|
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN [91279]
|
Facility
|
OP
|
$11.93
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
63323037600
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.95
|
| Rate for Payer: Aetna Government |
$0.95
|
| Rate for Payer: Brighton Health Commercial |
$8.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.11
|
| Rate for Payer: Group Health Inc Commercial |
$5.96
|
| Rate for Payer: Group Health Inc Medicare |
$4.17
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.96
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.75
|
|
|
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN [91279]
|
Facility
|
OP
|
$7.80
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
00641617510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$6.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.95
|
| Rate for Payer: Aetna Government |
$0.95
|
| 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
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.07
|
|
|
OCTREOTIDE ACETATE 100 MCG/ML SC SOSY [180661]
|
Facility
|
OP
|
$9.48
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
67457024500
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$7.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.95
|
| Rate for Payer: Aetna Government |
$0.95
|
| Rate for Payer: Brighton Health Commercial |
$7.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.45
|
| Rate for Payer: Group Health Inc Commercial |
$4.74
|
| Rate for Payer: Group Health Inc Medicare |
$3.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.74
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.16
|
|
|
OCTREOTIDE ACETATE 200 MCG/ML IJ SOLN [91280]
|
Facility
|
OP
|
$16.32
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
00641617701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$13.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.98
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.95
|
| Rate for Payer: Aetna Government |
$0.95
|
| Rate for Payer: Brighton Health Commercial |
$12.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.10
|
| Rate for Payer: Group Health Inc Commercial |
$8.16
|
| Rate for Payer: Group Health Inc Medicare |
$5.71
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.16
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.61
|
|
|
OCTREOTIDE ACETATE 20 MG IM KIT [24435]
|
Facility
|
OP
|
$5,430.94
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
00078081881
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$158.04 |
| Max. Negotiated Rate |
$15,804.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,987.02
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$210.83
|
| Rate for Payer: Aetna Government |
$210.83
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$355.59
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$355.59
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$158.04
|
| Rate for Payer: Amida Care Medicaid |
$158.04
|
| Rate for Payer: Brighton Health Commercial |
$4,073.20
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$210.83
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,344.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,693.04
|
| Rate for Payer: Elderplan Medicare Advantage |
$210.83
|
| Rate for Payer: EmblemHealth Commercial |
$210.83
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$15,804.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$158.04
|
| Rate for Payer: Fidelis Essential Plan QHP |
$158.04
|
| Rate for Payer: Fidelis Medicare Advantage |
$210.83
|
| Rate for Payer: Fidelis Qualified Health Plan |
$165.94
|
| Rate for Payer: Group Health Inc Commercial |
$210.83
|
| Rate for Payer: Group Health Inc Medicare |
$210.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$158.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$210.83
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$158.04
|
| Rate for Payer: Healthfirst Essential Plan |
$355.59
|
| Rate for Payer: Healthfirst Medicare Advantage |
$179.20
|
| Rate for Payer: Healthfirst QHP |
$158.04
|
| Rate for Payer: Humana Medicare |
$215.05
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$210.56
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$223.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$223.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$223.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$210.83
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$158.04
|
| Rate for Payer: SOMOS Essential |
$158.04
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$355.59
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$173.84
|
| Rate for Payer: United Healthcare Medicaid |
$158.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$210.83
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,530.11
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$168.66
|
| Rate for Payer: Wellcare Medicare |
$200.29
|
|
|
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN [91281]
|
Facility
|
OP
|
$17.88
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
63323037704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$14.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.95
|
| Rate for Payer: Aetna Government |
$0.95
|
| Rate for Payer: Brighton Health Commercial |
$13.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.16
|
| Rate for Payer: Group Health Inc Commercial |
$8.94
|
| Rate for Payer: Group Health Inc Medicare |
$6.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.94
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.62
|
|
|
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN [91281]
|
Facility
|
OP
|
$59.63
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
63323037701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$47.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$32.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.95
|
| Rate for Payer: Aetna Government |
$0.95
|
| Rate for Payer: Brighton Health Commercial |
$44.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$47.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$40.55
|
| Rate for Payer: Group Health Inc Commercial |
$29.81
|
| Rate for Payer: Group Health Inc Medicare |
$20.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$29.81
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$29.81
