|
PROBENECID 500 MG PO TABS
|
Facility
|
OP
|
$0.98
|
|
|
Service Code
|
NDC 0591534701
|
| Hospital Charge Code |
0591534701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.49
|
| Rate for Payer: Aetna Government |
$0.49
|
| Rate for Payer: Brighton Health Commercial |
$0.74
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.79
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.67
|
| Rate for Payer: EmblemHealth Commercial |
$0.49
|
| Rate for Payer: Group Health Inc Commercial |
$0.49
|
| Rate for Payer: Group Health Inc Medicare |
$0.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.49
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.64
|
|
|
PROBENECID 500 MG PO TABS
|
Facility
|
IP
|
$0.98
|
|
|
Service Code
|
NDC 0591534701
|
| Hospital Charge Code |
0591534701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.49
|
|
|
PR OBLTRJ AORTOPULMONARY SEPTAL DEFECT W/BYPASS
|
Professional
|
Both
|
$6,789.62
|
|
|
Service Code
|
HCPCS 33814
|
| Min. Negotiated Rate |
$1,254.00 |
| Max. Negotiated Rate |
$4,030.72 |
| Rate for Payer: Cash Price |
$1,808.41
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,791.43
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,612.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,612.29
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,701.86
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,791.43
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,701.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,791.43
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,791.43
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,343.57
|
| Rate for Payer: Healthfirst Commercial |
$1,791.43
|
| Rate for Payer: Healthfirst Essential Plan |
$4,030.72
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,701.86
|
| Rate for Payer: Healthfirst QHP |
$1,791.43
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,254.00
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,791.43
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,522.72
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,254.00
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,791.43
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,343.57
|
| Rate for Payer: SOMOS Essential |
$1,343.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,791.43
|
|
|
PR OBLTRJ AORTOPULMONARY SEPTAL DEFECT W/O BYPASS
|
Professional
|
Both
|
$5,529.27
|
|
|
Service Code
|
HCPCS 33813
|
| Rate for Payer: Cash Price |
$1,473.08
|
|
|
PR OBLTRJ CAROTID ARYSM ARTVEN CAROTID FISTULA DSJ
|
Professional
|
Both
|
$15,797.11
|
|
|
Service Code
|
HCPCS 61613
|
| Min. Negotiated Rate |
$2,867.02 |
| Max. Negotiated Rate |
$9,215.42 |
| Rate for Payer: Cash Price |
$4,150.82
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4,095.74
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3,686.17
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,686.17
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,890.95
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,095.74
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,890.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,095.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,095.74
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,071.80
|
| Rate for Payer: Healthfirst Commercial |
$4,095.74
|
| Rate for Payer: Healthfirst Essential Plan |
$9,215.42
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,890.95
|
| Rate for Payer: Healthfirst QHP |
$4,095.74
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2,867.02
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$4,095.74
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$3,481.38
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2,867.02
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4,095.74
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$3,071.80
|
| Rate for Payer: SOMOS Essential |
$3,071.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4,095.74
|
|
|
PR OBSTRUCTIVE MATERIAL REMOVAL FROM GI TUBE
|
Professional
|
Both
|
$207.69
|
|
|
Service Code
|
HCPCS 49460
|
| Min. Negotiated Rate |
$39.91 |
| Max. Negotiated Rate |
$128.29 |
| Rate for Payer: Cash Price |
$57.33
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$57.02
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$51.32
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$51.32
|
| Rate for Payer: Fidelis Essential Plan QHP |
$54.17
|
| Rate for Payer: Fidelis Medicare Advantage |
$57.02
|
| Rate for Payer: Fidelis Qualified Health Plan |
$54.17
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$57.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$57.02
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$42.77
|
| Rate for Payer: Healthfirst Commercial |
$57.02
|
| Rate for Payer: Healthfirst Essential Plan |
$128.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$54.17
|
| Rate for Payer: Healthfirst QHP |
$57.02
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$39.91
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$57.02
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$48.47
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$39.91
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$57.02
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$42.77
|
| Rate for Payer: SOMOS Essential |
$42.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$57.02
|
|
|
PR OBTAINING SCREEN PAP SMEAR
|
Professional
|
Both
|
$73.36
|
|
|
Service Code
|
HCPCS Q0091
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$44.55 |
| Rate for Payer: Cash Price |
$20.05
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$19.80
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$17.82
