|
MANIPULATE ELBOW W/ANESTHESIA
|
Facility
|
IP
|
$4,105.13
|
|
|
Service Code
|
HCPCS 24300
|
| Hospital Charge Code |
40029409
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,858.61
|
|
|
MANIPULATE ELBOW W/ANESTHESIA
|
Facility
|
OP
|
$4,105.13
|
|
|
Service Code
|
HCPCS 24300
|
| Hospital Charge Code |
40029409
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,301.03 |
| Max. Negotiated Rate |
$3,078.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| 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 |
$1,505.00
|
| 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 |
$1,409.00
|
| 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
|
|
|
Manipulation, elbow, under anesthesia
|
Facility
|
OP
|
$2,915.00
|
|
|
Service Code
|
CPT 24300
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,301.03 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| 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: 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 |
$1,505.00
|
| 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 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 |
$1,409.00
|
| 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
|
|
|
Manipulation, finger joint, under anesthesia, each joint
|
Facility
|
OP
|
$2,915.00
|
|
|
Service Code
|
CPT 26340
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$780.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| 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: 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 |
$1,505.00
|
| 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 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 |
$1,113.00
|
| 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
|
|
|
MANIPULATION KNEE
|
Facility
|
OP
|
$4,105.13
|
|
|
Service Code
|
HCPCS 27570
|
| Hospital Charge Code |
40014310
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,301.03 |
| Max. Negotiated Rate |
$3,078.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| 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 |
$1,505.00
|
| 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 |
$1,409.00
|
| 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
|
|
|
MANIPULATION KNEE
|
Facility
|
IP
|
$4,105.13
|
|
|
Service Code
|
HCPCS 27570
|
| Hospital Charge Code |
40014310
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,858.61
|
|
|
Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)
|
Facility
|
OP
|
$2,915.00
|
|
|
Service Code
|
CPT 27570
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,301.03 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,858.61
|
| 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: 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 |
$1,505.00
|
| 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 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 |
$1,409.00
|
| 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
|
|
|
Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)
|
Facility
|
OP
|
$2,915.00
|
|
|
Service Code
|
CPT 23700
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,301.03 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,858.61
|
| 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: 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 |
$1,505.00
|
| 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 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 |
$1,409.00
|
| 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
|
|
|
MANIPULATION UNDER ANESTHESIA TMJ
|
Facility
|
OP
|
$435.00
|
|
|
Service Code
|
HCPCS D7830
|
| Hospital Charge Code |
42301950
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$124.12 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$239.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$124.12
|
| Rate for Payer: Aetna Government |
$124.12
|
| Rate for Payer: Brighton Health Commercial |
$326.25
|
| 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: Group Health Inc Commercial |
$217.50
|
| Rate for Payer: Group Health Inc Medicare |
$152.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$217.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$217.50
|
|
|
MANIPULATOR UTERINE 7CM
|
Facility
|
OP
|
$137.50
|
|
| Hospital Charge Code |
64902970
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$48.12 |
| Max. Negotiated Rate |
$110.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$75.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$68.75
|
| Rate for Payer: Aetna Government |
$68.75
|
| Rate for Payer: Brighton Health Commercial |
$103.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$110.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$93.50
|
| Rate for Payer: Group Health Inc Commercial |
$68.75
|
| Rate for Payer: Group Health Inc Medicare |
$48.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$68.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$68.75
|
|
|
MANIPULATOR UTERINE LARGE
|
Facility
|
OP
|
$220.00
|
|
| Hospital Charge Code |
64904922
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$121.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$110.00
|
| Rate for Payer: Aetna Government |
$110.00
|
| Rate for Payer: Brighton Health Commercial |
$165.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$176.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$149.60
|
| Rate for Payer: Group Health Inc Commercial |
$110.00
|
| Rate for Payer: Group Health Inc Medicare |
$77.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$110.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$110.00
|
|
|
MANIPULATOR UTERINE MED
|
Facility
|
OP
|
$220.00
|
|
| Hospital Charge Code |
64904919
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$121.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$110.00
|
| Rate for Payer: Aetna Government |
$110.00
|
| Rate for Payer: Brighton Health Commercial |