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$38.76
|
|
|
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN [91281]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
25021045301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$33.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$23.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.95
|
| Rate for Payer: Aetna Government |
$0.95
|
| Rate for Payer: Brighton Health Commercial |
$31.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$33.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$28.56
|
| Rate for Payer: Group Health Inc Commercial |
$21.00
|
| Rate for Payer: Group Health Inc Medicare |
$14.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$21.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$21.00
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$27.30
|
|
|
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN [91281]
|
Facility
|
OP
|
$59.63
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
63323037700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$47.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$32.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.95
|
| Rate for Payer: Aetna Government |
$0.95
|
| Rate for Payer: Brighton Health Commercial |
$44.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$47.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$40.55
|
| Rate for Payer: Group Health Inc Commercial |
$29.82
|
| Rate for Payer: Group Health Inc Medicare |
$20.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$29.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$29.82
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$38.76
|
|
|
OCTREOTIDE ACETATE 50 MCG/ML SC SOSY [180660]
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
67457023901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.95
|
| Rate for Payer: Aetna Government |
$0.95
|
| Rate for Payer: Brighton Health Commercial |
$3.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.26
|
| 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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.12
|
|
|
OCULAR PROSTHESIS
|
Facility
|
OP
|
$2,392.50
|
|
|
Service Code
|
HCPCS D5916
|
| Hospital Charge Code |
42301240
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$776.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,315.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$776.00
|
| Rate for Payer: Aetna Government |
$776.00
|
| Rate for Payer: Brighton Health Commercial |
$1,794.38
|
| 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 |
$1,196.25
|
| Rate for Payer: Group Health Inc Medicare |
$837.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,196.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,196.25
|
|
|
OCULAR PROSTHESIS, INTERIM
|
Facility
|
OP
|
$1,087.50
|
|
|
Service Code
|
HCPCS D5923
|
| Hospital Charge Code |
42301255
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$52.95 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$598.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$52.95
|
| Rate for Payer: Aetna Government |
$52.95
|
| Rate for Payer: Brighton Health Commercial |
$815.62
|
| 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 |
$543.75
|
| Rate for Payer: Group Health Inc Medicare |
$380.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$543.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$543.75
|
|
|
OCULAR SPHERE
|
Facility
|
OP
|
$1,384.60
|
|
| Hospital Charge Code |
64907056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$484.61 |
| Max. Negotiated Rate |
$1,107.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$761.53
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$692.30
|
| Rate for Payer: Aetna Government |
$692.30
|
| Rate for Payer: Brighton Health Commercial |
$1,038.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,107.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$941.53
|
| Rate for Payer: Group Health Inc Commercial |
$692.30
|
| Rate for Payer: Group Health Inc Medicare |
$484.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$692.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$692.30
|
|
|
OCULAR VENTED CONFORMER
|
Facility
|
OP
|
$160.28
|
|
| Hospital Charge Code |
64907055
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$128.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$88.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$80.14
|
| Rate for Payer: Aetna Government |
$80.14
|
| Rate for Payer: Brighton Health Commercial |
$120.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$128.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$108.99
|
| Rate for Payer: Group Health Inc Commercial |
$80.14
|
| Rate for Payer: Group Health Inc Medicare |
$56.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$80.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$80.14
|
|
|
ODEFSEY 200-25-25MG TAB
|
Facility
|
OP
|
$195.97
|
|
| Hospital Charge Code |
41659598
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.59 |
| Max. Negotiated Rate |
$156.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$107.78
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$97.98
|
| Rate for Payer: Aetna Government |
$97.98
|
| Rate for Payer: Brighton Health Commercial |
$146.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$156.78
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$133.26
|
| Rate for Payer: Group Health Inc Commercial |
$97.98
|
| Rate for Payer: Group Health Inc Medicare |
$68.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$97.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$97.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.38
|
|
|
ODEFSEY 200-25-25MG TAB
|
Facility
|
OP
|
$195.97
|
|
| Hospital Charge Code |
41649598
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.59 |
| Max. Negotiated Rate |
$156.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$107.78
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$97.98
|
| Rate for Payer: Aetna Government |
$97.98
|
| Rate for Payer: Brighton Health Commercial |
$146.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$156.78
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$133.26
|
| Rate for Payer: Group Health Inc Commercial |
$97.98
|
| Rate for Payer: Group Health Inc Medicare |
