|
PREGABALIN 50 MG PO CAPS
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
NDC 0904699261
|
| Hospital Charge Code |
0904699261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.45
|
|
|
PREGABALIN 50 MG PO CAPS
|
Facility
|
OP
|
$8.43
|
|
|
Service Code
|
NDC 7220501290
|
| Hospital Charge Code |
7220501290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$6.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.63
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.21
|
| Rate for Payer: Aetna Government |
$4.21
|
| Rate for Payer: Brighton Health Commercial |
$6.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.73
|
| Rate for Payer: EmblemHealth Commercial |
$4.21
|
| Rate for Payer: Group Health Inc Commercial |
$4.21
|
| Rate for Payer: Group Health Inc Medicare |
$2.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.48
|
|
|
PREGABALIN 50 MG PO CAPS
|
Facility
|
IP
|
$8.43
|
|
|
Service Code
|
NDC 7220501290
|
| Hospital Charge Code |
7220501290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.21 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.21
|
|
|
PREGABALIN 75 MG PO CAPS
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 0904700061
|
| Hospital Charge Code |
0904700061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.46
|
|
|
PREGABALIN 75 MG PO CAPS
|
Facility
|
IP
|
$8.43
|
|
|
Service Code
|
NDC 7220501390
|
| Hospital Charge Code |
7220501390
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.21 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.21
|
|
|
PREGABALIN 75 MG PO CAPS
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 0904700061
|
| Hospital Charge Code |
0904700061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.46
|
| Rate for Payer: Aetna Government |
$0.46
|
| Rate for Payer: Brighton Health Commercial |
$0.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.63
|
| Rate for Payer: EmblemHealth Commercial |
$0.46
|
| Rate for Payer: Group Health Inc Commercial |
$0.46
|
| Rate for Payer: Group Health Inc Medicare |
$0.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.60
|
|
|
PREGABALIN 75 MG PO CAPS
|
Facility
|
OP
|
$8.43
|
|
|
Service Code
|
NDC 7220501390
|
| Hospital Charge Code |
7220501390
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$6.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.63
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.21
|
| Rate for Payer: Aetna Government |
$4.21
|
| Rate for Payer: Brighton Health Commercial |
$6.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.73
|
| Rate for Payer: EmblemHealth Commercial |
$4.21
|
| Rate for Payer: Group Health Inc Commercial |
$4.21
|
| Rate for Payer: Group Health Inc Medicare |
$2.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.48
|
|
|
PR EGD ABLATE TUMOR POLYP/LESION W/DILATION& WIRE
|
Professional
|
Both
|
$929.99
|
|
|
Service Code
|
HCPCS 43270
|
| Min. Negotiated Rate |
$176.48 |
| Max. Negotiated Rate |
$567.25 |
| Rate for Payer: Cash Price |
$252.94
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$252.11
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$226.90
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$226.90
|
| Rate for Payer: Fidelis Essential Plan QHP |
$239.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$252.11
|
| Rate for Payer: Fidelis Qualified Health Plan |
$239.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$252.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$252.11
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$189.08
|
| Rate for Payer: Healthfirst Commercial |
$252.11
|
| Rate for Payer: Healthfirst Essential Plan |
$567.25
|
| Rate for Payer: Healthfirst Medicare Advantage |
$239.50
|
| Rate for Payer: Healthfirst QHP |
$252.11
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$176.48
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$252.11
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$214.29
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$176.48
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$252.11
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$189.08
|
| Rate for Payer: SOMOS Essential |
$189.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$252.11
|
|
|
PR EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM
|
Professional
|
Both
|
$643.06
|
|
|
Service Code
|
HCPCS 43249
|
| Min. Negotiated Rate |
$120.94 |
| Max. Negotiated Rate |
$388.73 |
| Rate for Payer: Cash Price |
$174.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$172.77
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$155.49
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$155.49
|
| Rate for Payer: Fidelis Essential Plan QHP |
$164.13
|
| Rate for Payer: Fidelis Medicare Advantage |
$172.77
|
| Rate for Payer: Fidelis Qualified Health Plan |
$164.13
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$172.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$172.77
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$129.58
|
| Rate for Payer: Healthfirst Commercial |
$172.77
|
| Rate for Payer: Healthfirst Essential Plan |
$388.73
|
| Rate for Payer: Healthfirst Medicare Advantage |
$164.13
|
| Rate for Payer: Healthfirst QHP |
$172.77
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$120.94
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$172.77
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$146.85
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$120.94
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$172.77
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$129.58
|
| Rate for Payer: SOMOS Essential |
$129.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$172.77
|
|
|
PR EGD BAND LIGATION ESOPHGEAL/GASTRIC VARICES
|
Professional
|
Both
|
$1,015.63
|
|
|
Service Code
