|
PR IM ADM THRU 18YR ANY RTE ADDL VAC/TOX COMPT
|
Professional
|
Both
|
$41.09
|
|
|
Service Code
|
HCPCS 90461
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$21.46 |
| Rate for Payer: Cash Price |
$9.65
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$9.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$8.59
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$8.59
|
| Rate for Payer: Fidelis Essential Plan QHP |
$9.06
|
| Rate for Payer: Fidelis Medicare Advantage |
$9.54
|
| Rate for Payer: Fidelis Qualified Health Plan |
$9.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.54
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$7.16
|
| Rate for Payer: Healthfirst Commercial |
$9.54
|
| Rate for Payer: Healthfirst Essential Plan |
$21.46
|
| Rate for Payer: Healthfirst Medicare Advantage |
$9.06
|
| Rate for Payer: Healthfirst QHP |
$9.54
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$6.68
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$9.54
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$8.11
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$6.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$9.54
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$7.16
|
| Rate for Payer: SOMOS Essential |
$7.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.54
|
|
|
PR IMAGE FLUID COLLXN DRAINAG CATH TRANSREC/VAGINAL
|
Professional
|
Both
|
$843.89
|
|
|
Service Code
|
HCPCS 49407
|
| Min. Negotiated Rate |
$159.82 |
| Max. Negotiated Rate |
$513.72 |
| Rate for Payer: Cash Price |
$228.54
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$228.32
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$205.49
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$205.49
|
| Rate for Payer: Fidelis Essential Plan QHP |
$216.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$228.32
|
| Rate for Payer: Fidelis Qualified Health Plan |
$216.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$228.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$228.32
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$171.24
|
| Rate for Payer: Healthfirst Commercial |
$228.32
|
| Rate for Payer: Healthfirst Essential Plan |
$513.72
|
| Rate for Payer: Healthfirst Medicare Advantage |
$216.90
|
| Rate for Payer: Healthfirst QHP |
$228.32
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$159.82
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$228.32
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$194.07
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$159.82
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$228.32
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$171.24
|
| Rate for Payer: SOMOS Essential |
$171.24
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$228.32
|
|
|
PR IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ
|
Professional
|
Both
|
$791.84
|
|
|
Service Code
|
HCPCS 49405
|
| Min. Negotiated Rate |
$149.63 |
| Max. Negotiated Rate |
$480.96 |
| Rate for Payer: Cash Price |
$214.42
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$213.76
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$192.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$192.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$203.07
|
| Rate for Payer: Fidelis Medicare Advantage |
$213.76
|
| Rate for Payer: Fidelis Qualified Health Plan |
$203.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$213.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$213.76
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$160.32
|
| Rate for Payer: Healthfirst Commercial |
$213.76
|
| Rate for Payer: Healthfirst Essential Plan |
$480.96
|
| Rate for Payer: Healthfirst Medicare Advantage |
$203.07
|
| Rate for Payer: Healthfirst QHP |
$213.76
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$149.63
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$213.76
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$181.70
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$149.63
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$213.76
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$160.32
|
| Rate for Payer: SOMOS Essential |
$160.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$213.76
|
|
|
PRIMAQUINE PHOSPHATE 26.3 (15 BASE) MG PO TABS
|
Facility
|
OP
|
$2.46
|
|
|
Service Code
|
NDC 0024159601
|
| Hospital Charge Code |
0024159601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.23
|
| Rate for Payer: Aetna Government |
$1.23
|
| Rate for Payer: Brighton Health Commercial |
$1.84
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.67
|
| Rate for Payer: EmblemHealth Commercial |
$1.23
|
| Rate for Payer: Group Health Inc Commercial |
$1.23
|
| Rate for Payer: Group Health Inc Medicare |
$0.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.23
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.60
|
|
|
PRIMAQUINE PHOSPHATE 26.3 (15 BASE) MG PO TABS
|
Facility
|
IP
|
$2.46
|
|
|
Service Code
|
NDC 0024159601
|
| Hospital Charge Code |
0024159601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.23
