|
LOW RISK FOR RETINOPATHY
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 3072F
|
| Hospital Charge Code |
30305436
|
|
Hospital Revenue Code
|
969
|
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$0.01
|
| 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: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
LOW SKIN GFT FACE,HAND,FEET 100SQ
|
Facility
|
IP
|
$818.82
|
|
|
Service Code
|
HCPCS C5277
|
| Hospital Charge Code |
42500237
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$726.29
|
|
|
LOW SKIN GFT FACE,HAND,FEET 100SQ
|
Facility
|
OP
|
$818.82
|
|
|
Service Code
|
HCPCS C5277
|
| Hospital Charge Code |
42500237
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$173.89 |
| Max. Negotiated Rate |
$1,888.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| 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 |
$409.41
|
| 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
|
|
|
L PD-CST METL BASE W/RES SAD INC
|
Facility
|
OP
|
$1,400.00
|
|
|
Service Code
|
HCPCS D5214
|
| Hospital Charge Code |
42300995
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$285.71 |
| Max. Negotiated Rate |
$28,571.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$770.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$444.73
|
| Rate for Payer: Aetna Government |
$444.73
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$642.85
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$642.85
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$285.71
|
| Rate for Payer: Amida Care Medicaid |
$285.71
|
| Rate for Payer: Brighton Health Commercial |
$1,050.00
|
| 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: Fidelis CHP/HARP/Medicaid |
$28,571.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$285.71
|
| Rate for Payer: Fidelis Essential Plan QHP |
$285.71
|
| Rate for Payer: Fidelis Qualified Health Plan |
$300.00
|
| Rate for Payer: Group Health Inc Commercial |
$700.00
|
| Rate for Payer: Group Health Inc Medicare |
$490.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$285.71
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$700.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$285.71
|
| Rate for Payer: Healthfirst Essential Plan |
$642.85
|
| Rate for Payer: Healthfirst QHP |
$285.71
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$285.71
|
| Rate for Payer: SOMOS Essential |
$642.85
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$642.85
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$314.28
|
| Rate for Payer: United Healthcare Medicaid |
$285.71
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$285.71
|
|
|
L PD-RESIN BASE INCL. CONVEN. CLA
|
Facility
|
OP
|
$875.00
|
|
|
Service Code
|
HCPCS D5212
|
| Hospital Charge Code |
42300985
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$306.25 |
| Max. Negotiated Rate |
$37,121.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$481.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$395.13
|
| Rate for Payer: Aetna Government |
$395.13
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$835.22
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$835.22
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$371.21
|
| Rate for Payer: Amida Care Medicaid |
$371.21
|
| Rate for Payer: Brighton Health Commercial |
$656.25
|
| 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: Fidelis CHP/HARP/Medicaid |
$37,121.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$371.21
|
| Rate for Payer: Fidelis Essential Plan QHP |
$371.21
|
| Rate for Payer: Fidelis Qualified Health Plan |
$389.77
|
| Rate for Payer: Group Health Inc Commercial |
$437.50
|
| Rate for Payer: Group Health Inc Medicare |
$306.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$371.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$437.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$371.21
|
| Rate for Payer: Healthfirst Essential Plan |
$835.22
|
| Rate for Payer: Healthfirst QHP |
$371.21
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$371.21
|
| Rate for Payer: SOMOS Essential |
$835.22
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$835.22
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$408.33
|
| Rate for Payer: United Healthcare Medicaid |
$371.21
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$371.21
|
|
|
L. PNEUMOPHILA SEROGP 1 UR AG
|
Facility
|
OP
|
$29.95
|
|
|
Service Code
|
HCPCS 87449
|
| Hospital Charge Code |
40619196
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.39 |
| Max. Negotiated Rate |
$22.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.47
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.98
|
| Rate for Payer: Aetna Government |
$11.98
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$8.39
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$8.39
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$8.39
|
| Rate for Payer: Brighton Health Commercial |
$22.46
|
| Rate for Payer: Cash Price |
$11.98
|
| Rate for Payer: Cash Price |
$11.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$11.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.13
|
| Rate for Payer: Elderplan Medicare Advantage |
$11.98
|
| Rate for Payer: EmblemHealth Commercial |
$11.98
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$10.18
|
| Rate for Payer: Fidelis Essential Plan QHP |
$10.66
|
| Rate for Payer: Fidelis Medicare Advantage |
$11.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$10.66
|
| Rate for Payer: Group Health Inc Commercial |
$11.98
|
| Rate for Payer: Group Health Inc Medicare |
$11.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$11.98
|
| Rate for Payer: Healthfirst QHP |
$11.98
|
| Rate for Payer: Humana Medicare |
$12.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$11.98
|
| Rate for Payer: United Healthcare Commercial |
$15.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.98
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$9.58
