|
LATANOPROST 0.005% OPHTHALMIC SOLN 2.5 M
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
41640658
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.00
|
| Rate for Payer: Aetna Government |
$3.00
|
| Rate for Payer: Brighton Health Commercial |
$4.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.08
|
| Rate for Payer: Group Health Inc Commercial |
$3.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.90
|
|
|
LATANOPROST 0.005 % OP SOLN [18621]
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
NDC 61314054701
|
| Hospital Charge Code |
61314054701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.00
|
| Rate for Payer: Aetna Government |
$19.00
|
| Rate for Payer: Brighton Health Commercial |
$28.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$30.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$25.84
|
| Rate for Payer: Group Health Inc Commercial |
$19.00
|
| Rate for Payer: Group Health Inc Medicare |
$13.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.70
|
|
|
LATANOPROST 0.005 % OP SOLN [18621]
|
Facility
|
OP
|
$126.86
|
|
|
Service Code
|
NDC 00013830304
|
| Hospital Charge Code |
00013830304
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.40 |
| Max. Negotiated Rate |
$101.49 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$69.77
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$63.43
|
| Rate for Payer: Aetna Government |
$63.43
|
| Rate for Payer: Brighton Health Commercial |
$95.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$101.49
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$86.26
|
| Rate for Payer: Group Health Inc Commercial |
$63.43
|
| Rate for Payer: Group Health Inc Medicare |
$44.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$63.43
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$63.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$82.46
|
|
|
LATANOPROST 0.005 % OP SOLN [18621]
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
NDC 70069042101
|
| Hospital Charge Code |
70069042101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.00
|
| Rate for Payer: Aetna Government |
$19.00
|
| Rate for Payer: Brighton Health Commercial |
$28.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$30.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$25.84
|
| Rate for Payer: Group Health Inc Commercial |
$19.00
|
| Rate for Payer: Group Health Inc Medicare |
$13.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.70
|
|
|
LATANOPROST 0.005 % OP SOLN [18621]
|
Facility
|
OP
|
$38.11
|
|
|
Service Code
|
NDC 59762033302
|
| Hospital Charge Code |
59762033302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.34 |
| Max. Negotiated Rate |
$30.49 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.05
|
| Rate for Payer: Aetna Government |
$19.05
|
| Rate for Payer: Brighton Health Commercial |
$28.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$30.49
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$25.91
|
| Rate for Payer: Group Health Inc Commercial |
$19.05
|
| Rate for Payer: Group Health Inc Medicare |
$13.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.77
|
|
|
LATANOPROST 0.005 % OP SOLN [18621]
|
Facility
|
OP
|
$9.75
|
|
|
Service Code
|
NDC 24208046325
|
| Hospital Charge Code |
24208046325
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$7.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.36
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.88
|
| Rate for Payer: Aetna Government |
$4.88
|
| Rate for Payer: Brighton Health Commercial |
$7.31
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.63
|
| Rate for Payer: Group Health Inc Commercial |
$4.88
|
| Rate for Payer: Group Health Inc Medicare |
$3.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.88
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.34
|
|
|
LATANOPROST 0.005 % OP SOLN [18621]
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
NDC 64980051625
|
| Hospital Charge Code |
64980051625
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.00
|
| Rate for Payer: Aetna Government |
$19.00
|
| Rate for Payer: Brighton Health Commercial |
$28.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$30.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$25.84
|
| Rate for Payer: Group Health Inc Commercial |
$19.00
|
| Rate for Payer: Group Health Inc Medicare |
$13.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.70
|
|
|
LATANOPROST 0.005 % OP SOLN [18621]
|
Facility
|
OP
|
$3.64
|
|
|
Service Code
|
NDC 70069042103
|
| Hospital Charge Code |
70069042103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.82
|
| Rate for Payer: Aetna Government |
$1.82
|
| Rate for Payer: Brighton Health Commercial |
$2.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.91
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.47
|
| Rate for Payer: Group Health Inc Commercial |
$1.82
|
| Rate for Payer: Group Health Inc Medicare |
$1.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.36
|
|
|
LATERAL CANTHOPEXY
|
Facility
|
OP
|
$7,933.18
|
|
|
Service Code
|
HCPCS 21282
|
| Hospital Charge Code |
40024142
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,409.00 |
| Max. Negotiated Rate |
$5,949.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,880.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,723.23
|
| Rate for Payer: Aetna Government |
$3,723.23
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,606.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,606.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,606.26
|
| Rate for Payer: Brighton Health Commercial |
$5,949.88
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,723.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$3,723.23
