|
PR RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS
|
Professional
|
Both
|
$6,799.28
|
|
|
Service Code
|
HCPCS 21146
|
| Min. Negotiated Rate |
$1,285.49 |
| Max. Negotiated Rate |
$4,131.94 |
| Rate for Payer: Cash Price |
$1,844.37
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,836.42
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,652.78
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,652.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,744.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,836.42
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,744.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,836.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,836.42
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,377.32
|
| Rate for Payer: Healthfirst Commercial |
$1,836.42
|
| Rate for Payer: Healthfirst Essential Plan |
$4,131.94
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,744.60
|
| Rate for Payer: Healthfirst QHP |
$1,836.42
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,285.49
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,836.42
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,560.96
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,285.49
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,836.42
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,377.32
|
| Rate for Payer: SOMOS Essential |
$1,377.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,836.42
|
|
|
PR RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT
|
Professional
|
Both
|
$5,756.28
|
|
|
Service Code
|
HCPCS 21142
|
| Min. Negotiated Rate |
$1,088.34 |
| Max. Negotiated Rate |
$3,498.23 |
| Rate for Payer: Cash Price |
$1,561.77
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,554.77
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,399.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,399.29
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,477.03
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,554.77
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,477.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,554.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,554.77
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,166.08
|
| Rate for Payer: Healthfirst Commercial |
$1,554.77
|
| Rate for Payer: Healthfirst Essential Plan |
$3,498.23
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,477.03
|
| Rate for Payer: Healthfirst QHP |
$1,554.77
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,088.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,554.77
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,321.55
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,088.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,554.77
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,166.08
|
| Rate for Payer: SOMOS Essential |
$1,166.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,554.77
|
|
|
PR RCNSTJ MIDFACE LEFORT I 3/> PIECE W/BONE GRAFTS
|
Professional
|
Both
|
$7,162.37
|
|
|
Service Code
|
HCPCS 21147
|
| Min. Negotiated Rate |
$1,350.94 |
| Max. Negotiated Rate |
$4,342.32 |
| Rate for Payer: Cash Price |
$1,939.26
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,929.92
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,736.93
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,736.93
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,833.42
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,929.92
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,833.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,929.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,929.92
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,447.44
|
| Rate for Payer: Healthfirst Commercial |
$1,929.92
|
| Rate for Payer: Healthfirst Essential Plan |
$4,342.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,833.42
|
| Rate for Payer: Healthfirst QHP |
$1,929.92
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,350.94
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,929.92
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,640.43
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,350.94
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,929.92
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,447.44
|
| Rate for Payer: SOMOS Essential |
$1,447.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,929.92
|
|
|
PR RCNSTJ MIDFACE LEFORT I 3/> PIECE W/O BONE GRAFT
|
Professional
|
Both
|
$5,927.92
|
|
|
Service Code
|
HCPCS 21143
|
| Min. Negotiated Rate |
$1,121.34 |
| Max. Negotiated Rate |
$3,604.32 |
| Rate for Payer: Cash Price |
$1,609.35
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,601.92
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,441.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,441.73
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,521.82
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,601.92
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,521.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,601.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,601.92
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,201.44
|
| Rate for Payer: Healthfirst Commercial |
$1,601.92
|
| Rate for Payer: Healthfirst Essential Plan |
$3,604.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,521.82
|
| Rate for Payer: Healthfirst QHP |
$1,601.92
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,121.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,601.92
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,361.63
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,121.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,601.92
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,201.44
|
| Rate for Payer: SOMOS Essential |
$1,201.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,601.92
|
|
|
PR RCNSTJ MIDFACE LEFORT II ANTERIOR INTRUSION
|
Professional
|
Both
|
$7,069.93
|
|
|
Service Code
|
HCPCS 21150
|
| Min. Negotiated Rate |
$1,318.76 |
| Max. Negotiated Rate |
$4,238.86 |
| Rate for Payer: Cash Price |
$1,908.82
