|
LEVEL 2 L&D HEMATOMA
|
Facility
|
IP
|
$4,157.25
|
|
|
Service Code
|
HCPCS 10140
|
| Hospital Charge Code |
30305350
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$1,874.89
|
|
|
LEVEL 2 L&D HEMATOMA
|
Facility
|
OP
|
$4,157.25
|
|
|
Service Code
|
HCPCS 10140
|
| Hospital Charge Code |
30305350
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,874.89
|
| Rate for Payer: Aetna Government |
$1,874.89
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,312.42
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,312.42
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,312.42
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,874.89
|
| 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 |
$1,874.89
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,593.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,668.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,874.89
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,668.65
|
| 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 |
$2,078.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,874.89
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,593.66
|
| Rate for Payer: Healthfirst QHP |
$1,874.89
|
| Rate for Payer: Humana Medicare |
$1,912.39
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,874.89
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,874.89
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,874.89
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,874.89
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,499.91
|
| Rate for Payer: Wellcare Medicare |
$1,781.15
|
|
|
LEVEL 3 I&D DRAIN BELOW FAS
|
Facility
|
IP
|
$4,105.13
|
|
|
Service Code
|
HCPCS 28002
|
| Hospital Charge Code |
42500143
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,858.61
|
|
|
LEVEL 3 I&D DRAIN BELOW FAS
|
Facility
|
OP
|
$4,105.13
|
|
|
Service Code
|
HCPCS 28002
|
| Hospital Charge Code |
42500143
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,301.03 |
| Max. Negotiated Rate |
$3,078.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,858.61
|
| Rate for Payer: Aetna Government |
$1,858.61
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,301.03
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,301.03
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,301.03
|
| Rate for Payer: Brighton Health Commercial |
$3,078.85
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,858.61
|
| 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 |
$1,858.61
|
| Rate for Payer: EmblemHealth Commercial |
$1,858.61
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,579.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,654.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,858.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,654.16
|
| Rate for Payer: Group Health Inc Commercial |
$1,858.61
|
| Rate for Payer: Group Health Inc Medicare |
$1,858.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,052.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,858.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,579.82
|
| Rate for Payer: Healthfirst QHP |
$1,858.61
|
| Rate for Payer: Humana Medicare |
$1,895.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,858.61
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,858.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,858.61
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,486.89
|
| Rate for Payer: Wellcare Medicare |
$1,765.68
|
|
|
LEVEL 3 I&D DRAIN BURSA
|
Facility
|
IP
|
$4,157.25
|
|
|
Service Code
|
HCPCS 28001
|
| Hospital Charge Code |
42500151
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,874.89
|
|
|
LEVEL 3 I&D DRAIN BURSA
|
Facility
|
OP
|
$4,157.25
|
|
|
Service Code
|
HCPCS 28001
|
| Hospital Charge Code |
42500151
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,312.42 |
| Max. Negotiated Rate |
$3,117.94 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,874.89
|
| Rate for Payer: Aetna Government |
$1,874.89
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,312.42
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,312.42
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,312.42
|
| Rate for Payer: Brighton Health Commercial |
$3,117.94
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,874.89
|
| 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 |
$1,874.89
|
| Rate for Payer: EmblemHealth Commercial |
$1,874.89
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,593.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,668.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,874.89
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,668.65
|
| Rate for Payer: Group Health Inc Commercial |
$1,874.89
|
| Rate for Payer: Group Health Inc Medicare |
$1,874.89
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,078.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,874.89
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,593.66
|
| Rate for Payer: Healthfirst QHP |
$1,874.89
|
| Rate for Payer: Humana Medicare |
$1,912.39
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,874.89
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,874.89
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,874.89
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,499.91
|
| Rate for Payer: Wellcare Medicare |
$1,781.15
|
|
|
LEVEL 4 O/P CONSULT
|
Facility
|
OP
|
$528.33
|
|
|
Service Code
|
HCPCS 99244
|
| Hospital Charge Code |
42500105
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$113.18 |
| Max. Negotiated Rate |
$290.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$290.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$113.18
|
| Rate for Payer: Aetna Government |
$113.18
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$264.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$264.16
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
LEVEL 5 O/P CONSULT
|
Facility
|
OP
|
$559.74
|
|
|
Service Code
|
HCPCS 99245
|
| Hospital Charge Code |
42500110
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$139.91 |
| Max. Negotiated Rate |
$307.86 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$307.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$139.91
|
| Rate for Payer: Aetna Government |
$139.91
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$279.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$279.87
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
LEVEL I&D PUNCTURE DRAIN
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 10160
|
| Hospital Charge Code |
42500142
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$322.78 |
| 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 |
$725.80
|
| 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 |
$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 |
$461.12
|
| Rate for Payer: Group Health Inc Medicare |
$461.12
|
| 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: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| 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
|
|
|
LEVEL I&D PUNCTURE DRAIN
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 10160
|
| Hospital Charge Code |
42500142
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
LEVEL I&D SKIN ABSCESS
|
Facility
|
IP
|
$547.93
|
|
|
Service Code
|
HCPCS 10060
|
| Hospital Charge Code |
42500141
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$231.52
|
|
|
LEVEL I&D SKIN ABSCESS
|
Facility
|
OP
|
$547.93
|
|
|
Service Code
|
HCPCS 10060
|
| Hospital Charge Code |
42500141
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$162.06 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$231.52
|
| Rate for Payer: Aetna Government |
$231.52
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$162.06
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$162.06
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$162.06
|
| Rate for Payer: Brighton Health Commercial |
$410.95
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$231.52
|
| 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 |
$231.52
|
| Rate for Payer: EmblemHealth Commercial |