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,164.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,313.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,723.23
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,313.67
|
| Rate for Payer: Group Health Inc Commercial |
$3,723.23
|
| Rate for Payer: Group Health Inc Medicare |
$3,723.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,966.59
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,723.23
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,164.75
|
| Rate for Payer: Healthfirst QHP |
$3,723.23
|
| Rate for Payer: Humana Medicare |
$3,797.69
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,723.23
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,723.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,723.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,978.58
|
| Rate for Payer: Wellcare Medicare |
$3,537.07
|
|
|
LATERAL CANTHOPEXY
|
Facility
|
IP
|
$7,933.18
|
|
|
Service Code
|
HCPCS 21282
|
| Hospital Charge Code |
40024142
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$3,723.23
|
|
|
LAVAGE TRAY
|
Facility
|
OP
|
$45.36
|
|
| Hospital Charge Code |
40203610
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.88 |
| Max. Negotiated Rate |
$36.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$24.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$22.68
|
| Rate for Payer: Aetna Government |
$22.68
|
| Rate for Payer: Brighton Health Commercial |
$34.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$36.29
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$30.84
|
| Rate for Payer: Group Health Inc Commercial |
$22.68
|
| Rate for Payer: Group Health Inc Medicare |
$15.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$22.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$22.68
|
|
|
LAYER CLOS OF WOUND 2.6-7.5CM
|
Facility
|
IP
|
$934.02
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
30306414
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
LAYER CLOS OF WOUND 2.6-7.5CM
|
Facility
|
OP
|
$934.02
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
30306414
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$461.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$467.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$391.95
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$461.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
LAYER CLOS. OF WOUND 2.6 TO 7.5CM
|
Facility
|
OP
|
$934.02
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
30101155
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$461.12
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$461.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$467.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$461.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
LAYER CLOS. OF WOUND 2.6 TO 7.5CM
|
Facility
|
IP
|
$934.02
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
30101155
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
LAYER CLOS.OF WOUND 2.6 TO 7.5CM
|
Facility
|
OP
|
$934.02
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
30103021
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$461.12
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$461.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$467.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$461.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
LAYER CLOS.OF WOUND 2.6 TO 7.5CM
|
Facility
|
IP
|
$934.02
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
30103021
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
LAYER CLOSURE OF WOUND
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 12051
|
| Hospital Charge Code |
30300104
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$461.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$391.95
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$461.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
LAYER CLOSURE OF WOUND
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 12051
|
| Hospital Charge Code |
30103022
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
LAYER CLOSURE OF WOUND
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 12051
|
| Hospital Charge Code |
30301040
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
LAYER CLOSURE OF WOUND
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 12051
|
| Hospital Charge Code |
30103022
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$461.12
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$461.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$461.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
LAYER CLOSURE OF WOUND
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 12051
|
| Hospital Charge Code |
30301040
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$461.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$391.95
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$461.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
LAYER CLOSURE OF WOUND
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 12051
|
| Hospital Charge Code |
30300104
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
LAYER CLOSURE OF WOUND 5.1- 7.5CM
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
30305074
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$461.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$391.95
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$461.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
LAYER CLOSURE OF WOUND 5.1- 7.5CM
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
30101138
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$461.12
|
|