|
|
|
PR IMBRICATION DIAPHRAGM EVENTRATION
|
Professional
|
Both
|
$3,994.06
|
|
|
Service Code
|
HCPCS 39545
|
| Min. Negotiated Rate |
$741.69 |
| Max. Negotiated Rate |
$2,384.01 |
| Rate for Payer: Cash Price |
$1,066.91
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,059.56
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$953.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$953.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,006.58
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,059.56
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,006.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,059.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,059.56
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$794.67
|
| Rate for Payer: Healthfirst Commercial |
$1,059.56
|
| Rate for Payer: Healthfirst Essential Plan |
$2,384.01
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,006.58
|
| Rate for Payer: Healthfirst QHP |
$1,059.56
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$741.69
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,059.56
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$900.63
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$741.69
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,059.56
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$794.67
|
| Rate for Payer: SOMOS Essential |
$794.67
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,059.56
|
|
|
PR IMG-GUIDED FLU COLLJ DRG CATH SOFT TISS PERQ
|
Professional
|
Both
|
$558.92
|
|
|
Service Code
|
HCPCS 10030
|
| Min. Negotiated Rate |
$104.68 |
| Max. Negotiated Rate |
$336.46 |
| Rate for Payer: Cash Price |
$151.05
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$149.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$134.59
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$134.59
|
| Rate for Payer: Fidelis Essential Plan QHP |
$142.06
|
| Rate for Payer: Fidelis Medicare Advantage |
$149.54
|
| Rate for Payer: Fidelis Qualified Health Plan |
$142.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$149.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$149.54
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$112.16
|
| Rate for Payer: Healthfirst Commercial |
$149.54
|
| Rate for Payer: Healthfirst Essential Plan |
$336.46
|
| Rate for Payer: Healthfirst Medicare Advantage |
$142.06
|
| Rate for Payer: Healthfirst QHP |
$149.54
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$104.68
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$149.54
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$127.11
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$104.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$149.54
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$112.16
|
| Rate for Payer: SOMOS Essential |
$112.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$149.54
|
|
|
PR IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ
|
Professional
|
Both
|
$791.84
|
|
|
Service Code
|
HCPCS 49406
|
| Min. Negotiated Rate |
$149.36 |
| Max. Negotiated Rate |
$480.08 |
| Rate for Payer: Cash Price |
$214.42
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$213.37
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$192.03
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$192.03
|
| Rate for Payer: Fidelis Essential Plan QHP |
$202.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$213.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$202.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$213.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$213.37
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$160.03
|
| Rate for Payer: Healthfirst Commercial |
$213.37
|
| Rate for Payer: Healthfirst Essential Plan |
$480.08
|
| Rate for Payer: Healthfirst Medicare Advantage |
$202.70
|
| Rate for Payer: Healthfirst QHP |
$213.37
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$149.36
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$213.37
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$181.36
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$149.36
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$213.37
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$160.03
|
| Rate for Payer: SOMOS Essential |
$160.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$213.37
|
|
|
PR IMG RETINA DETCJ/MNTR DS POC AUTON A/R UNI/BI
|
Professional
|
Both
|
$195.37
|
|
|
Service Code
|
HCPCS 92229
|
| Min. Negotiated Rate |
$36.84 |
| Max. Negotiated Rate |
$118.42 |
| Rate for Payer: Cash Price |
$48.56
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$52.63
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$47.37
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$47.37
|
| Rate for Payer: Fidelis Essential Plan QHP |
$50.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$52.63
|
| Rate for Payer: Fidelis Qualified Health Plan |
$50.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$52.63
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$52.63
