IN .9 NS 500CC
|
Facility
OP
|
$8.86
|
|
Hospital Charge Code |
40509785
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$3.10 |
Max. Negotiated Rate |
$7.09 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.87
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.43
|
Rate for Payer: Aetna Government |
$4.43
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.09
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.02
|
Rate for Payer: Group Health Inc Commercial |
$4.43
|
Rate for Payer: Group Health Inc Medicare |
$3.10
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.43
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$4.43
|
|
10% DEXTROSE 1000 CC
|
Facility
OP
|
$4.97
|
|
Hospital Charge Code |
40501200
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$1.74 |
Max. Negotiated Rate |
$3.98 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.73
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.48
|
Rate for Payer: Aetna Government |
$2.48
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.98
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.38
|
Rate for Payer: Group Health Inc Commercial |
$2.48
|
Rate for Payer: Group Health Inc Medicare |
$1.74
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.48
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$2.48
|
|
10H CURV PLT UP MALL CNDSD
|
Facility
IP
|
$366.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40209800
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$183.00 |
Max. Negotiated Rate |
$183.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$183.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$183.00
|
|
10H CURV PLT UP MALL CNDSD
|
Facility
OP
|
$366.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40209800
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$128.10 |
Max. Negotiated Rate |
$384.30 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$201.30
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
Rate for Payer: Aetna Government |
$134.20
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$183.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$210.45
|
Rate for Payer: Fidelis Medicare Advantage |
$384.30
|
Rate for Payer: Group Health Inc Commercial |
$183.00
|
Rate for Payer: Group Health Inc Medicare |
$128.10
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$183.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$183.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$237.90
|
|
10H CURV PLT UPPERFACE
|
Facility
OP
|
$2,036.00
|
|
Service Code
|
HCPCS C1781
|
Hospital Charge Code |
40209802
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$69.35 |
Max. Negotiated Rate |
$2,137.80 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,119.80
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$69.35
|
Rate for Payer: Aetna Government |
$69.35
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,018.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,170.70
|
Rate for Payer: Fidelis Medicare Advantage |
$2,137.80
|
Rate for Payer: Group Health Inc Commercial |
$1,018.00
|
Rate for Payer: Group Health Inc Medicare |
$712.60
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,018.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,323.40
|
|
10H CURV PLT UPPERFACE
|
Facility
IP
|
$2,036.00
|
|
Service Code
|
HCPCS C1781
|
Hospital Charge Code |
40209802
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,018.00 |
Max. Negotiated Rate |
$1,018.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,018.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.00
|
|
10% INVRT SURG IN WATER-1000CC
|
Facility
OP
|
$14.53
|
|
Hospital Charge Code |
40501500
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$5.09 |
Max. Negotiated Rate |
$11.62 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.99
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.26
|
Rate for Payer: Aetna Government |
$7.26
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.62
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.88
|
Rate for Payer: Group Health Inc Commercial |
$7.26
|
Rate for Payer: Group Health Inc Medicare |
$5.09
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.26
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$7.26
|
|
10X10 H 3D PLATE UPFC MALLEABLE
|
Facility
OP
|
$2,130.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200577
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$2,236.50 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,171.50
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
Rate for Payer: Aetna Government |
$134.20
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,065.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,224.75
|
Rate for Payer: Fidelis Medicare Advantage |
$2,236.50
|
Rate for Payer: Group Health Inc Commercial |
$1,065.00
|
Rate for Payer: Group Health Inc Medicare |
$745.50
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,065.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,065.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,384.50
|
|
10X10 H 3D PLATE UPFC MALLEABLE
|
Facility
IP
|
$2,130.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200577
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,065.00 |
Max. Negotiated Rate |
$1,065.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,065.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,065.00
|
|
10X10H 3D PLT UPPERFACE
|
Facility
OP
|
$450.00
|
|
Service Code
|
HCPCS C1781
|
Hospital Charge Code |
40209803
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$69.35 |
Max. Negotiated Rate |
$472.50 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$247.50
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$69.35
|
Rate for Payer: Aetna Government |
$69.35
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$225.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$258.75
|
Rate for Payer: Fidelis Medicare Advantage |
$472.50
|
Rate for Payer: Group Health Inc Commercial |
$225.00
|
Rate for Payer: Group Health Inc Medicare |
$157.50
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$225.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$225.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$292.50