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$17.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$18.81
|
| Rate for Payer: Fidelis Medicare Advantage |
$19.80
|
| Rate for Payer: Fidelis Qualified Health Plan |
$18.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.80
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$14.85
|
| Rate for Payer: Healthfirst Commercial |
$19.80
|
| Rate for Payer: Healthfirst Essential Plan |
$44.55
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18.81
|
| Rate for Payer: Healthfirst QHP |
$19.80
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$13.86
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$19.80
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$16.83
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$13.86
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$19.80
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$14.85
|
| Rate for Payer: SOMOS Essential |
$14.85
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.80
|
|
|
PROCAINAMIDE HCL 100 MG/ML IJ SOLN
|
Facility
|
OP
|
$11.05
|
|
|
Service Code
|
HCPCS J2690
|
| Hospital Charge Code |
0409190211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$300.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$294.69
|
| Rate for Payer: Aetna Government |
$294.69
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$206.28
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$206.28
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$206.28
|
| Rate for Payer: Brighton Health Commercial |
$8.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$294.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.51
|
| Rate for Payer: Elderplan Medicare Advantage |
$294.69
|
| Rate for Payer: EmblemHealth Commercial |
$294.69
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$265.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$250.49
|
| Rate for Payer: Fidelis Essential Plan QHP |
$262.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$294.69
|
| Rate for Payer: Fidelis Qualified Health Plan |
$262.27
|
| Rate for Payer: Group Health Inc Commercial |
$294.69
|
| Rate for Payer: Group Health Inc Medicare |
$294.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$294.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$294.69
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$294.69
|
| Rate for Payer: Healthfirst Medicare Advantage |
$250.49
|
| Rate for Payer: Healthfirst QHP |
$294.69
|
| Rate for Payer: Humana Medicare |
$300.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$294.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$294.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$279.96
|
| Rate for Payer: Wellcare Medicare |
$279.96
|
|
|
PROCAINAMIDE HCL 100 MG/ML IJ SOLN
|
Facility
|
IP
|
$11.05
|
|
|
Service Code
|
HCPCS J2690
|
| Hospital Charge Code |
0409190211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.52 |
| Max. Negotiated Rate |
$5.52 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.52
|
|
|
PROCAINAMIDE HCL 500 MG/ML IJ SOLN
|
Facility
|
IP
|
$360.00
|
|
|
Service Code
|
HCPCS J2690
|
| Hospital Charge Code |
1478990002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$180.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$180.00
|
|
|
PROCAINAMIDE HCL 500 MG/ML IJ SOLN
|
Facility
|
OP
|
$360.00
|
|
|
Service Code
|
HCPCS J2690
|
| Hospital Charge Code |
1478990002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$198.00 |
| Max. Negotiated Rate |
$300.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$198.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$294.69
|
| Rate for Payer: Aetna Government |
$294.69
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$206.28
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$206.28
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$206.28
|
| Rate for Payer: Brighton Health Commercial |
$270.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$294.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$288.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$244.80
|
| Rate for Payer: Elderplan Medicare Advantage |
$294.69
|
| Rate for Payer: EmblemHealth Commercial |
$294.69
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$265.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$250.49
|
| Rate for Payer: Fidelis Essential Plan QHP |
$262.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$294.69
|
| Rate for Payer: Fidelis Qualified Health Plan |
$262.27
|
| Rate for Payer: Group Health Inc Commercial |
$294.69
|
| Rate for Payer: Group Health Inc Medicare |
$294.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$294.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$294.69
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$294.69
|
| Rate for Payer: Healthfirst Medicare Advantage |
$250.49
|
| Rate for Payer: Healthfirst QHP |
$294.69
|
| Rate for Payer: Humana Medicare |
$300.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$294.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$294.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$234.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$279.96
|
| Rate for Payer: Wellcare Medicare |
$279.96
|
|
|
PROCAINAMIDE HCL 500 MG/ML IJ SOLN
|
Facility
|
IP
|
$360.00
|
|
|
Service Code
|
HCPCS J2690
|
| Hospital Charge Code |
1478990007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$180.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$180.00
|
|
|
PROCAINAMIDE HCL 500 MG/ML IJ SOLN
|
Facility
|
OP
|
$360.00
|
|
|
Service Code
|
HCPCS J2690
|
| Hospital Charge Code |
1478990007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$198.00 |
| Max. Negotiated Rate |
$300.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$198.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$294.69