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$39.47
|
| Rate for Payer: Healthfirst Commercial |
$52.63
|
| Rate for Payer: Healthfirst Essential Plan |
$118.42
|
| Rate for Payer: Healthfirst Medicare Advantage |
$50.00
|
| Rate for Payer: Healthfirst QHP |
$52.63
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$36.84
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$52.63
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$44.74
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$36.84
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$52.63
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$39.47
|
| Rate for Payer: SOMOS Essential |
$39.47
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$52.63
|
|
|
PR IMG RETINA DETCJ/MNTR DS REM CLIN STAFF UNI/BI
|
Professional
|
Both
|
$73.19
|
|
|
Service Code
|
HCPCS 92227
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$46.80 |
| Rate for Payer: Cash Price |
$21.06
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$20.80
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$18.72
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$18.72
|
| Rate for Payer: Fidelis Essential Plan QHP |
$19.76
|
| Rate for Payer: Fidelis Medicare Advantage |
$20.80
|
| Rate for Payer: Fidelis Qualified Health Plan |
$19.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.80
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$15.60
|
| Rate for Payer: Healthfirst Commercial |
$20.80
|
| Rate for Payer: Healthfirst Essential Plan |
$46.80
|
| Rate for Payer: Healthfirst Medicare Advantage |
$19.76
|
| Rate for Payer: Healthfirst QHP |
$20.80
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$14.56
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$20.80
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$17.68
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$14.56
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$20.80
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$15.60
|
| Rate for Payer: SOMOS Essential |
$15.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$20.80
|
|
|
PR IMG RETINA DETCJ/MNTR DS REM PHYS/QHP I&R UNI/BI
|
Professional
|
Both
|
$121.73
|
|
|
Service Code
|
HCPCS 92228
|
| Min. Negotiated Rate |
$23.53 |
| Max. Negotiated Rate |
$75.62 |
| Rate for Payer: Cash Price |
$34.02
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$33.61
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$30.25
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$30.25
|
| Rate for Payer: Fidelis Essential Plan QHP |
$31.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$33.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$31.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$33.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$33.61
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$25.21
|
| Rate for Payer: Healthfirst Commercial |
$33.61
|
| Rate for Payer: Healthfirst Essential Plan |
$75.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$31.93
|
| Rate for Payer: Healthfirst QHP |
$33.61
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$23.53
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$33.61
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$28.57
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$23.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$33.61
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$25.21
|
| Rate for Payer: SOMOS Essential |
$25.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$33.61
|
|
|
PR IMG RETINA DETCJ/MNTR DS REM PHYS/QHP I&R UNI/BI
|
Professional
|
Both
|
$55.93
|
|
|
Service Code
|
HCPCS 92228 TC
|
| Min. Negotiated Rate |
$11.03 |
| Max. Negotiated Rate |
$35.46 |
| Rate for Payer: Cash Price |
$15.95
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$15.76
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$14.18
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$14.18
|
| Rate for Payer: Fidelis Essential Plan QHP |
$14.97
|
| Rate for Payer: Fidelis Medicare Advantage |
$15.76
|
| Rate for Payer: Fidelis Qualified Health Plan |
$14.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.76
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$11.82
|
| Rate for Payer: Healthfirst Commercial |
$15.76
|
| Rate for Payer: Healthfirst Essential Plan |
$35.46
|
| Rate for Payer: Healthfirst Medicare Advantage |
$14.97
|
| Rate for Payer: Healthfirst QHP |
$15.76
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$11.03
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$15.76
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$13.40
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$11.03
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$15.76
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$11.82
|
| Rate for Payer: SOMOS Essential |
$11.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.76
|
|
|
PR IMG RETINA DETCJ/MNTR DS REM PHYS/QHP I&R UNI/BI
|
Professional
|
Both
|
$65.80
|
|
|
Service Code
|
HCPCS 92228 26
|
| Min. Negotiated Rate |
