|
LOW AP SKIN GFT FACE,HAND,FT EA A
|
Facility
|
OP
|
$261.10
|
|
|
Service Code
|
HCPCS C5278
|
| Hospital Charge Code |
42500238
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$130.55 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$130.55
|
| Rate for Payer: Aetna Government |
$130.55
|
| 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 |
$130.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$130.55
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
LOW COST SKIN AP GFT EA ADTL 25CM
|
Facility
|
OP
|
$120.25
|
|
|
Service Code
|
HCPCS C5272
|
| Hospital Charge Code |
42500232
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$36.00
|
| Rate for Payer: Aetna Government |
$36.00
|
| 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 |
$60.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$60.12
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
LOW COST SKIN AP GFT FACE,HND,FEE
|
Facility
|
IP
|
$1,390.00
|
|
|
Service Code
|
HCPCS C5275
|
| Hospital Charge Code |
42500235
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$726.29
|
|
|
LOW COST SKIN AP GFT FACE,HND,FEE
|
Facility
|
OP
|
$1,390.00
|
|
|
Service Code
|
HCPCS C5275
|
| Hospital Charge Code |
42500235
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$173.89 |
| Max. Negotiated Rate |
$780.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$726.29
|
| Rate for Payer: Aetna Government |
$726.29
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$508.40
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$508.40
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$508.40
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$726.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$726.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$617.35
|
| Rate for Payer: Fidelis Essential Plan QHP |
$646.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$726.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$646.40
|
| 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 |
$695.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$726.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$617.35
|
| Rate for Payer: Healthfirst QHP |
$726.29
|
| Rate for Payer: Humana Medicare |
$740.82
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$726.29
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$726.29
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$726.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$726.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$581.03
|
| Rate for Payer: Wellcare Medicare |
$689.98
|
|
|
LOW COST SKIN AP GFT TRK, ARM,LEG
|
Facility
|
IP
|
$1,390.00
|
|
|
Service Code
|
HCPCS C5271
|
| Hospital Charge Code |
42500231
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$726.29
|
|
|
LOW COST SKIN AP GFT TRK, ARM,LEG
|
Facility
|
OP
|
$1,390.00
|
|
|
Service Code
|
HCPCS C5271
|
| Hospital Charge Code |
42500231
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$173.89 |
| Max. Negotiated Rate |
$780.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$726.29
|
| Rate for Payer: Aetna Government |
$726.29
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$508.40
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$508.40
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$508.40
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$726.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$726.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$617.35
|
| Rate for Payer: Fidelis Essential Plan QHP |
$646.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$726.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$646.40
|
| 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 |
$695.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$726.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$617.35
|
| Rate for Payer: Healthfirst QHP |
$726.29
|
| Rate for Payer: Humana Medicare |
$740.82
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$726.29
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$726.29
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$726.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$726.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$581.03
|
| Rate for Payer: Wellcare Medicare |
$689.98
|
|
|
LOW COST SKIN AP TOTAL WOUND SUR
|
Facility
|
IP
|
$2,742.38
|
|
|
Service Code
|
HCPCS C5273
|
| Hospital Charge Code |
42500233
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$2,108.87
|
|
|
LOW COST SKIN AP TOTAL WOUND SUR
|
Facility
|
OP
|
$2,742.38
|
|
|
Service Code
|
HCPCS C5273
|
| Hospital Charge Code |
42500233
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$173.89 |
| Max. Negotiated Rate |
$2,151.05 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,108.87
|
| Rate for Payer: Aetna Government |
$2,108.87
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,476.21
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,476.21
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,476.21
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$2,108.87
|
| Rate for Payer: Cash Price |
$2,108.87
|
| Rate for Payer: Cash Price |
$2,108.87
|
| Rate for Payer: Cash Price |
$2,108.87
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2,108.87
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$2,108.87
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,792.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,876.89
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,108.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,876.89
|
| 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 |
$1,371.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,108.87
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,792.54
|
| Rate for Payer: Healthfirst QHP |
$2,108.87
|
| Rate for Payer: Humana Medicare |
$2,151.05
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2,108.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,108.87
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,108.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,108.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,687.10
|
| Rate for Payer: Wellcare Medicare |
$2,003.43
|
|
|
LOW COST SKIN SUB APP
|
Facility
|
OP
|
$1,390.00
|
|
|
Service Code
|
HCPCS C5275
|
| Hospital Charge Code |
42500456