|
| Rate for Payer: Aetna Government |
$294.69
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$206.28
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$206.28
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$206.28
|
| Rate for Payer: Brighton Health Commercial |
$270.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$294.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$288.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$244.80
|
| Rate for Payer: Elderplan Medicare Advantage |
$294.69
|
| Rate for Payer: EmblemHealth Commercial |
$294.69
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$265.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$250.49
|
| Rate for Payer: Fidelis Essential Plan QHP |
$262.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$294.69
|
| Rate for Payer: Fidelis Qualified Health Plan |
$262.27
|
| Rate for Payer: Group Health Inc Commercial |
$294.69
|
| Rate for Payer: Group Health Inc Medicare |
$294.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$294.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$294.69
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$294.69
|
| Rate for Payer: Healthfirst Medicare Advantage |
$250.49
|
| Rate for Payer: Healthfirst QHP |
$294.69
|
| Rate for Payer: Humana Medicare |
$300.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$294.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$294.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$234.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$279.96
|
| Rate for Payer: Wellcare Medicare |
$279.96
|
|
|
PR OCCLUSION FLP TUBE DEV VAG/SUPRAPUBIC APPR
|
Professional
|
Both
|
$1,108.31
|
|
|
Service Code
|
HCPCS 58615
|
| Min. Negotiated Rate |
$205.46 |
| Max. Negotiated Rate |
$660.42 |
| Rate for Payer: Cash Price |
$299.56
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$293.52
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$264.17
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$264.17
|
| Rate for Payer: Fidelis Essential Plan QHP |
$278.84
|
| Rate for Payer: Fidelis Medicare Advantage |
$293.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$278.84
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$293.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$293.52
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$220.14
|
| Rate for Payer: Healthfirst Commercial |
$293.52
|
| Rate for Payer: Healthfirst Essential Plan |
$660.42
|
| Rate for Payer: Healthfirst Medicare Advantage |
$278.84
|
| Rate for Payer: Healthfirst QHP |
$293.52
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$205.46
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$293.52
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$249.49
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$205.46
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$293.52
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$220.14
|
| Rate for Payer: SOMOS Essential |
$220.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$293.52
|
|
|
PR OCCULAR SURFACE RECONSTRUCTION LIMBAL AUTOGRAFT
|
Professional
|
Both
|
$4,703.48
|
|
|
Service Code
|
HCPCS 65782
|
| Min. Negotiated Rate |
$895.86 |
| Max. Negotiated Rate |
$2,879.55 |
| Rate for Payer: Cash Price |
$1,295.37
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,279.80
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,151.82
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,151.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,215.81
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,279.80
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,215.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,279.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,279.80
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$959.85
|
| Rate for Payer: Healthfirst Commercial |
$1,279.80
|
| Rate for Payer: Healthfirst Essential Plan |
$2,879.55
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,215.81
|
| Rate for Payer: Healthfirst QHP |
$1,279.80
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$895.86
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,279.80
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,087.83
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$895.86
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,279.80
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$959.85
|
| Rate for Payer: SOMOS Essential |
$959.85
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,279.80
|
|
|
PR OCCUPATIONAL THERAPY EVAL HIGH COMPLEX 60 MINS
|
Professional
|
Both
|
$407.96
|
|
|
Service Code
|
HCPCS 97167
|
| Min. Negotiated Rate |
$80.44 |
| Max. Negotiated Rate |
$258.55 |
| Rate for Payer: Cash Price |
$113.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$114.91
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$103.42
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$103.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$109.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$114.91
|
| Rate for Payer: Fidelis Qualified Health Plan |
$109.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$114.91
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$114.91
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$86.18
|
| Rate for Payer: Healthfirst Commercial |
$114.91
|
| Rate for Payer: Healthfirst Essential Plan |
$258.55
|
| Rate for Payer: Healthfirst Medicare Advantage |
$109.16
|
| Rate for Payer: Healthfirst QHP |
$114.91
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$80.44
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$114.91
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$97.67