$12.49 |
| Max. Negotiated Rate |
$40.16 |
| Rate for Payer: Cash Price |
$18.07
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$17.85
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$16.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.96
|
| Rate for Payer: Fidelis Medicare Advantage |
$17.85
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.85
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$13.39
|
| Rate for Payer: Healthfirst Commercial |
$17.85
|
| Rate for Payer: Healthfirst Essential Plan |
$40.16
|
| Rate for Payer: Healthfirst Medicare Advantage |
$16.96
|
| Rate for Payer: Healthfirst QHP |
$17.85
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$12.49
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$17.85
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$15.17
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$12.49
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$17.85
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$13.39
|
| Rate for Payer: SOMOS Essential |
$13.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$17.85
|
|
|
PRIMIDONE 250 MG PO TABS
|
Facility
|
OP
|
$1.05
|
|
|
Service Code
|
NDC 6808420301
|
| Hospital Charge Code |
6808420301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.52
|
| Rate for Payer: Aetna Government |
$0.52
|
| Rate for Payer: Brighton Health Commercial |
$0.79
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.71
|
| Rate for Payer: EmblemHealth Commercial |
$0.52
|
| Rate for Payer: Group Health Inc Commercial |
$0.52
|
| Rate for Payer: Group Health Inc Medicare |
$0.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.68
|
|
|
PRIMIDONE 250 MG PO TABS
|
Facility
|
IP
|
$1.05
|
|
|
Service Code
|
NDC 6808420301
|
| Hospital Charge Code |
6808420301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.52
|
|
|
PRIMIDONE 50 MG PO TABS
|
Facility
|
OP
|
$0.95
|
|
|
Service Code
|
NDC 5026868615
|
| Hospital Charge Code |
5026868615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.52
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.48
|
| Rate for Payer: Aetna Government |
$0.48
|
| Rate for Payer: Brighton Health Commercial |
$0.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.76
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.65
|
| Rate for Payer: EmblemHealth Commercial |
$0.48
|
| Rate for Payer: Group Health Inc Commercial |
$0.48
|
| Rate for Payer: Group Health Inc Medicare |
$0.33
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.62
|
|
|
PRIMIDONE 50 MG PO TABS
|
Facility
|
IP
|
$0.95
|
|
|
Service Code
|
NDC 5026868615
|
| Hospital Charge Code |
5026868615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.48
|
|
|
PRIMIDONE 50 MG PO TABS
|
Facility
|
IP
|
$0.95
|
|
|
Service Code
|
NDC 5026868611
|
| Hospital Charge Code |
5026868611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.48
|
|
|
PRIMIDONE 50 MG PO TABS
|
Facility
|
OP
|
$0.95
|
|
|
Service Code
|
NDC 5026868611
|
| Hospital Charge Code |
5026868611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.52
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.48
|
| Rate for Payer: Aetna Government |
$0.48
|
| Rate for Payer: Brighton Health Commercial |
$0.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.76
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.65
|
| Rate for Payer: EmblemHealth Commercial |
$0.48
|
| Rate for Payer: Group Health Inc Commercial |
$0.48
|
| Rate for Payer: Group Health Inc Medicare |
$0.33
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.62
|
|
|
PRIMIDONE 50 MG PO TABS
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 7288804501
|
| Hospital Charge Code |
7288804501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.25
|
|
|
PRIMIDONE 50 MG PO TABS
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 7288804501
|
| Hospital Charge Code |
7288804501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.25
|
| Rate for Payer: Aetna Government |
$0.25
|
| Rate for Payer: Brighton Health Commercial |
$0.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.34
|
| Rate for Payer: EmblemHealth Commercial |
$0.25
|
| Rate for Payer: Group Health Inc Commercial |
$0.25
|
| Rate for Payer: Group Health Inc Medicare |
$0.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.33
|
|
|
PR IMPL ABSRB MESH/PRSTH DLYD CLSR DFCT INFCTJ/TRMA
|
Professional
|
Both
|
$1,716.65
|
|
|
Service Code
|
HCPCS 15778
|
| Min. Negotiated Rate |
$325.68 |
| Max. Negotiated Rate |
$1,046.81 |
| Rate for Payer: Cash Price |
$458.03
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$465.25
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$418.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$418.73
|
| Rate for Payer: Fidelis Essential Plan QHP |
$441.99
|
| Rate for Payer: Fidelis Medicare Advantage |
$465.25
|
| Rate for Payer: Fidelis Qualified Health Plan |
$441.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$465.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$465.25
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$348.94
