|
NASAL/SINUS ENDO TOTAL
|
Facility
|
OP
|
$16,477.50
|
|
|
Service Code
|
HCPCS 31255
|
| Hospital Charge Code |
40014062
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$12,358.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,880.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7,914.90
|
| Rate for Payer: Aetna Government |
$7,914.90
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5,540.43
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5,540.43
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5,540.43
|
| Rate for Payer: Brighton Health Commercial |
$12,358.12
|
| Rate for Payer: Cash Price |
$7,914.90
|
| Rate for Payer: Cash Price |
$7,914.90
|
| Rate for Payer: Cash Price |
$7,914.90
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$7,914.90
|
| 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 |
$7,914.90
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$6,727.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7,044.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$7,914.90
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7,044.26
|
| Rate for Payer: Group Health Inc Commercial |
$7,914.90
|
| Rate for Payer: Group Health Inc Medicare |
$7,914.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8,238.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7,914.90
|
| Rate for Payer: Healthfirst Medicare Advantage |
$6,727.66
|
| Rate for Payer: Healthfirst QHP |
$7,914.90
|
| Rate for Payer: Humana Medicare |
$8,073.20
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$7,914.90
|
| Rate for Payer: United Healthcare Commercial |
$1,835.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,914.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7,914.90
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6,331.92
|
| Rate for Payer: Wellcare Medicare |
$7,519.16
|
|
|
NASO ESPHAGEAL TRAY (RU)
|
Facility
|
OP
|
$38.63
|
|
| Hospital Charge Code |
40207801
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.52 |
| Max. Negotiated Rate |
$30.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$21.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.32
|
| Rate for Payer: Aetna Government |
$19.32
|
| Rate for Payer: Brighton Health Commercial |
$28.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$30.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$26.27
|
| Rate for Payer: Group Health Inc Commercial |
$19.32
|
| Rate for Payer: Group Health Inc Medicare |
$13.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.32
|
|
|
NASO PHARANGEAL AIRWAYS
|
Facility
|
OP
|
$7.80
|
|
| Hospital Charge Code |
40200020
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$6.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.90
|
| Rate for Payer: Aetna Government |
$3.90
|
| Rate for Payer: Brighton Health Commercial |
$5.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.30
|
| Rate for Payer: Group Health Inc Commercial |
$3.90
|
| Rate for Payer: Group Health Inc Medicare |
$2.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.90
|
|
|
NASO-PHARYNGEAL
|
Facility
|
IP
|
$474.15
|
|
|
Service Code
|
HCPCS 92511 TC
|
| Hospital Charge Code |
41005000
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$229.07
|
|
|
NASO-PHARYNGEAL
|
Facility
|
OP
|
$474.15
|
|
|
Service Code
|
HCPCS 92511 TC
|
| Hospital Charge Code |
41005000
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$160.35 |
| Max. Negotiated Rate |
$260.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$260.78
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$229.07
|
| Rate for Payer: Aetna Government |
$229.07
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$160.35
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$160.35
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$160.35
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$229.07
|
| Rate for Payer: Cash Price |
$229.07
|
| Rate for Payer: Cash Price |
$229.07
|
| Rate for Payer: Cash Price |
$229.07
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$229.07
|
| 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 |
$229.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$194.71
|
| Rate for Payer: Fidelis Essential Plan QHP |
$203.87
|
| Rate for Payer: Fidelis Medicare Advantage |
$229.07
|
| Rate for Payer: Fidelis Qualified Health Plan |
$203.87
|
| 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 |
$237.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$229.07
|
| Rate for Payer: Healthfirst Medicare Advantage |
$194.71
|
| Rate for Payer: Healthfirst QHP |
$229.07
|
| Rate for Payer: Humana Medicare |
$233.65
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$229.07
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$229.07
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$229.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$229.07
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$183.26
|
| Rate for Payer: Wellcare Medicare |
$217.62
|
|
|
NA SULFATE-K SULFATE-MG SULF 17.5-3.13-1.6 GM/177ML PO SOLN [106061]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 52268001201
|
| Hospital Charge Code |
52268001201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.20
|
| Rate for Payer: Aetna Government |
$0.20
|
| Rate for Payer: Brighton Health Commercial |
$0.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.31
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.27
|
| Rate for Payer: Group Health Inc Commercial |
$0.20
|
| Rate for Payer: Group Health Inc Medicare |