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,883.94
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,695.55
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,695.55
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,789.74
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,883.94
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,789.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,883.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,883.94
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,412.95
|
| Rate for Payer: Healthfirst Commercial |
$1,883.94
|
| Rate for Payer: Healthfirst Essential Plan |
$4,238.86
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,789.74
|
| Rate for Payer: Healthfirst QHP |
$1,883.94
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,318.76
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,883.94
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,601.35
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,318.76
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,883.94
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,412.95
|
| Rate for Payer: SOMOS Essential |
$1,412.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,883.94
|
|
|
PR RCNSTJ MIDFACE LEFORT III W/FHD W/LEFORT I
|
Professional
|
Both
|
$12,057.47
|
|
|
Service Code
|
HCPCS 21160
|
| Min. Negotiated Rate |
$2,249.81 |
| Max. Negotiated Rate |
$7,231.55 |
| Rate for Payer: Cash Price |
$3,251.79
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,214.02
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$2,892.62
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2,892.62
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,053.32
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,214.02
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,053.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,214.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,214.02
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$2,410.51
|
| Rate for Payer: Healthfirst Commercial |
$3,214.02
|
| Rate for Payer: Healthfirst Essential Plan |
$7,231.55
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,053.32
|
| Rate for Payer: Healthfirst QHP |
$3,214.02
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2,249.81
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$3,214.02
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2,731.92
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2,249.81
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,214.02
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$2,410.51
|
| Rate for Payer: SOMOS Essential |
$2,410.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,214.02
|
|
|
PR RCNSTJ MIDFACE LEFORT III W/FHD W/O LEFORT I
|
Professional
|
Both
|
$11,115.65
|
|
|
Service Code
|
HCPCS 21159
|
| Min. Negotiated Rate |
$2,075.59 |
| Max. Negotiated Rate |
$6,671.54 |
| Rate for Payer: Cash Price |
$2,999.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2,965.13
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$2,668.62
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2,668.62
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2,816.87
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,965.13
|
| Rate for Payer: Fidelis Qualified Health Plan |
$2,816.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,965.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,965.13
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$2,223.85
|
| Rate for Payer: Healthfirst Commercial |
$2,965.13
|
| Rate for Payer: Healthfirst Essential Plan |
$6,671.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2,816.87
|
| Rate for Payer: Healthfirst QHP |
$2,965.13
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2,075.59
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2,965.13
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2,520.36
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2,075.59
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,965.13
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$2,223.85
|
| Rate for Payer: SOMOS Essential |
$2,223.85
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,965.13
|
|
|
PR RCNSTJ MIDFACE LEFORT III W/LEFORT I
|
Professional
|
Both
|
$9,281.06
|
|
|
Service Code
|
HCPCS 21155
|
| Min. Negotiated Rate |
$1,732.79 |
| Max. Negotiated Rate |
$5,569.69 |
| Rate for Payer: Cash Price |
$2,506.47
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2,475.42
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$2,227.88
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2,227.88
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2,351.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,475.42
|
| Rate for Payer: Fidelis Qualified Health Plan |
$2,351.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,475.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,475.42
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,856.57
|
| Rate for Payer: Healthfirst Commercial |
$2,475.42
|
| Rate for Payer: Healthfirst Essential Plan |
$5,569.69
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2,351.65
|
| Rate for Payer: Healthfirst QHP |
$2,475.42
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,732.79
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2,475.42
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2,104.11
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,732.79
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,475.42
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,856.57
|
| Rate for Payer: SOMOS Essential |
$1,856.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,475.42
|
|
|
PR RCNSTJ MIDFACE LEFORT III W/O LEFORT I
|
Professional
|
Both
|
$8,369.66
|
|
|
Service Code
|
HCPCS 21154
|
| Min. Negotiated Rate |
$1,562.83 |
| Max. Negotiated Rate |
$5,023.37 |
| Rate for Payer: Cash Price |
$2,260.20
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2,232.61
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$2,009.35
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2,009.35
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2,120.98