|
| Rate for Payer: Healthfirst Commercial |
$465.25
|
| Rate for Payer: Healthfirst Essential Plan |
$1,046.81
|
| Rate for Payer: Healthfirst Medicare Advantage |
$441.99
|
| Rate for Payer: Healthfirst QHP |
$465.25
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$325.68
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$465.25
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$395.46
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$325.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$465.25
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$348.94
|
| Rate for Payer: SOMOS Essential |
$348.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$465.25
|
|
|
PR IMPLANTATION INTRASTROMAL CORNEAL RING SEGMENTS
|
Professional
|
Both
|
$1,829.45
|
|
|
Service Code
|
HCPCS 65785
|
| Min. Negotiated Rate |
$349.92 |
| Max. Negotiated Rate |
$1,124.75 |
| Rate for Payer: Cash Price |
$505.01
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$499.89
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$449.90
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$449.90
|
| Rate for Payer: Fidelis Essential Plan QHP |
$474.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$499.89
|
| Rate for Payer: Fidelis Qualified Health Plan |
$474.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$499.89
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$499.89
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$374.92
|
| Rate for Payer: Healthfirst Commercial |
$499.89
|
| Rate for Payer: Healthfirst Essential Plan |
$1,124.75
|
| Rate for Payer: Healthfirst Medicare Advantage |
$474.90
|
| Rate for Payer: Healthfirst QHP |
$499.89
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$349.92
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$499.89
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$424.91
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$349.92
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$499.89
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$374.92
|
| Rate for Payer: SOMOS Essential |
$374.92
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$499.89
|
|
|
PR IMPLANTATION NERVE END BONE/MUSCLE
|
Professional
|
Both
|
$1,018.96
|
|
|
Service Code
|
HCPCS 64787
|
| Min. Negotiated Rate |
$189.65 |
| Max. Negotiated Rate |
$609.59 |
| Rate for Payer: Cash Price |
$270.96
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$270.93
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$243.84
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$243.84
|
| Rate for Payer: Fidelis Essential Plan QHP |
$257.38
|
| Rate for Payer: Fidelis Medicare Advantage |
$270.93
|
| Rate for Payer: Fidelis Qualified Health Plan |
$257.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$270.93
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$270.93
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$203.20
|
| Rate for Payer: Healthfirst Commercial |
$270.93
|
| Rate for Payer: Healthfirst Essential Plan |
$609.59
|
| Rate for Payer: Healthfirst Medicare Advantage |
$257.38
|
| Rate for Payer: Healthfirst QHP |
$270.93
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$189.65
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$270.93
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$230.29
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$189.65
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$270.93
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$203.20
|
| Rate for Payer: SOMOS Essential |
$203.20
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$270.93
|
|
|
PR IMPLNT BIO IMPLNT FOR SOFT TISSUE REINFORCEMENT
|
Professional
|
Both
|
$937.76
|
|
|
Service Code
|
HCPCS 15777
|
| Min. Negotiated Rate |
$174.39 |
| Max. Negotiated Rate |
$560.54 |
| Rate for Payer: Cash Price |
$250.69
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$249.13
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$224.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$224.22
|
| Rate for Payer: Fidelis Essential Plan QHP |
$236.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$249.13
|
| Rate for Payer: Fidelis Qualified Health Plan |
$236.67
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$249.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$249.13
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$186.85
|
| Rate for Payer: Healthfirst Commercial |
$249.13
|
| Rate for Payer: Healthfirst Essential Plan |
$560.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$236.67
|
| Rate for Payer: Healthfirst QHP |
$249.13
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$174.39
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$249.13
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$211.76
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$174.39
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$249.13
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$186.85
|
| Rate for Payer: SOMOS Essential |
$186.85
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$249.13
|
|