$165.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$176.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$149.60
|
| Rate for Payer: Group Health Inc Commercial |
$110.00
|
| Rate for Payer: Group Health Inc Medicare |
$77.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$110.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$110.00
|
|
|
MANNITOL 20% INFUSION 500 ML
|
Facility
|
OP
|
$30.99
|
|
|
Service Code
|
HCPCS J2150
|
| Hospital Charge Code |
41641221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$20.14 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$17.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.52
|
| Rate for Payer: Aetna Government |
$2.52
|
| Rate for Payer: Brighton Health Commercial |
$18.59
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.82
|
| Rate for Payer: Group Health Inc Commercial |
$15.50
|
| Rate for Payer: Group Health Inc Medicare |
$10.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$4.79
|
| Rate for Payer: SOMOS Essential |
$4.79
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$20.14
|
|
|
MANNITOL 20% INFUSION 500 ML
|
Facility
|
IP
|
$30.99
|
|
|
Service Code
|
HCPCS J2150
|
| Hospital Charge Code |
41641221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$15.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.50
|
|
|
MANNITOL 20% INFUSION 500 ML
|
Facility
|
IP
|
$30.99
|
|
|
Service Code
|
HCPCS J2150
|
| Hospital Charge Code |
41651221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$15.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.50
|
|
|
MANNITOL 20% INFUSION 500 ML
|
Facility
|
OP
|
$30.99
|
|
|
Service Code
|
HCPCS J2150
|
| Hospital Charge Code |
41651221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$20.14 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$17.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.52
|
| Rate for Payer: Aetna Government |
$2.52
|
| Rate for Payer: Brighton Health Commercial |
$18.59
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.82
|
| Rate for Payer: Group Health Inc Commercial |
$15.50
|
| Rate for Payer: Group Health Inc Medicare |
$10.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$4.79
|
| Rate for Payer: SOMOS Essential |
$4.79
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$20.14
|
|
|
MANNITOL 20 % IV SOLN [4749]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 00338035703
|
| Hospital Charge Code |
00338035703
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.08
|
|
|
MANNITOL 20 % IV SOLN [4749]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 00338035703
|
| Hospital Charge Code |
00338035703
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.08
|
| Rate for Payer: Aetna Government |
$0.08
|
| Rate for Payer: Brighton Health Commercial |
$0.09
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.09
|
| Rate for Payer: EmblemHealth Commercial |
$0.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$0.16
|
| Rate for Payer: Group Health Inc Commercial |
$0.08
|
| Rate for Payer: Group Health Inc Medicare |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.10
|
|
|
MANNITOL 25% 12.5 GRAM INJ
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
HCPCS J2150
|
| Hospital Charge Code |
41643780
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.40
|
|
|
MANNITOL 25% 12.5 GRAM INJ
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
HCPCS J2150
|
| Hospital Charge Code |
41653780
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$4.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.52
|
| Rate for Payer: Aetna Government |
$2.52
|
| Rate for Payer: Brighton Health Commercial |
$2.88
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.76
|
| Rate for Payer: Group Health Inc Commercial |
$2.40
|
| Rate for Payer: Group Health Inc Medicare |
$1.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.40
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$4.79
|
| Rate for Payer: SOMOS Essential |
$4.79
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.12
|
|
|
MANNITOL 25% 12.5 GRAM INJ
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
HCPCS J2150
|
| Hospital Charge Code |
41653780
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.40
|
|
|
MANNITOL 25% 12.5 GRAM INJ
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
HCPCS J2150
|
| Hospital Charge Code |
41643780
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$4.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.52
|
| Rate for Payer: Aetna Government |
$2.52
|
| Rate for Payer: Brighton Health Commercial |
$2.88
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.76
|
| Rate for Payer: Group Health Inc Commercial |
$2.40
|
| Rate for Payer: Group Health Inc Medicare |
$1.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.40
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$4.79
|
| Rate for Payer: SOMOS Essential |
$4.79
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.12
|
|
|
MANNITOL 25 % IV SOLN [4750]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
HCPCS J2150
|
| Hospital Charge Code |
63323002425
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
|
|
MANNITOL 25 % IV SOLN [4750]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
HCPCS J2150
|
| Hospital Charge Code |
63323002425
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.52
|
| Rate for Payer: Aetna Government |
$2.52
|
| Rate for Payer: Brighton Health Commercial |
$0.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.07
|
| Rate for Payer: EmblemHealth Commercial |
$0.06
|
| Rate for Payer: Fidelis Medicare Advantage |
$0.13
|
| Rate for Payer: Group Health Inc Commercial |
$0.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.08
|
|
|
M ANTIGEN
|
Facility
|
IP
|
$858.38
|
|
|
Service Code
|
HCPCS 86905
|
| Hospital Charge Code |
40701260
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$415.67
|
|