|
|
10X10H 3D PLT UPPERFACE
|
Facility
IP
|
$450.00
|
|
Service Code
|
HCPCS C1781
|
Hospital Charge Code |
40209803
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$225.00 |
Max. Negotiated Rate |
$225.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$225.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$225.00
|
|
10X10H 3D PLT UPPER FC MALLBL
|
Facility
OP
|
$2,132.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40209807
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$2,238.60 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,172.60
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
Rate for Payer: Aetna Government |
$134.20
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,066.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,225.90
|
Rate for Payer: Fidelis Medicare Advantage |
$2,238.60
|
Rate for Payer: Group Health Inc Commercial |
$1,066.00
|
Rate for Payer: Group Health Inc Medicare |
$746.20
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,066.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,066.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,385.80
|
|
10X10H 3D PLT UPPER FC MALLBL
|
Facility
IP
|
$2,132.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40209807
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,066.00 |
Max. Negotiated Rate |
$1,066.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,066.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,066.00
|
|
10X35CM RIGIFLEX ACHALAS
|
Facility
OP
|
$1,656.00
|
|
Hospital Charge Code |
40203563
|
Hospital Revenue Code
|
272
|
Min. Negotiated Rate |
$579.60 |
Max. Negotiated Rate |
$1,324.80 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$910.80
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$828.00
|
Rate for Payer: Aetna Government |
$828.00
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,324.80
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,126.08
|
Rate for Payer: Group Health Inc Commercial |
$828.00
|
Rate for Payer: Group Health Inc Medicare |
$579.60
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$828.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$828.00
|
|
11MMX360MMX130
|
Facility
OP
|
$2,650.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40209808
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$2,782.50 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,457.50
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
Rate for Payer: Aetna Government |
$134.20
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,325.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,523.75
|
Rate for Payer: Fidelis Medicare Advantage |
$2,782.50
|
Rate for Payer: Group Health Inc Commercial |
$1,325.00
|
Rate for Payer: Group Health Inc Medicare |
$927.50
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,325.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,325.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,722.50
|
|
11MMX360MMX130
|
Facility
IP
|
$2,650.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40209808
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,325.00 |
Max. Negotiated Rate |
$1,325.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,325.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,325.00
|
|
1-1 NURSING SHIFT - CNA
|
Facility
OP
|
$467.78
|
|
Hospital Charge Code |
30011001
|
Hospital Revenue Code
|
239
|
Min. Negotiated Rate |
$163.72 |
Max. Negotiated Rate |
$374.22 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$257.28
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$233.89
|
Rate for Payer: Aetna Government |
$233.89
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$374.22
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$318.09
|
Rate for Payer: Group Health Inc Commercial |
$233.89
|
Rate for Payer: Group Health Inc Medicare |
$163.72
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$233.89
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$233.89
|
|
1-1 NURSING SHIFT - RN
|
Facility
OP
|
$467.78
|
|
Hospital Charge Code |
30011002
|
Hospital Revenue Code
|
239
|
Min. Negotiated Rate |
$163.72 |
Max. Negotiated Rate |
$374.22 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$257.28
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$233.89
|
Rate for Payer: Aetna Government |
$233.89
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$374.22
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$318.09
|
Rate for Payer: Group Health Inc Commercial |
$233.89
|
Rate for Payer: Group Health Inc Medicare |
$163.72
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$233.89
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$233.89
|
|
11X180MMX125DEG TROCHANTERIC NKIT
|
Facility
OP
|
$1,500.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200573
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$1,575.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$825.00
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
Rate for Payer: Aetna Government |
$134.20
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$750.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$862.50
|
Rate for Payer: Fidelis Medicare Advantage |
$1,575.00
|
Rate for Payer: Group Health Inc Commercial |
$750.00
|
Rate for Payer: Group Health Inc Medicare |
$525.00
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$750.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$750.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$975.00
|
|
11X180MMX125DEG TROCHANTERIC NKIT
|
Facility
IP
|
$1,500.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200573
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$750.00 |
Max. Negotiated Rate |
$750.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$750.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$750.00
|
|
11X300MM X 125 RIGHT
|
Facility
IP
|
$2,650.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200575
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,325.00 |
Max. Negotiated Rate |
$1,325.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,325.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,325.00
|
|