|
| Rate for Payer: Wellcare Medicare |
$10.78
|
|
|
L. PNEUMOPHILA SEROGP 1 UR AG
|
Facility
|
IP
|
$29.95
|
|
|
Service Code
|
HCPCS 87449
|
| Hospital Charge Code |
40619196
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$11.98
|
|
|
LP+NONHDL
|
Facility
|
IP
|
$33.48
|
|
|
Service Code
|
HCPCS 80061
|
| Hospital Charge Code |
40609820
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$13.39
|
|
|
LP+NONHDL
|
Facility
|
OP
|
$33.48
|
|
|
Service Code
|
HCPCS 80061
|
| Hospital Charge Code |
40609820
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.37 |
| Max. Negotiated Rate |
$25.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.41
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$13.39
|
| Rate for Payer: Aetna Government |
$13.39
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$9.37
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$9.37
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$9.37
|
| Rate for Payer: Brighton Health Commercial |
$25.11
|
| Rate for Payer: Cash Price |
$13.39
|
| Rate for Payer: Cash Price |
$13.39
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$13.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$20.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.51
|
| Rate for Payer: Elderplan Medicare Advantage |
$13.39
|
| Rate for Payer: EmblemHealth Commercial |
$13.39
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$11.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$11.92
|
| Rate for Payer: Fidelis Medicare Advantage |
$13.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$11.92
|
| Rate for Payer: Group Health Inc Commercial |
$13.39
|
| Rate for Payer: Group Health Inc Medicare |
$13.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.39
|
| Rate for Payer: Healthfirst Medicare Advantage |
$13.39
|
| Rate for Payer: Healthfirst QHP |
$13.39
|
| Rate for Payer: Humana Medicare |
$13.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$13.39
|
| Rate for Payer: United Healthcare Commercial |
$16.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.39
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$10.71
|
| Rate for Payer: Wellcare Medicare |
$12.05
|
|
|
LP PLT LSHAPE R LONG 0.6MM CP TIT
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40209900
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$150.00 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$150.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$150.00
|
|
|
LP PLT LSHAPE R LONG 0.6MM CP TIT
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40209900
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$315.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$165.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$180.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$150.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$172.50
|
| Rate for Payer: EmblemHealth Commercial |
$150.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$315.00
|
| Rate for Payer: Group Health Inc Commercial |
$150.00
|
| Rate for Payer: Group Health Inc Medicare |
$105.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$150.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$150.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$195.00
|
|
|
LP READER
|
Facility
|
OP
|
$697.50
|
|
| Hospital Charge Code |
64905947
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$244.12 |
| Max. Negotiated Rate |
$558.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$383.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$348.75
|
| Rate for Payer: Aetna Government |
$348.75
|
| Rate for Payer: Brighton Health Commercial |
$523.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$558.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$474.30
|
| Rate for Payer: Group Health Inc Commercial |
$348.75
|
| Rate for Payer: Group Health Inc Medicare |
$244.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$348.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$348.75
|
|
|
LP Tray Peds
|
Facility
|
OP
|
$72.65
|
|
| Hospital Charge Code |
40203800
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$25.43 |
| Max. Negotiated Rate |
$58.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$39.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$36.32
|
| Rate for Payer: Aetna Government |
$36.32
|
| Rate for Payer: Brighton Health Commercial |
$54.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$58.12
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$49.40
|
| Rate for Payer: Group Health Inc Commercial |
$36.32
|
| Rate for Payer: Group Health Inc Medicare |
$25.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$36.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$36.32
|
|
|
LRG AL ID PLAQUE CLEAR BT TRAY
|
Facility
|
OP
|
$13.50
|
|
| Hospital Charge Code |
64903492
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.72 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.75
|
| Rate for Payer: Aetna Government |
$6.75
|
| Rate for Payer: Brighton Health Commercial |
$10.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.18
|
| Rate for Payer: Group Health Inc Commercial |
$6.75
|
| Rate for Payer: Group Health Inc Medicare |
$4.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.75
|
|
|
LRG AL ID PLAQUE CLEAR CERC ST
|
Facility
|
OP
|
$13.50
|
|
| Hospital Charge Code |
64903490
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.72 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.75
|
| Rate for Payer: Aetna Government |
$6.75
|
| Rate for Payer: Brighton Health Commercial |
$10.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.18
|
| Rate for Payer: Group Health Inc Commercial |
$6.75
|
| Rate for Payer: Group Health Inc Medicare |
$4.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.75
|
|
|
LRG AL ID PLAQUE CLEAR L&D TRAY
|
Facility
|
OP
|
$15.75
|
|
| Hospital Charge Code |
64903495
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.51 |