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,232.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$2,120.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,232.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,232.61
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,674.46
|
| Rate for Payer: Healthfirst Commercial |
$2,232.61
|
| Rate for Payer: Healthfirst Essential Plan |
$5,023.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2,120.98
|
| Rate for Payer: Healthfirst QHP |
$2,232.61
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,562.83
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2,232.61
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,897.72
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,562.83
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,232.61
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,674.46
|
| Rate for Payer: SOMOS Essential |
$1,674.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,232.61
|
|
|
PR RCNSTJ MIDFACE LEFORT II W/BONE GRAFTS
|
Professional
|
Both
|
$7,780.61
|
|
|
Service Code
|
HCPCS 21151
|
| Min. Negotiated Rate |
$1,450.99 |
| Max. Negotiated Rate |
$4,663.89 |
| Rate for Payer: Cash Price |
$2,099.88
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2,072.84
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,865.56
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,865.56
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,969.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,072.84
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,969.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,072.84
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,072.84
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,554.63
|
| Rate for Payer: Healthfirst Commercial |
$2,072.84
|
| Rate for Payer: Healthfirst Essential Plan |
$4,663.89
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,969.20
|
| Rate for Payer: Healthfirst QHP |
$2,072.84
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,450.99
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2,072.84
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,761.91
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,450.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,072.84
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,554.63
|
| Rate for Payer: SOMOS Essential |
$1,554.63
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,072.84
|
|
|
PR RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT COMPLETE
|
Professional
|
Both
|
$3,572.52
|
|
|
Service Code
|
HCPCS 21246
|
| Min. Negotiated Rate |
$676.63 |
| Max. Negotiated Rate |
$2,174.89 |
| Rate for Payer: Cash Price |
$970.32
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$966.62
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$869.96
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$869.96
|
| Rate for Payer: Fidelis Essential Plan QHP |
$918.29
|
| Rate for Payer: Fidelis Medicare Advantage |
$966.62
|
| Rate for Payer: Fidelis Qualified Health Plan |
$918.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$966.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$966.62
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$724.97
|
| Rate for Payer: Healthfirst Commercial |
$966.62
|
| Rate for Payer: Healthfirst Essential Plan |
$2,174.89
|
| Rate for Payer: Healthfirst Medicare Advantage |
$918.29
|
| Rate for Payer: Healthfirst QHP |
$966.62
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$676.63
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$966.62
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$821.63
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$676.63
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$966.62
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$724.97
|
| Rate for Payer: SOMOS Essential |
$724.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$966.62
|
|
|
PR RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT PARTIAL
|
Professional
|
Both
|
$3,999.80
|
|
|
Service Code
|
HCPCS 21245
|
| Min. Negotiated Rate |
$754.91 |
| Max. Negotiated Rate |
$2,426.51 |
| Rate for Payer: Cash Price |
$1,084.64
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,078.45
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$970.61
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$970.61
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,024.53
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,078.45
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,024.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,078.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,078.45
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$808.84
|
| Rate for Payer: Healthfirst Commercial |
$1,078.45
|
| Rate for Payer: Healthfirst Essential Plan |
$2,426.51
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,024.53
|
| Rate for Payer: Healthfirst QHP |
$1,078.45
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$754.91
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,078.45
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$916.68
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$754.91
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,078.45
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$808.84
|
| Rate for Payer: SOMOS Essential |
$808.84
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,078.45
|
|
|
PR RCNSTJ MNDBLR CONDYLE W/BONE CARTLG AUTOGRAFTS
|
Professional
|
Both
|
$6,640.76
|
|
|
Service Code
|
HCPCS 21247
|
| Min. Negotiated Rate |
$1,255.19 |
| Max. Negotiated Rate |
$4,034.54 |
| Rate for Payer: Cash Price |
$1,800.79
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,793.13
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,613.82
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,613.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,703.47
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,793.13
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,703.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,793.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,793.13