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$80.44
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$114.91
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$86.18
|
| Rate for Payer: SOMOS Essential |
$86.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$114.91
|
|
|
PR OCCUPATIONAL THERAPY EVAL LOW COMPLEX 30 MINS
|
Professional
|
Both
|
$407.96
|
|
|
Service Code
|
HCPCS 97165
|
| Min. Negotiated Rate |
$80.44 |
| Max. Negotiated Rate |
$258.55 |
| Rate for Payer: Cash Price |
$113.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$114.91
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$103.42
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$103.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$109.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$114.91
|
| Rate for Payer: Fidelis Qualified Health Plan |
$109.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$114.91
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$114.91
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$86.18
|
| Rate for Payer: Healthfirst Commercial |
$114.91
|
| Rate for Payer: Healthfirst Essential Plan |
$258.55
|
| Rate for Payer: Healthfirst Medicare Advantage |
$109.16
|
| Rate for Payer: Healthfirst QHP |
$114.91
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$80.44
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$114.91
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$97.67
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$80.44
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$114.91
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$86.18
|
| Rate for Payer: SOMOS Essential |
$86.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$114.91
|
|
|
PR OCCUPATIONAL THERAPY EVAL MOD COMPLEX 45 MINS
|
Professional
|
Both
|
$407.96
|
|
|
Service Code
|
HCPCS 97166
|
| Min. Negotiated Rate |
$80.44 |
| Max. Negotiated Rate |
$258.55 |
| Rate for Payer: Cash Price |
$113.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$114.91
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$103.42
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$103.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$109.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$114.91
|
| Rate for Payer: Fidelis Qualified Health Plan |
$109.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$114.91
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$114.91
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$86.18
|
| Rate for Payer: Healthfirst Commercial |
$114.91
|
| Rate for Payer: Healthfirst Essential Plan |
$258.55
|
| Rate for Payer: Healthfirst Medicare Advantage |
$109.16
|
| Rate for Payer: Healthfirst QHP |
$114.91
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$80.44
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$114.91
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$97.67
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$80.44
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$114.91
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$86.18
|
| Rate for Payer: SOMOS Essential |
$86.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$114.91
|
|
|
PR OCCUPATIONAL THER RE-EVAL EST PLAN CARE 30 MINS
|
Professional
|
Both
|
$285.01
|
|
|
Service Code
|
HCPCS 97168
|
| Min. Negotiated Rate |
$55.97 |
| Max. Negotiated Rate |
$179.89 |
| Rate for Payer: Cash Price |
$78.97
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$79.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$71.95
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$71.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$75.95
|
| Rate for Payer: Fidelis Medicare Advantage |
$79.95
|
| Rate for Payer: Fidelis Qualified Health Plan |
$75.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$79.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$79.95
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$59.96
|
| Rate for Payer: Healthfirst Commercial |
$79.95
|
| Rate for Payer: Healthfirst Essential Plan |
$179.89
|
| Rate for Payer: Healthfirst Medicare Advantage |
$75.95
|
| Rate for Payer: Healthfirst QHP |
$79.95
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$55.97
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$79.95
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$67.96
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$55.97
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$79.95
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$59.96
|
| Rate for Payer: SOMOS Essential |
$59.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$79.95
|
|
|
Procedures for obesity
|
Facility
|
IP
|
$54,556.76
|
|
|
Service Code
|
APR-DRG 4032
|
| Min. Negotiated Rate |
$15,640.00 |
| Max. Negotiated Rate |
$54,556.76 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$54,556.76
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$54,556.76
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$24,247.45
|
| Rate for Payer: Amida Care Medicaid |
$24,247.45
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$54,556.76
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$24,247.45
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$24,247.45
|
| Rate for Payer: Fidelis Qualified Health Plan |
$29,096.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24,247.45
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$24,247.45
|
| Rate for Payer: Healthfirst Commercial |
$26,278.00
|
| Rate for Payer: Healthfirst Essential Plan |
$54,556.76
|
| Rate for Payer: Healthfirst QHP |
$15,640.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$24,247.45
|
| Rate for Payer: SOMOS Essential |
$54,556.76
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$54,556.76