$0.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.20
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.25
|
|
|
NATALIZUMAB 300 MG/15 ML INJ
|
Facility
|
OP
|
$9.35
|
|
|
Service Code
|
HCPCS J2323
|
| Hospital Charge Code |
41643854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$1,656.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.45
|
| Rate for Payer: Aetna Government |
$24.45
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$37.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$37.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$16.56
|
| Rate for Payer: Amida Care Medicaid |
$16.56
|
| Rate for Payer: Brighton Health Commercial |
$5.61
|
| Rate for Payer: Cash Price |
$24.45
|
| Rate for Payer: Cash Price |
$24.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$24.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.38
|
| Rate for Payer: Elderplan Medicare Advantage |
$24.45
|
| Rate for Payer: EmblemHealth Commercial |
$24.45
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,656.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$16.56
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.56
|
| Rate for Payer: Fidelis Medicare Advantage |
$24.45
|
| Rate for Payer: Fidelis Qualified Health Plan |
$17.39
|
| Rate for Payer: Group Health Inc Commercial |
$24.45
|
| Rate for Payer: Group Health Inc Medicare |
$24.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.68
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$16.56
|
| Rate for Payer: Healthfirst Essential Plan |
$37.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$20.78
|
| Rate for Payer: Healthfirst QHP |
$16.56
|
| Rate for Payer: Humana Medicare |
$24.94
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$24.45
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$16.56
|
| Rate for Payer: SOMOS Essential |
$16.56
|
| Rate for Payer: United Healthcare Commercial |
$23.82
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$37.26
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$18.22
|
| Rate for Payer: United Healthcare Medicaid |
$16.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$19.56
|
| Rate for Payer: Wellcare Medicare |
$23.23
|
|
|
NATALIZUMAB 300 MG/15 ML INJ
|
Facility
|
IP
|
$9.35
|
|
|
Service Code
|
HCPCS J2323
|
| Hospital Charge Code |
41643854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Cash Price |
$24.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.68
|
|
|
NATALIZUMAB 300 MG/15 ML INJ
|
Facility
|
OP
|
$9.35
|
|
|
Service Code
|
HCPCS J2323
|
| Hospital Charge Code |
41653854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$1,656.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.45
|
| Rate for Payer: Aetna Government |
$24.45
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$37.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$37.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$16.56
|
| Rate for Payer: Amida Care Medicaid |
$16.56
|
| Rate for Payer: Brighton Health Commercial |
$5.61
|
| Rate for Payer: Cash Price |
$24.45
|
| Rate for Payer: Cash Price |
$24.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$24.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.38
|
| Rate for Payer: Elderplan Medicare Advantage |
$24.45
|
| Rate for Payer: EmblemHealth Commercial |
$24.45
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,656.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$16.56
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.56
|
| Rate for Payer: Fidelis Medicare Advantage |
$24.45
|
| Rate for Payer: Fidelis Qualified Health Plan |
$17.39
|
| Rate for Payer: Group Health Inc Commercial |
$24.45
|
| Rate for Payer: Group Health Inc Medicare |
$24.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.68
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$16.56
|
| Rate for Payer: Healthfirst Essential Plan |
$37.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$20.78
|
| Rate for Payer: Healthfirst QHP |
$16.56
|
| Rate for Payer: Humana Medicare |
$24.94
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$24.45
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$16.56
|
| Rate for Payer: SOMOS Essential |
$16.56
|
| Rate for Payer: United Healthcare Commercial |
$23.82
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$37.26
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$18.22
|
| Rate for Payer: United Healthcare Medicaid |
$16.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$19.56
|
| Rate for Payer: Wellcare Medicare |
$23.23
|
|
|
NATALIZUMAB 300 MG/15 ML INJ
|
Facility
|
IP
|
$9.35
|
|
|
Service Code
|
HCPCS J2323
|
| Hospital Charge Code |
41653854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Cash Price |
$24.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.68
|
|
|
NATALIZUMAB 300 MG/15ML IV CONC [40120]
|
Facility
|
OP
|
$656.75
|
|
|
Service Code
|
HCPCS J2323
|
| Hospital Charge Code |
64406000801
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16.56 |
| Max. Negotiated Rate |
$1,656.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$361.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.45
|
| Rate for Payer: Aetna Government |
$24.45
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$37.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$37.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$16.56
|
| Rate for Payer: Amida Care Medicaid |
$16.56
|
| Rate for Payer: Brighton Health Commercial |
$394.05