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,344.85
|
| Rate for Payer: Healthfirst Commercial |
$1,793.13
|
| Rate for Payer: Healthfirst Essential Plan |
$4,034.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,703.47
|
| Rate for Payer: Healthfirst QHP |
$1,793.13
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,255.19
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,793.13
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,524.16
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,255.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,793.13
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,344.85
|
| Rate for Payer: SOMOS Essential |
$1,344.85
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,793.13
|
|
|
PR RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FI
|
Professional
|
Both
|
$6,032.88
|
|
|
Service Code
|
HCPCS 21196
|
| Min. Negotiated Rate |
$1,136.25 |
| Max. Negotiated Rate |
$3,652.24 |
| Rate for Payer: Cash Price |
$1,633.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,623.22
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,460.90
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,460.90
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,542.06
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,623.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,542.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,623.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,623.22
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,217.41
|
| Rate for Payer: Healthfirst Commercial |
$1,623.22
|
| Rate for Payer: Healthfirst Essential Plan |
$3,652.24
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,542.06
|
| Rate for Payer: Healthfirst QHP |
$1,623.22
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,136.25
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,623.22
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,379.74
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,136.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,623.22
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,217.41
|
| Rate for Payer: SOMOS Essential |
$1,217.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,623.22
|
|
|
PR RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD
|
Professional
|
Both
|
$5,653.31
|
|
|
Service Code
|
HCPCS 21195
|
| Min. Negotiated Rate |
$1,064.17 |
| Max. Negotiated Rate |
$3,420.56 |
| Rate for Payer: Cash Price |
$1,530.76
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,520.25
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,368.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,368.22
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,444.24
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,520.25
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,444.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,520.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,520.25
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,140.19
|
| Rate for Payer: Healthfirst Commercial |
$1,520.25
|
| Rate for Payer: Healthfirst Essential Plan |
$3,420.56
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,444.24
|
| Rate for Payer: Healthfirst QHP |
$1,520.25
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,064.17
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,520.25
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,292.21
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,064.17
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,520.25
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,140.19
|
| Rate for Payer: SOMOS Essential |
$1,140.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,520.25
|
|
|
PR RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRAFT
|
Professional
|
Both
|
$5,988.61
|
|
|
Service Code
|
HCPCS 21194
|
| Min. Negotiated Rate |
$1,131.58 |
| Max. Negotiated Rate |
$3,637.22 |
| Rate for Payer: Cash Price |
$1,622.27
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,616.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,454.89
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,454.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,535.71
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,616.54
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,535.71
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,616.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,616.54
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,212.40
|
| Rate for Payer: Healthfirst Commercial |
$1,616.54
|
| Rate for Payer: Healthfirst Essential Plan |
$3,637.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,535.71
|
| Rate for Payer: Healthfirst QHP |
$1,616.54
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,131.58
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,616.54
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,374.06
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,131.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,616.54
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,212.40
|
| Rate for Payer: SOMOS Essential |
$1,212.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,616.54
|
|
|
PR RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF
|
Professional
|
Both
|
$5,179.72
|
|
|
Service Code
|
HCPCS 21193
|
| Min. Negotiated Rate |
$979.01 |
| Max. Negotiated Rate |
$3,146.83 |
| Rate for Payer: Cash Price |
$1,403.44
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,398.59
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,258.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,258.73
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,328.66
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,398.59
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,328.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,398.59
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,398.59
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,048.94
|
| Rate for Payer: Healthfirst Commercial |
$1,398.59
|
| Rate for Payer: Healthfirst Essential Plan |
$3,146.83
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,328.66
|