$68.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$97.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$97.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.38
|
|
|
ODONTECTOMY
|
Facility
|
OP
|
$616.78
|
|
|
Service Code
|
HCPCS 41899
|
| Hospital Charge Code |
40011295
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$225.98 |
| Max. Negotiated Rate |
$142,987.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,880.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$282.47
|
| Rate for Payer: Aetna Government |
$282.47
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,217.21
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,217.21
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,429.87
|
| Rate for Payer: Amida Care Medicaid |
$1,429.87
|
| Rate for Payer: Brighton Health Commercial |
$462.58
|
| Rate for Payer: Cash Price |
$282.47
|
| Rate for Payer: Cash Price |
$282.47
|
| Rate for Payer: Cash Price |
$282.47
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$282.47
|
| 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 |
$282.47
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$142,987.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,429.87
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,429.87
|
| Rate for Payer: Fidelis Medicare Advantage |
$282.47
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,501.36
|
| Rate for Payer: Group Health Inc Commercial |
$282.47
|
| Rate for Payer: Group Health Inc Medicare |
$282.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,429.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$282.47
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,429.87
|
| Rate for Payer: Healthfirst Essential Plan |
$3,217.21
|
| Rate for Payer: Healthfirst Medicare Advantage |
$240.10
|
| Rate for Payer: Healthfirst QHP |
$1,429.87
|
| Rate for Payer: Humana Medicare |
$288.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$282.47
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,429.87
|
| Rate for Payer: SOMOS Essential |
$3,217.21
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$3,217.21
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$1,572.86
|
| Rate for Payer: United Healthcare Medicaid |
$1,429.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$282.47
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$282.47
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$225.98
|
| Rate for Payer: Wellcare Medicare |
$268.35
|
|
|
ODONTECTOMY
|
Facility
|
IP
|
$616.78
|
|
|
Service Code
|
HCPCS 41899
|
| Hospital Charge Code |
40011295
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$282.47
|
|
|
ODONTOPLASTY 1 - 2 TEETH
|
Facility
|
OP
|
$496.00
|
|
|
Service Code
|
HCPCS D9971
|
| Hospital Charge Code |
42303377
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$21.45 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$272.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$21.45
|
| Rate for Payer: Aetna Government |
$21.45
|
| Rate for Payer: Brighton Health Commercial |
$372.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Group Health Inc Commercial |
$248.00
|
| Rate for Payer: Group Health Inc Medicare |
$173.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$248.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$248.00
|
|
|
OFFICE CNSLT NEW/EST FOC HISTORY
|
Facility
|
OP
|
$358.63
|
|
|
Service Code
|
HCPCS 99241
|
| Hospital Charge Code |
30104001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$24.02 |
| Max. Negotiated Rate |
$874.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$694.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.02
|
| Rate for Payer: Aetna Government |
$24.02
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$747.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$635.21
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$179.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.32
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
|
|
OFFICE CONSULT
|
Facility
|
OP
|
$358.63
|
|
|
Service Code
|
HCPCS 99241
|
| Hospital Charge Code |
42101300
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$24.02 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.02
|
| Rate for Payer: Aetna Government |
$24.02
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$179.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.32
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
OFFICE CONSULTATION
|
Facility
|
OP
|
$358.63
|
|
|
Service Code
|
HCPCS 99241
|
| Hospital Charge Code |
30301130
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.02 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.02
|
| Rate for Payer: Aetna Government |
$24.02
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$179.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.32
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
OFFICE CONSULTATION, LEVEL 1
|
Facility
|
OP
|
$358.63
|
|
|
Service Code
|
HCPCS 99241
|
| Hospital Charge Code |
40501008
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.02 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.02
|
| Rate for Payer: Aetna Government |
$24.02
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$179.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.32
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
OFFICE CONSULTATION LEVEL 2
|
Facility
|
OP
|
$395.39
|
|
|
Service Code
|
HCPCS 99242
|
| Hospital Charge Code |
40500003
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.34 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$217.46
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$50.34
|
| Rate for Payer: Aetna Government |
$50.34
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$197.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$197.70
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
OFFICE CONSULTATION LEVEL 3
|
Facility
|
OP
|
$479.51
|
|
|
Service Code
|
HCPCS 99243
|
| Hospital Charge Code |
40500004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$70.38 |
| Max. Negotiated Rate |
$263.73 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$263.73
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$70.38
|
| Rate for Payer: Aetna Government |
$70.38
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$239.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$239.76
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