|
HCPCS 43244
|
| Min. Negotiated Rate |
$191.21 |
| Max. Negotiated Rate |
$614.59 |
| Rate for Payer: Cash Price |
$276.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$273.15
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$245.84
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$245.84
|
| Rate for Payer: Fidelis Essential Plan QHP |
$259.49
|
| Rate for Payer: Fidelis Medicare Advantage |
$273.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$259.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$273.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$273.15
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$204.86
|
| Rate for Payer: Healthfirst Commercial |
$273.15
|
| Rate for Payer: Healthfirst Essential Plan |
$614.59
|
| Rate for Payer: Healthfirst Medicare Advantage |
$259.49
|
| Rate for Payer: Healthfirst QHP |
$273.15
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$191.21
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$273.15
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$232.18
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$191.21
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$273.15
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$204.86
|
| Rate for Payer: SOMOS Essential |
$204.86
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$273.15
|
|
|
PR EGD DELIVER THERMAL ENERGY SPHNCTR/CARDIA GERD
|
Professional
|
Both
|
$973.60
|
|
|
Service Code
|
HCPCS 43257
|
| Min. Negotiated Rate |
$182.03 |
| Max. Negotiated Rate |
$585.09 |
| Rate for Payer: Cash Price |
$267.37
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$260.04
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$234.04
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$234.04
|
| Rate for Payer: Fidelis Essential Plan QHP |
$247.04
|
| Rate for Payer: Fidelis Medicare Advantage |
$260.04
|
| Rate for Payer: Fidelis Qualified Health Plan |
$247.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$260.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$260.04
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$195.03
|
| Rate for Payer: Healthfirst Commercial |
$260.04
|
| Rate for Payer: Healthfirst Essential Plan |
$585.09
|
| Rate for Payer: Healthfirst Medicare Advantage |
$247.04
|
| Rate for Payer: Healthfirst QHP |
$260.04
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$182.03
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$260.04
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$221.03
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$182.03
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$260.04
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$195.03
|
| Rate for Payer: SOMOS Essential |
$195.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$260.04
|
|
|
PR EGD DILATION GASTRIC/DUODENAL STRICTURE
|
Professional
|
Both
|
$740.60
|
|
|
Service Code
|
HCPCS 43245
|
| Min. Negotiated Rate |
$140.53 |
| Max. Negotiated Rate |
$451.69 |
| Rate for Payer: Cash Price |
$200.56
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$200.75
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$180.68
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$180.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$190.71
|
| Rate for Payer: Fidelis Medicare Advantage |
$200.75
|
| Rate for Payer: Fidelis Qualified Health Plan |
$190.71
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$200.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$200.75
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$150.56
|
| Rate for Payer: Healthfirst Commercial |
$200.75
|
| Rate for Payer: Healthfirst Essential Plan |
$451.69
|
| Rate for Payer: Healthfirst Medicare Advantage |
$190.71
|
| Rate for Payer: Healthfirst QHP |
$200.75
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$140.53
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$200.75
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$170.64
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$140.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$200.75
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$150.56
|
| Rate for Payer: SOMOS Essential |
$150.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$200.75
|
|
|
PR EGD ENDOSCOPIC STENT PLACEMENT W/WIRE& DILATION
|
Professional
|
Both
|
$910.84
|
|
|
Service Code
|
HCPCS 43266
|
| Min. Negotiated Rate |
$171.37 |
| Max. Negotiated Rate |
$550.85 |
| Rate for Payer: Cash Price |
$247.04
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$244.82
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$220.34
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$220.34
|
| Rate for Payer: Fidelis Essential Plan QHP |
$232.58
|
| Rate for Payer: Fidelis Medicare Advantage |
$244.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$232.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$244.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$244.82
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$183.62
|
| Rate for Payer: Healthfirst Commercial |
$244.82
|
| Rate for Payer: Healthfirst Essential Plan |
$550.85
|
| Rate for Payer: Healthfirst Medicare Advantage |
$232.58
|
| Rate for Payer: Healthfirst QHP |
$244.82
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$171.37
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$244.82
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$208.10
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$171.37
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$244.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$183.62
|
| Rate for Payer: SOMOS Essential |
$183.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$244.82
|
|
|
PR EGD ESOPHAGUS BALLOON DILATION 30 MM OR LARGER
|
Professional
|
Both