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$508.40 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$726.29
|
| Rate for Payer: Aetna Government |
$726.29
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$508.40
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$508.40
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$508.40
|
| Rate for Payer: Brighton Health Commercial |
$1,042.50
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$726.29
|
| 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 |
$726.29
|
| Rate for Payer: EmblemHealth Commercial |
$726.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$617.35
|
| Rate for Payer: Fidelis Essential Plan QHP |
$646.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$726.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$646.40
|
| Rate for Payer: Group Health Inc Commercial |
$726.29
|
| Rate for Payer: Group Health Inc Medicare |
$726.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$695.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$726.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$617.35
|
| Rate for Payer: Healthfirst QHP |
$726.29
|
| Rate for Payer: Humana Medicare |
$740.82
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$726.29
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$726.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$726.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$581.03
|
| Rate for Payer: Wellcare Medicare |
$689.98
|
|
|
LOW COST SKIN SUB APP
|
Facility
|
IP
|
$1,390.00
|
|
|
Service Code
|
HCPCS C5275
|
| Hospital Charge Code |
42500456
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$726.29
|
|
|
LOW COST SKIN SUB GRFT ADL 100CM
|
Facility
|
OP
|
$261.11
|
|
|
Service Code
|
HCPCS C5274
|
| Hospital Charge Code |
42500234
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$130.56 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$130.56
|
| Rate for Payer: Aetna Government |
$130.56
|
| 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 |
$130.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$130.56
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
LOW CST SKIN AP GFT FACE,HAND,FT
|
Facility
|
OP
|
$120.25
|
|
|
Service Code
|
HCPCS C5276
|
| Hospital Charge Code |
42500236
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$60.12 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$60.12
|
| Rate for Payer: Aetna Government |
$60.12
|
| 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 |
$60.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$60.12
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC
|
Facility
|
IP
|
$55,870.58
|
|
|
Service Code
|
MSDRG 493
|
| Min. Negotiated Rate |
$18,894.41 |
| Max. Negotiated Rate |
$55,870.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$35,413.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$40,633.15
|
| Rate for Payer: Aetna Government |
$40,633.15
|
| Rate for Payer: Brighton Health Commercial |
$34,824.65
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$41,445.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$41,474.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$34,226.91
|
| Rate for Payer: Elderplan Medicare Advantage |
$38,601.49
|
| Rate for Payer: EmblemHealth Commercial |
$20,594.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$40,633.15
|
| Rate for Payer: Group Health Inc Commercial |
$40,633.15
|
| Rate for Payer: Group Health Inc Medicare |
$40,633.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$40,633.15
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18,894.41
|
| Rate for Payer: Humana Medicare |
$55,870.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$40,633.15
|
| Rate for Payer: United Healthcare Commercial |
$47,762.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40,633.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$40,633.15
|
| Rate for Payer: Wellcare Medicare |
$38,601.49
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC
|
Facility
|
IP
|
$76,089.92
|
|
|
Service Code
|
MSDRG 492
|
| Min. Negotiated Rate |
$25,732.23 |
| Max. Negotiated Rate |
$76,089.92 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$51,048.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$55,338.12
|
| Rate for Payer: Aetna Government |
$55,338.12
|
| Rate for Payer: Brighton Health Commercial |
$50,200.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$56,444.88
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$59,787.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$49,338.80
|
| Rate for Payer: Elderplan Medicare Advantage |
$52,571.21
|
| Rate for Payer: EmblemHealth Commercial |
$29,687.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$55,338.12
|
| Rate for Payer: Group Health Inc Commercial |
$55,338.12
|
| Rate for Payer: Group Health Inc Medicare |
$55,338.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$55,338.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25,732.23
|
| Rate for Payer: Humana Medicare |
$76,089.92
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$55,338.12
|
| Rate for Payer: United Healthcare Commercial |
$68,850.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$55,338.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$55,338.12
|
| Rate for Payer: Wellcare Medicare |
$52,571.21
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC
|
Facility
|
IP
|
$45,717.03
|
|
|
Service Code
|
MSDRG 494
|
| Min. Negotiated Rate |
$15,460.67 |
| Max. Negotiated Rate |
$45,717.03 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$27,561.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$33,248.75
|
| Rate for Payer: Aetna Government |
$33,248.75
|
| Rate for Payer: Brighton Health Commercial |
$27,103.40
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$33,913.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$32,279.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$26,638.19
|
| Rate for Payer: Elderplan Medicare Advantage |
$31,586.31
|
| Rate for Payer: EmblemHealth Commercial |
$16,028.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$33,248.75
|
| Rate for Payer: Group Health Inc Commercial |
$33,248.75
|
| Rate for Payer: Group Health Inc Medicare |
$33,248.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$33,248.75
|
| Rate for Payer: Healthfirst Medicare Advantage |
$15,460.67
|
| Rate for Payer: Humana Medicare |
$45,717.03