| Rate for Payer: Healthfirst QHP |
$1,398.59
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$979.01
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,398.59
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,188.80
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$979.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,398.59
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,048.94
|
| Rate for Payer: SOMOS Essential |
$1,048.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,398.59
|
|
|
PR RCNSTJ MNDBL XTRORAL W/TRANSOSTEAL BONE PLATE
|
Professional
|
Both
|
$4,312.35
|
|
|
Service Code
|
HCPCS 21244
|
| Min. Negotiated Rate |
$809.27 |
| Max. Negotiated Rate |
$2,601.22 |
| Rate for Payer: Cash Price |
$1,169.37
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,156.10
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,040.49
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,040.49
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,098.30
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,156.10
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,098.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,156.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,156.10
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$867.08
|
| Rate for Payer: Healthfirst Commercial |
$1,156.10
|
| Rate for Payer: Healthfirst Essential Plan |
$2,601.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,098.30
|
| Rate for Payer: Healthfirst QHP |
$1,156.10
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$809.27
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,156.10
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$982.68
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$809.27
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,156.10
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$867.08
|
| Rate for Payer: SOMOS Essential |
$867.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,156.10
|
|
|
PR RCNSTJ ORBIT/FHD/NASETHMD EXC BONE GRF>40 <80
|
Professional
|
Both
|
$10,044.23
|
|
|
Service Code
|
HCPCS 21183
|
| Min. Negotiated Rate |
$1,878.14 |
| Max. Negotiated Rate |
$6,036.89 |
| Rate for Payer: Cash Price |
$2,696.30
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2,683.06
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$2,414.75
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2,414.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2,548.91
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,683.06
|
| Rate for Payer: Fidelis Qualified Health Plan |
$2,548.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,683.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,683.06
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$2,012.30
|
| Rate for Payer: Healthfirst Commercial |
$2,683.06
|
| Rate for Payer: Healthfirst Essential Plan |
$6,036.89
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2,548.91
|
| Rate for Payer: Healthfirst QHP |
$2,683.06
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,878.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2,683.06
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2,280.60
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,878.14
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,683.06
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$2,012.30
|
| Rate for Payer: SOMOS Essential |
$2,012.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,683.06
|
|
|
PR RCNSTJ ORBIT/FHD/NASETHMD EXCBONE TUM GRF<40SQCM
|
Professional
|
Both
|
$9,231.57
|
|
|
Service Code
|
HCPCS 21182
|
| Min. Negotiated Rate |
$1,727.59 |
| Max. Negotiated Rate |
$5,552.98 |
| Rate for Payer: Cash Price |
$2,479.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2,467.99
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$2,221.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2,221.19
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2,344.59
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,467.99
|
| Rate for Payer: Fidelis Qualified Health Plan |
$2,344.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,467.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,467.99
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,850.99
|
| Rate for Payer: Healthfirst Commercial |
$2,467.99
|
| Rate for Payer: Healthfirst Essential Plan |
$5,552.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2,344.59
|
| Rate for Payer: Healthfirst QHP |
$2,467.99
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,727.59
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2,467.99
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2,097.79
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,727.59
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,467.99
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,850.99
|
| Rate for Payer: SOMOS Essential |
$1,850.99
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,467.99
|
|
|
PR RCNSTJ ORBIT/FHD/NASETHMD EXC BONE TUM GRF>80SQ
|
Professional
|
Both
|
$10,798.20
|
|
|
Service Code
|
HCPCS 21184
|
| Min. Negotiated Rate |
$2,018.88 |
| Max. Negotiated Rate |
$6,489.25 |
| Rate for Payer: Cash Price |
$2,900.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2,884.11
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$2,595.70
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2,595.70
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2,739.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,884.11
|
| Rate for Payer: Fidelis Qualified Health Plan |
$2,739.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,884.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,884.11
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$2,163.08
|
| Rate for Payer: Healthfirst Commercial |
$2,884.11
|
| Rate for Payer: Healthfirst Essential Plan |
$6,489.25
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2,739.90
|
| Rate for Payer: Healthfirst QHP |
$2,884.11
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2,018.88
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2,884.11
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2,451.49