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$24.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$328.37
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$377.63
|
| Rate for Payer: Elderplan Medicare Advantage |
$24.45
|
| Rate for Payer: EmblemHealth Commercial |
$328.37
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,656.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$16.56
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.56
|
| Rate for Payer: Fidelis Medicare Advantage |
$24.45
|
| Rate for Payer: Fidelis Qualified Health Plan |
$17.39
|
| Rate for Payer: Group Health Inc Commercial |
$24.45
|
| Rate for Payer: Group Health Inc Medicare |
$24.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$328.37
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$16.56
|
| Rate for Payer: Healthfirst Essential Plan |
$37.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$20.78
|
| Rate for Payer: Healthfirst QHP |
$16.56
|
| Rate for Payer: Humana Medicare |
$24.94
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$24.45
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$16.56
|
| Rate for Payer: SOMOS Essential |
$16.56
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$37.26
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$18.22
|
| Rate for Payer: United Healthcare Medicaid |
$16.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$426.89
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$19.56
|
|
|
NATALIZUMAB 300 MG/15ML IV CONC [40120]
|
Facility
|
IP
|
$656.75
|
|
|
Service Code
|
HCPCS J2323
|
| Hospital Charge Code |
64406000801
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$328.37 |
| Max. Negotiated Rate |
$328.37 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$328.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$328.37
|
|
|
NATRELLE INSPIRA RESTERIL SIZER
|
Facility
|
OP
|
$420.00
|
|
| Hospital Charge Code |
40004695
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$147.00 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$231.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$210.00
|
| Rate for Payer: Aetna Government |
$210.00
|
| Rate for Payer: Brighton Health Commercial |
$315.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$336.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$285.60
|
| Rate for Payer: Group Health Inc Commercial |
$210.00
|
| Rate for Payer: Group Health Inc Medicare |
$147.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$210.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$210.00
|
|
|
NATURAL TIBIA 5D R SZ E
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905312
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,500.00 |
| Max. Negotiated Rate |
$2,500.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,500.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,500.00
|
|
|
NATURAL TIBIA 5D R SZ E
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905312
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,750.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$3,000.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,500.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,875.00
|
| Rate for Payer: EmblemHealth Commercial |
$2,500.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$5,250.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,500.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,500.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,500.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,250.00
|
|
|
NATURAL TIBIA CEMENT 5D C
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905449
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,500.00 |
| Max. Negotiated Rate |
$2,500.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,500.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,500.00
|
|
|
NATURAL TIBIA CEMENT 5D C
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905449
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,750.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$3,000.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,500.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,875.00
|
| Rate for Payer: EmblemHealth Commercial |
$2,500.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$5,250.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,500.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,500.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,500.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,250.00
|
|
|
NATURAL TIBIA CEMENT 5D G
|
Facility
|
IP
|
$5,500.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64905455
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,750.00 |
| Max. Negotiated Rate |
$2,750.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,750.00
|
|
|
NATURAL TIBIA CEMENT 5D G
|
Facility
|
OP
|
$5,500.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64905455
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$5,775.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3,025.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$3,300.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,750.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,162.50
|
| Rate for Payer: EmblemHealth Commercial |
$2,750.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$5,775.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,750.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,925.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,750.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,575.00