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$33,248.75
|
| Rate for Payer: United Healthcare Commercial |
$37,172.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33,248.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$33,248.75
|
| Rate for Payer: Wellcare Medicare |
$31,586.31
|
|
|
LOWER EXTREMITY STUDY UNI/LIMITED
|
Facility
|
OP
|
$330.30
|
|
|
Service Code
|
HCPCS 93926
|
| Hospital Charge Code |
30101695
|
|
Hospital Revenue Code
|
929
|
| Min. Negotiated Rate |
$89.00 |
| Max. Negotiated Rate |
$264.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$181.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$247.72
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$264.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$224.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$127.14
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$127.14
|
| Rate for Payer: Group Health Inc Medicare |
$127.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$165.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$108.07
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Commercial |
$94.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
LOWER EXTREMITY STUDY UNI/LIMITED
|
Facility
|
IP
|
$330.30
|
|
|
Service Code
|
HCPCS 93926
|
| Hospital Charge Code |
30101695
|
|
Hospital Revenue Code
|
929
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
LOWER LEG SPLINT
|
Facility
|
OP
|
$405.08
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
42500140
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$127.55 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$182.22
|
| Rate for Payer: Aetna Government |
$182.22
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$127.55
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$127.55
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$127.55
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$182.22
|
| 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 |
$182.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$154.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$162.18
|
| Rate for Payer: Fidelis Medicare Advantage |
$182.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$162.18
|
| 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 |
$202.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$182.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$154.89
|
| Rate for Payer: Healthfirst QHP |
$182.22
|
| Rate for Payer: Humana Medicare |
$185.86
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$182.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$182.22
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$182.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$182.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.78
|
| Rate for Payer: Wellcare Medicare |
$173.11
|
|
|
LOWER LEG SPLINT
|
Facility
|
IP
|
$405.08
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
42500140
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$182.22
|
|
|
LOW PROFILE 7 X 10CM
|
Facility
|
OP
|
$425.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903094
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$446.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$233.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$255.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$212.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$244.38
|
| Rate for Payer: EmblemHealth Commercial |
$212.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$446.25
|
| Rate for Payer: Group Health Inc Commercial |
$212.50
|
| Rate for Payer: Group Health Inc Medicare |
$148.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$212.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$212.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$276.25
|
|
|
LOW PROFILE 7 X 10CM
|
Facility
|
IP
|
$425.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903094
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$212.50 |
| Max. Negotiated Rate |
$212.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$212.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$212.50
|
|
|
LOW PROFILE 7 X 80CM
|
Facility
|
OP
|
$425.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903092
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$446.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$233.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$255.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$212.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$244.38
|
| Rate for Payer: EmblemHealth Commercial |
$212.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$446.25
|
| Rate for Payer: Group Health Inc Commercial |
$212.50
|
| Rate for Payer: Group Health Inc Medicare |
$148.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$212.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$212.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$276.25
|
|
|
LOW PROFILE 7 X 80CM
|
Facility
|
IP
|
$425.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903092
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$212.50 |
| Max. Negotiated Rate |
$212.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$212.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$212.50
|
|
|
LOW PROF MED 2H STRGHT PLATE
|
Facility
|
IP
|
$925.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40209980
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$462.60 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$462.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$462.60
|
|
|
LOW PROF MED 2H STRGHT PLATE
|
Facility
|
OP
|
$925.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40209980
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$971.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$508.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$555.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$462.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$531.99
|
| Rate for Payer: EmblemHealth Commercial |
$462.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$971.46
|
| Rate for Payer: Group Health Inc Commercial |
$462.60
|
| Rate for Payer: Group Health Inc Medicare |
$323.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$462.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$462.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$601.38
|
|