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2,018.88
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,884.11
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$2,163.08
|
| Rate for Payer: SOMOS Essential |
$2,163.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,884.11
|
|
|
PR RCNSTJ PLSTC BILIARY DUCTS W/END-TO-END ANAST
|
Professional
|
Both
|
$6,967.56
|
|
|
Service Code
|
HCPCS 47800
|
| Min. Negotiated Rate |
$1,294.15 |
| Max. Negotiated Rate |
$4,159.78 |
| Rate for Payer: Cash Price |
$1,855.36
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,848.79
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,663.91
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,663.91
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,756.35
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,848.79
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,756.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,848.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,848.79
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,386.59
|
| Rate for Payer: Healthfirst Commercial |
$1,848.79
|
| Rate for Payer: Healthfirst Essential Plan |
$4,159.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,756.35
|
| Rate for Payer: Healthfirst QHP |
$1,848.79
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,294.15
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,848.79
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,571.47
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,294.15
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,848.79
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,386.59
|
| Rate for Payer: SOMOS Essential |
$1,386.59
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,848.79
|
|
|
PR RCNSTJ POLYDACTYLOUS DIGIT SOFT TISSUE & BONE
|
Professional
|
Both
|
$4,620.49
|
|
|
Service Code
|
HCPCS 26587
|
| Min. Negotiated Rate |
$871.23 |
| Max. Negotiated Rate |
$2,800.37 |
| Rate for Payer: Cash Price |
$1,248.51
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,244.61
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,120.15
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,120.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,182.38
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,244.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,182.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,244.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,244.61
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$933.46
|
| Rate for Payer: Healthfirst Commercial |
$1,244.61
|
| Rate for Payer: Healthfirst Essential Plan |
$2,800.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,182.38
|
| Rate for Payer: Healthfirst QHP |
$1,244.61
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$871.23
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,244.61
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,057.92
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$871.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,244.61
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$933.46
|
| Rate for Payer: SOMOS Essential |
$933.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,244.61
|
|
|
PR RCNSTJ PST TIBL TDN W/EXC ACCESSORY TARSL NAVCLR
|
Professional
|
Both
|
$2,075.68
|
|
|
Service Code
|
HCPCS 28238
|
| Min. Negotiated Rate |
$389.96 |
| Max. Negotiated Rate |
$1,253.45 |
| Rate for Payer: Cash Price |
$567.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$557.09
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$501.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$501.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$529.24
|
| Rate for Payer: Fidelis Medicare Advantage |
$557.09
|
| Rate for Payer: Fidelis Qualified Health Plan |
$529.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$557.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$557.09
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$417.82
|
| Rate for Payer: Healthfirst Commercial |
$557.09
|
| Rate for Payer: Healthfirst Essential Plan |
$1,253.45
|
| Rate for Payer: Healthfirst Medicare Advantage |
$529.24
|
| Rate for Payer: Healthfirst QHP |
$557.09
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$389.96
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$557.09
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$473.53
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$389.96
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$557.09
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$417.82
|
| Rate for Payer: SOMOS Essential |
$417.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$557.09
|
|
|
PR RCNSTJ STABLJ DSTL U/DSTL JT 2 SOFT TISS STABLJ
|
Professional
|
Both
|
$3,908.94
|
|
|
Service Code
|
HCPCS 25337
|
| Min. Negotiated Rate |
$741.83 |
| Max. Negotiated Rate |
$2,384.44 |
| Rate for Payer: Cash Price |
$1,061.06
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,059.75
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$953.77
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$953.77
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,006.76
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,059.75
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,006.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,059.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,059.75
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$794.81
|
| Rate for Payer: Healthfirst Commercial |
$1,059.75
|
| Rate for Payer: Healthfirst Essential Plan |
$2,384.44
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,006.76
|
| Rate for Payer: Healthfirst QHP |
$1,059.75
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$741.83
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,059.75
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$900.79
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$741.83
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,059.75
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$794.81
|
| Rate for Payer: SOMOS Essential |
$794.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,059.75
|
|