| Max. Negotiated Rate |
$12.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.88
|
| Rate for Payer: Aetna Government |
$7.88
|
| Rate for Payer: Brighton Health Commercial |
$11.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.71
|
| Rate for Payer: Group Health Inc Commercial |
$7.88
|
| Rate for Payer: Group Health Inc Medicare |
$5.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.88
|
|
|
LRG AL ID PLAQUE CLEAR PROLAP ST
|
Facility
|
OP
|
$15.75
|
|
| Hospital Charge Code |
64903466
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.51 |
| Max. Negotiated Rate |
$12.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.88
|
| Rate for Payer: Aetna Government |
$7.88
|
| Rate for Payer: Brighton Health Commercial |
$11.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.71
|
| Rate for Payer: Group Health Inc Commercial |
$7.88
|
| Rate for Payer: Group Health Inc Medicare |
$5.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.88
|
|
|
LRG AL ID PLAQUE CLEAR VAG SET
|
Facility
|
OP
|
$15.75
|
|
| Hospital Charge Code |
64903488
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.51 |
| Max. Negotiated Rate |
$12.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.88
|
| Rate for Payer: Aetna Government |
$7.88
|
| Rate for Payer: Brighton Health Commercial |
$11.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.71
|
| Rate for Payer: Group Health Inc Commercial |
$7.88
|
| Rate for Payer: Group Health Inc Medicare |
$5.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.88
|
|
|
LRPYODPRTMUM HONRY 15ML GEL
|
Facility
|
OP
|
$10.30
|
|
|
Service Code
|
HCPCS A6261
|
| Hospital Charge Code |
41646484
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$8.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.84
|
| Rate for Payer: Aetna Government |
$1.84
|
| Rate for Payer: Brighton Health Commercial |
$7.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.00
|
| Rate for Payer: Group Health Inc Commercial |
$5.15
|
| Rate for Payer: Group Health Inc Medicare |
$3.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.15
|
|
|
LS 1037 10MM LIGA SURE ATLAS
|
Facility
|
OP
|
$5,340.00
|
|
| Hospital Charge Code |
40209568
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,869.00 |
| Max. Negotiated Rate |
$4,272.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,937.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,670.00
|
| Rate for Payer: Aetna Government |
$2,670.00
|
| Rate for Payer: Brighton Health Commercial |
$4,005.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,272.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,631.20
|
| Rate for Payer: Group Health Inc Commercial |
$2,670.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,869.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,670.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,670.00
|
|
|
LS 1500 5MM LIGA SURE V
|
Facility
|
OP
|
$5,624.80
|
|
| Hospital Charge Code |
40209567
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,968.68 |
| Max. Negotiated Rate |
$4,499.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3,093.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,812.40
|
| Rate for Payer: Aetna Government |
$2,812.40
|
| Rate for Payer: Brighton Health Commercial |
$4,218.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,499.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,824.86
|
| Rate for Payer: Group Health Inc Commercial |
$2,812.40
|
| Rate for Payer: Group Health Inc Medicare |
$1,968.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,812.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,812.40
|
|
|
L STD,LONG DR PLATE
|
Facility
|
OP
|
$1,400.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40201360
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$1,470.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$770.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$840.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$700.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$805.00
|
| Rate for Payer: EmblemHealth Commercial |
$700.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,470.00
|
| Rate for Payer: Group Health Inc Commercial |
$700.00
|
| Rate for Payer: Group Health Inc Medicare |
$490.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$700.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$700.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$910.00
|
|
|
L STD,LONG DR PLATE
|
Facility
|
IP
|
$1,400.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40201360
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$700.00 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$700.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$700.00
|
|
|
LT/5HL/L/5MM ADVC 100D RT STD
|
Facility
|
OP
|
$317.10
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40204203
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$110.98 |
| Max. Negotiated Rate |
$332.96 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$174.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$190.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$158.55
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$182.33
|
| Rate for Payer: EmblemHealth Commercial |
$158.55
|
| Rate for Payer: Fidelis Medicare Advantage |
$332.96
|
| Rate for Payer: Group Health Inc Commercial |
$158.55
|
| Rate for Payer: Group Health Inc Medicare |
$110.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$158.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$158.55
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$206.12
|
|
|
LT/5HL/L/5MM ADVC 100D RT STD
|
Facility
|
IP
|
$317.10
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40204203
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$158.55 |
| Max. Negotiated Rate |
$158.55 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$158.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$158.55
|
|