|
$965.90
|
|
|
Service Code
|
HCPCS 43233
|
| Min. Negotiated Rate |
$182.36 |
| Max. Negotiated Rate |
$586.15 |
| Rate for Payer: Cash Price |
$262.69
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$260.51
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$234.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$234.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$247.48
|
| Rate for Payer: Fidelis Medicare Advantage |
$260.51
|
| Rate for Payer: Fidelis Qualified Health Plan |
$247.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$260.51
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$260.51
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$195.38
|
| Rate for Payer: Healthfirst Commercial |
$260.51
|
| Rate for Payer: Healthfirst Essential Plan |
$586.15
|
| Rate for Payer: Healthfirst Medicare Advantage |
$247.48
|
| Rate for Payer: Healthfirst QHP |
$260.51
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$182.36
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$260.51
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$221.43
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$182.36
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$260.51
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$195.38
|
| Rate for Payer: SOMOS Essential |
$195.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$260.51
|
|
|
PR EGD FLEXIBLE FOREIGN BODY REMOVAL
|
Professional
|
Both
|
$740.46
|
|
|
Service Code
|
HCPCS 43247
|
| Min. Negotiated Rate |
$139.04 |
| Max. Negotiated Rate |
$446.92 |
| Rate for Payer: Cash Price |
$200.67
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$198.63
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$178.77
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$178.77
|
| Rate for Payer: Fidelis Essential Plan QHP |
$188.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$198.63
|
| Rate for Payer: Fidelis Qualified Health Plan |
$188.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$198.63
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$198.63
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$148.97
|
| Rate for Payer: Healthfirst Commercial |
$198.63
|
| Rate for Payer: Healthfirst Essential Plan |
$446.92
|
| Rate for Payer: Healthfirst Medicare Advantage |
$188.70
|
| Rate for Payer: Healthfirst QHP |
$198.63
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$139.04
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$198.63
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$168.84
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$139.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$198.63
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$148.97
|
| Rate for Payer: SOMOS Essential |
$148.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$198.63
|
|
|
PR EGD FLEX REMOVAL LESION(S) BY HOT BIOPSY FORCEPS
|
Professional
|
Both
|
$719.64
|
|
|
Service Code
|
HCPCS 43250
|
| Min. Negotiated Rate |
$135.49 |
| Max. Negotiated Rate |
$435.51 |
| Rate for Payer: Cash Price |
$194.53
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$193.56
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$174.20
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$174.20
|
| Rate for Payer: Fidelis Essential Plan QHP |
$183.88
|
| Rate for Payer: Fidelis Medicare Advantage |
$193.56
|
| Rate for Payer: Fidelis Qualified Health Plan |
$183.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$193.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$193.56
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$145.17
|
| Rate for Payer: Healthfirst Commercial |
$193.56
|
| Rate for Payer: Healthfirst Essential Plan |
$435.51
|
| Rate for Payer: Healthfirst Medicare Advantage |
$183.88
|
| Rate for Payer: Healthfirst QHP |
$193.56
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$135.49
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$193.56
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$164.53
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$135.49
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$193.56
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$145.17
|
| Rate for Payer: SOMOS Essential |
$145.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$193.56
|
|
|
PR EGD FLEX TRANSORAL W/OPTICAL ENDOMICROSCOPY
|
Professional
|
Both
|
$699.37
|
|
|
Service Code
|
HCPCS 43252
|
| Min. Negotiated Rate |
$132.06 |
| Max. Negotiated Rate |
$424.49 |
| Rate for Payer: Cash Price |
$190.58
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$188.66
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$169.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$169.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$179.23
|
| Rate for Payer: Fidelis Medicare Advantage |
$188.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$179.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$188.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$188.66
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$141.50
|
| Rate for Payer: Healthfirst Commercial |
$188.66
|
| Rate for Payer: Healthfirst Essential Plan |
$424.49
|
| Rate for Payer: Healthfirst Medicare Advantage |
$179.23
|
| Rate for Payer: Healthfirst QHP |
$188.66
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$132.06
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$188.66
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$160.36
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$132.06
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$188.66
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$141.50
|
| Rate for Payer: SOMOS Essential |
$141.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$188.66
|
|
|
PR EGD FLX TRNSORL W/DPLMNT NTRGSTR BARIATRIC BALO
|