$231.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$196.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$206.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$231.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$206.05
|
| Rate for Payer: Group Health Inc Commercial |
$231.52
|
| Rate for Payer: Group Health Inc Medicare |
$231.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$273.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$231.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$196.79
|
| Rate for Payer: Healthfirst QHP |
$231.52
|
| Rate for Payer: Humana Medicare |
$236.15
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$231.52
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$231.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$231.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$185.22
|
| Rate for Payer: Wellcare Medicare |
$219.94
|
|
|
LEVEL III NERVE INJECTIONS
|
Facility
|
OP
|
$2,459.50
|
|
|
Service Code
|
HCPCS 64493
|
| Hospital Charge Code |
40014107
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$737.84 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,054.06
|
| Rate for Payer: Aetna Government |
$1,054.06
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$737.84
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$737.84
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$737.84
|
| Rate for Payer: Brighton Health Commercial |
$1,844.62
|
| Rate for Payer: Cash Price |
$1,054.06
|
| Rate for Payer: Cash Price |
$1,054.06
|
| Rate for Payer: Cash Price |
$1,054.06
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,054.06
|
| 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 |
$1,054.06
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$895.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$938.11
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,054.06
|
| Rate for Payer: Fidelis Qualified Health Plan |
$938.11
|
| Rate for Payer: Group Health Inc Commercial |
$1,054.06
|
| Rate for Payer: Group Health Inc Medicare |
$1,054.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,229.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,054.06
|
| Rate for Payer: Healthfirst Medicare Advantage |
$895.95
|
| Rate for Payer: Healthfirst QHP |
$1,054.06
|
| Rate for Payer: Humana Medicare |
$1,075.14
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,054.06
|
| Rate for Payer: United Healthcare Commercial |
$1,188.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,054.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,054.06
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$843.25
|
| Rate for Payer: Wellcare Medicare |
$1,001.36
|
|
|
LEVEL III NERVE INJECTIONS
|
Facility
|
IP
|
$2,459.50
|
|
|
Service Code
|
HCPCS 64493
|
| Hospital Charge Code |
40014107
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,054.06
|
|
|
LEVEL III NERVE INJECTIONS ADD-ON
|
Facility
|
OP
|
$146.06
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
40014162
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$51.12 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$60.11
|
| Rate for Payer: Aetna Government |
$60.11
|
| Rate for Payer: Brighton Health Commercial |
$109.54
|
| 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: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Group Health Inc Commercial |
$73.03
|
| Rate for Payer: Group Health Inc Medicare |
$51.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$73.03
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$73.03
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
|
|
LEVERAGE ALLOGRAFT 8MM
|
Facility
|
IP
|
$3,232.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903860
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,616.25 |
| Max. Negotiated Rate |
$1,616.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,616.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,616.25
|
|
|
LEVERAGE ALLOGRAFT 8MM
|
Facility
|
OP
|
$3,232.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903860
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$3,394.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,777.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$1,939.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,616.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,858.69
|
| Rate for Payer: EmblemHealth Commercial |
$1,616.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,394.12
|
| Rate for Payer: Group Health Inc Commercial |
$1,616.25
|
| Rate for Payer: Group Health Inc Medicare |
$1,131.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,616.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,616.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,101.12
|
|
|
LEVERAGE ALLOGRAFT 9.5MM
|
Facility
|
OP
|
$3,232.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903862
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$3,394.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,777.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$1,939.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,616.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,858.69
|
| Rate for Payer: EmblemHealth Commercial |
$1,616.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,394.12
|
| Rate for Payer: Group Health Inc Commercial |
$1,616.25
|
| Rate for Payer: Group Health Inc Medicare |
$1,131.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,616.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,616.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,101.12
|
|
|
LEVERAGE ALLOGRAFT 9.5MM
|
Facility
|
IP
|
$3,232.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903862
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,616.25 |
| Max. Negotiated Rate |
$1,616.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,616.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,616.25
|
|
|
LEVETIRACETAM 1000MG/100ML PREMIX
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
41647938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.27
|
|
|
LEVETIRACETAM 1000MG/100ML PREMIX
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
41647938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.09
|
| Rate for Payer: Aetna Government |
$0.09
|
| Rate for Payer: Brighton Health Commercial |
$0.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.30
|
| Rate for Payer: Group Health Inc Commercial |
$0.27
|
| Rate for Payer: Group Health Inc Medicare |
$0.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.27
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.07
|
| Rate for Payer: SOMOS Essential |
$0.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.34
|
|
|
LEVETIRACETAM 1000MG/100ML PREMIX
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
41657938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.09
|
| Rate for Payer: Aetna Government |
$0.09
|
| Rate for Payer: Brighton Health Commercial |
$0.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.30
|
| Rate for Payer: Group Health Inc Commercial |
$0.27
|
| Rate for Payer: Group Health Inc Medicare |
$0.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.27
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.07
|
| Rate for Payer: SOMOS Essential |
$0.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.34
|
|
|
LEVETIRACETAM 1000MG/100ML PREMIX
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
41657938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.27
|
|
|
LEVETIRACETAM 100 MG/ML INJ
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
41644576
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.09
|
| Rate for Payer: Aetna Government |
$0.09
|
| Rate for Payer: Brighton Health Commercial |
$0.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.22
|
| Rate for Payer: Group Health Inc Commercial |
$0.20
|
| Rate for Payer: Group Health Inc Medicare |
$0.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.20
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.07
|
| Rate for Payer: SOMOS Essential |
$0.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.25
|
|
|
LEVETIRACETAM 100 MG/ML INJ
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
41644576
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.20
|
|