|
|
|
NAVIFLEX RX DELIVERY SYSTEM A
|
Facility
|
OP
|
$309.75
|
|
| Hospital Charge Code |
64905326
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$108.41 |
| Max. Negotiated Rate |
$247.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$170.36
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$154.88
|
| Rate for Payer: Aetna Government |
$154.88
|
| Rate for Payer: Brighton Health Commercial |
$232.31
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$247.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$210.63
|
| Rate for Payer: Group Health Inc Commercial |
$154.88
|
| Rate for Payer: Group Health Inc Medicare |
$108.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$154.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$154.88
|
|
|
NAVIFLEX RX DELIVERY SYSTEM B
|
Facility
|
OP
|
$320.00
|
|
| Hospital Charge Code |
64905328
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$112.00 |
| Max. Negotiated Rate |
$256.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$176.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$160.00
|
| Rate for Payer: Aetna Government |
$160.00
|
| Rate for Payer: Brighton Health Commercial |
$240.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$256.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$217.60
|
| Rate for Payer: Group Health Inc Commercial |
$160.00
|
| Rate for Payer: Group Health Inc Medicare |
$112.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$160.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$160.00
|
|
|
N BLOCK INJ INTERCOST MLT
|
Facility
|
IP
|
$2,459.50
|
|
|
Service Code
|
HCPCS 64421
|
| Hospital Charge Code |
40004377
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,054.06
|
|
|
N BLOCK INJ INTERCOST MLT
|
Facility
|
OP
|
$2,459.50
|
|
|
Service Code
|
HCPCS 64421
|
| Hospital Charge Code |
40004377
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$737.84 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,054.06
|
| Rate for Payer: Aetna Government |
$1,054.06
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$737.84
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$737.84
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$737.84
|
| Rate for Payer: Brighton Health Commercial |
$1,844.62
|
| Rate for Payer: Cash Price |
$1,054.06
|
| Rate for Payer: Cash Price |
$1,054.06
|
| Rate for Payer: Cash Price |
$1,054.06
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,054.06
|
| 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 |
$1,054.06
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$895.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$938.11
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,054.06
|
| Rate for Payer: Fidelis Qualified Health Plan |
$938.11
|
| Rate for Payer: Group Health Inc Commercial |
$1,054.06
|
| Rate for Payer: Group Health Inc Medicare |
$1,054.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,229.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,054.06
|
| Rate for Payer: Healthfirst Medicare Advantage |
$895.95
|
| Rate for Payer: Healthfirst QHP |
$1,054.06
|
| Rate for Payer: Humana Medicare |
$1,075.14
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,054.06
|
| Rate for Payer: United Healthcare Commercial |
$1,188.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,054.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,054.06
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$843.25
|
| Rate for Payer: Wellcare Medicare |
$1,001.36
|
|
|
N BLOCK INJ SCIATIC SNG
|
Facility
|
IP
|
$1,893.13
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
40009402
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$799.72
|
|
|
N BLOCK INJ SCIATIC SNG
|
Facility
|
OP
|
$1,893.13
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
40009402
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$559.80 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$799.72
|
| Rate for Payer: Aetna Government |
$799.72
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$559.80
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$559.80
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$559.80
|
| Rate for Payer: Brighton Health Commercial |
$1,419.85
|
| Rate for Payer: Cash Price |
$799.72
|
| Rate for Payer: Cash Price |
$799.72
|
| Rate for Payer: Cash Price |
$799.72
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$799.72
|
| 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 |
$799.72
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$679.76
|
| Rate for Payer: Fidelis Essential Plan QHP |
$711.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$799.72
|
| Rate for Payer: Fidelis Qualified Health Plan |
$711.75
|
| Rate for Payer: Group Health Inc Commercial |
$799.72
|
| Rate for Payer: Group Health Inc Medicare |
$799.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$946.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$799.72
|
| Rate for Payer: Healthfirst Medicare Advantage |
$679.76
|
| Rate for Payer: Healthfirst QHP |
$799.72
|
| Rate for Payer: Humana Medicare |
$815.71
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$799.72
|
| Rate for Payer: United Healthcare Commercial |
$1,188.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$799.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$799.72
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$639.78
|
| Rate for Payer: Wellcare Medicare |
$759.73
|
|