Professional
|
Both
|
$798.53
|
|
|
Service Code
|
HCPCS 43290
|
| Min. Negotiated Rate |
$143.14 |
| Max. Negotiated Rate |
$460.10 |
| Rate for Payer: Cash Price |
$213.71
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$204.49
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$184.04
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$184.04
|
| Rate for Payer: Fidelis Essential Plan QHP |
$194.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$204.49
|
| Rate for Payer: Fidelis Qualified Health Plan |
$194.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$204.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$204.49
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$153.37
|
| Rate for Payer: Healthfirst Commercial |
$204.49
|
| Rate for Payer: Healthfirst Essential Plan |
$460.10
|
| Rate for Payer: Healthfirst Medicare Advantage |
$194.27
|
| Rate for Payer: Healthfirst QHP |
$204.49
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$143.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$204.49
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$173.82
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$143.14
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$204.49
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$153.37
|
| Rate for Payer: SOMOS Essential |
$153.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$204.49
|
|
|
PR EGD FLX TRNSORL W/RMVL NTRGSTR BARIATRIC BALO
|
Professional
|
Both
|
$672.00
|
|
|
Service Code
|
HCPCS 43291
|
| Min. Negotiated Rate |
$127.87 |
| Max. Negotiated Rate |
$411.01 |
| Rate for Payer: Cash Price |
$182.49
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$182.67
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$164.40
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$164.40
|
| Rate for Payer: Fidelis Essential Plan QHP |
$173.54
|
| Rate for Payer: Fidelis Medicare Advantage |
$182.67
|
| Rate for Payer: Fidelis Qualified Health Plan |
$173.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$182.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$182.67
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$137.00
|
| Rate for Payer: Healthfirst Commercial |
$182.67
|
| Rate for Payer: Healthfirst Essential Plan |
$411.01
|
| Rate for Payer: Healthfirst Medicare Advantage |
$173.54
|
| Rate for Payer: Healthfirst QHP |
$182.67
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$127.87
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$182.67
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$155.27
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$127.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$182.67
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$137.00
|
| Rate for Payer: SOMOS Essential |
$137.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$182.67
|
|
|
PR EGD INJECTION SCLEROSIS ESOPHGL/GASTRIC VARICES
|
Professional
|
Both
|
$991.62
|
|
|
Service Code
|
HCPCS 43243
|
| Min. Negotiated Rate |
$187.73 |
| Max. Negotiated Rate |
$603.43 |
| Rate for Payer: Cash Price |
$269.84
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$268.19
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$241.37
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$241.37
|
| Rate for Payer: Fidelis Essential Plan QHP |
$254.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$268.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$254.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$268.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$268.19
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$201.14
|
| Rate for Payer: Healthfirst Commercial |
$268.19
|
| Rate for Payer: Healthfirst Essential Plan |
$603.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$254.78
|
| Rate for Payer: Healthfirst QHP |
$268.19
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$187.73
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$268.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$227.96
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$187.73
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$268.19
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$201.14
|
| Rate for Payer: SOMOS Essential |
$201.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$268.19
|
|
|
PR EGD INSERT GUIDE WIRE DILATOR PASSAGE ESOPHAGUS
|
Professional
|
Both
|
$691.67
|
|
|
Service Code
|
HCPCS 43248
|
| Min. Negotiated Rate |
$130.59 |
| Max. Negotiated Rate |
$419.74 |
| Rate for Payer: Cash Price |
$188.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$186.55
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$167.90
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$167.90
|
| Rate for Payer: Fidelis Essential Plan QHP |
$177.22
|
| Rate for Payer: Fidelis Medicare Advantage |
$186.55
|
| Rate for Payer: Fidelis Qualified Health Plan |
$177.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$186.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$186.55
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$139.91
|
| Rate for Payer: Healthfirst Commercial |
$186.55
|
| Rate for Payer: Healthfirst Essential Plan |
$419.74
|
| Rate for Payer: Healthfirst Medicare Advantage |
$177.22
|
| Rate for Payer: Healthfirst QHP |
$186.55
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$130.59
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$186.55
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$158.57
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$130.59
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$186.55
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$139.91
|
| Rate for Payer: SOMOS Essential |
$139.91
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$186.55
|
|
|
PR EGD INTRALUMINAL TUBE/CATHETER INSERTION