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$54,556.76
|
| Rate for Payer: United Healthcare Medicaid |
$24,247.45
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$24,247.45
|
|
|
Procedures for obesity
|
Facility
|
IP
|
$68,960.88
|
|
|
Service Code
|
APR-DRG 4033
|
| Min. Negotiated Rate |
$22,982.00 |
| Max. Negotiated Rate |
$68,960.88 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$68,960.88
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$68,960.88
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$30,649.28
|
| Rate for Payer: Amida Care Medicaid |
$30,649.28
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$68,960.88
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$30,649.28
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$30,649.28
|
| Rate for Payer: Fidelis Qualified Health Plan |
$36,779.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30,649.28
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$30,649.28
|
| Rate for Payer: Healthfirst Commercial |
$45,579.00
|
| Rate for Payer: Healthfirst Essential Plan |
$68,960.88
|
| Rate for Payer: Healthfirst QHP |
$22,982.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$30,649.28
|
| Rate for Payer: SOMOS Essential |
$68,960.88
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$68,960.88
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$68,960.88
|
| Rate for Payer: United Healthcare Medicaid |
$30,649.28
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$30,649.28
|
|
|
Procedures for obesity
|
Facility
|
IP
|
$147,684.13
|
|
|
Service Code
|
APR-DRG 4034
|
| Min. Negotiated Rate |
$65,637.39 |
| Max. Negotiated Rate |
$147,684.13 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$147,684.13
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$147,684.13
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$65,637.39
|
| Rate for Payer: Amida Care Medicaid |
$65,637.39
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$147,684.13
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$65,637.39
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$65,637.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$78,764.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$65,637.39
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$65,637.39
|
| Rate for Payer: Healthfirst Commercial |
$124,862.00
|
| Rate for Payer: Healthfirst Essential Plan |
$147,684.13
|
| Rate for Payer: Healthfirst QHP |
$77,206.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$65,637.39
|
| Rate for Payer: SOMOS Essential |
$147,684.13
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$147,684.13
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$147,684.13
|
| Rate for Payer: United Healthcare Medicaid |
$65,637.39
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$65,637.39
|
|
|
Procedures for obesity
|
Facility
|
IP
|
$52,066.37
|
|
|
Service Code
|
APR-DRG 4031
|
| Min. Negotiated Rate |
$14,760.00 |
| Max. Negotiated Rate |
$52,066.37 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$52,066.37
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$52,066.37
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$23,140.61
|
| Rate for Payer: Amida Care Medicaid |
$23,140.61
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$52,066.37
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$23,140.61
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$23,140.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$27,768.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23,140.61
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$23,140.61
|
| Rate for Payer: Healthfirst Commercial |
$23,755.00
|
| Rate for Payer: Healthfirst Essential Plan |
$52,066.37
|
| Rate for Payer: Healthfirst QHP |
$14,760.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$23,140.61
|
| Rate for Payer: SOMOS Essential |
$52,066.37
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$52,066.37
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$52,066.37
|
| Rate for Payer: United Healthcare Medicaid |
$23,140.61
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$23,140.61
|
|
|
PROCEDURES FOR REVISION OR REMOVAL OF NEUROSTIMULATOR DEVICES
|
Facility
|
OP
|
$2,439.27
|
|
|
Service Code
|
EAPG 00276
|
| Min. Negotiated Rate |
$2,439.27 |
| Max. Negotiated Rate |
$2,439.27 |
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$2,439.27
|
|
|
Procedure w diag of rehab, aftercare or oth contact w health service
|
Facility
|
IP
|
$52,437.46
|
|
|
Service Code
|
APR-DRG 8501
|
| Min. Negotiated Rate |
$13,223.00 |
| Max. Negotiated Rate |
$52,437.46 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$52,437.46
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$52,437.46
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$23,305.54
|
| Rate for Payer: Amida Care Medicaid |
$23,305.54
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$52,437.46
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$23,305.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$23,305.54
|
| Rate for Payer: Fidelis Qualified Health Plan |
$27,966.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23,305.54
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$23,305.54
|
| Rate for Payer: Healthfirst Commercial |
$22,015.00
|
| Rate for Payer: Healthfirst Essential Plan |
$52,437.46
|
| Rate for Payer: Healthfirst QHP |
$13,223.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$23,305.54
|
| Rate for Payer: SOMOS Essential |
$52,437.46
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$52,437.46
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$52,437.46
|
| Rate for Payer: United Healthcare Medicaid |
$23,305.54
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$23,305.54
|
|