|
Professional
|
Both
|
$590.91
|
|
|
Service Code
|
HCPCS 43241
|
| Min. Negotiated Rate |
$112.64 |
| Max. Negotiated Rate |
$362.05 |
| Rate for Payer: Cash Price |
$162.10
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$160.91
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$144.82
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$144.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$152.86
|
| Rate for Payer: Fidelis Medicare Advantage |
$160.91
|
| Rate for Payer: Fidelis Qualified Health Plan |
$152.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$160.91
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$160.91
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$120.68
|
| Rate for Payer: Healthfirst Commercial |
$160.91
|
| Rate for Payer: Healthfirst Essential Plan |
$362.05
|
| Rate for Payer: Healthfirst Medicare Advantage |
$152.86
|
| Rate for Payer: Healthfirst QHP |
$160.91
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$112.64
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$160.91
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$136.77
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$112.64
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$160.91
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$120.68
|
| Rate for Payer: SOMOS Essential |
$120.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$160.91
|
|
|
PR EGD INTRMURAL NEEDLE ASPIR/BIOP ALTERED ANATOMY
|
Professional
|
Both
|
$1,092.21
|
|
|
Service Code
|
HCPCS 43242
|
| Min. Negotiated Rate |
$204.97 |
| Max. Negotiated Rate |
$658.85 |
| Rate for Payer: Cash Price |
$296.02
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$292.82
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$263.54
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$263.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$278.18
|
| Rate for Payer: Fidelis Medicare Advantage |
$292.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$278.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$292.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$292.82
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$219.62
|
| Rate for Payer: Healthfirst Commercial |
$292.82
|
| Rate for Payer: Healthfirst Essential Plan |
$658.85
|
| Rate for Payer: Healthfirst Medicare Advantage |
$278.18
|
| Rate for Payer: Healthfirst QHP |
$292.82
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$204.97
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$292.82
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$248.90
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$204.97
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$292.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$219.62
|
| Rate for Payer: SOMOS Essential |
$219.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$292.82
|
|
|
PR EGD INTRMURAL US NEEDLE ASPIRATE/BIOPSY ESOPHAGS
|
Professional
|
Both
|
$961.56
|
|
|
Service Code
|
HCPCS 43238
|
| Min. Negotiated Rate |
$182.27 |
| Max. Negotiated Rate |
$585.88 |
| Rate for Payer: Cash Price |
$261.55
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$260.39
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$234.35
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$234.35
|
| Rate for Payer: Fidelis Essential Plan QHP |
$247.37
|
| Rate for Payer: Fidelis Medicare Advantage |
$260.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$247.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$260.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$260.39
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$195.29
|
| Rate for Payer: Healthfirst Commercial |
$260.39
|
| Rate for Payer: Healthfirst Essential Plan |
$585.88
|
| Rate for Payer: Healthfirst Medicare Advantage |
$247.37
|
| Rate for Payer: Healthfirst QHP |
$260.39
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$182.27
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$260.39
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$221.33
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$182.27
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$260.39
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$195.29
|
| Rate for Payer: SOMOS Essential |
$195.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$260.39
|
|
|
PR EGD PARTIAL/COMPL ESOPHAGOGASTRIC FUNDOPLASTY
|
Professional
|
Both
|
$1,847.90
|
|
|
Service Code
|
HCPCS 43210
|
| Min. Negotiated Rate |
$343.57 |
| Max. Negotiated Rate |
$1,104.32 |
| Rate for Payer: Cash Price |
$496.05
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$490.81
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$441.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$441.73
|
| Rate for Payer: Fidelis Essential Plan QHP |
$466.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$490.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$466.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$490.81
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$490.81
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$368.11
|
| Rate for Payer: Healthfirst Commercial |
$490.81
|
| Rate for Payer: Healthfirst Essential Plan |
$1,104.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$466.27
|
| Rate for Payer: Healthfirst QHP |
$490.81
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$343.57
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$490.81
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$417.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$343.57
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$490.81
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$368.11
|
| Rate for Payer: SOMOS Essential |
$368.11
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$490.81
|
|
