|
Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)
|
Facility
|
OP
|
$6,937.00
|
|
|
Service Code
|
CPT 92929
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$384.04 |
| Max. Negotiated Rate |
$6,937.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$384.04
|
| Rate for Payer: Aetna Government |
$384.04
|
| Rate for Payer: Brighton Health Commercial |
$6,937.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,959.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4,215.78
|
| Rate for Payer: United Healthcare Commercial |
$2,546.00
|
|
|
Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch
|
Facility
|
OP
|
$16,751.00
|
|
|
Service Code
|
CPT 92928
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,546.00 |
| Max. Negotiated Rate |
$16,751.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16,751.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12,721.98
|
| Rate for Payer: Aetna Government |
$12,721.98
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$8,905.39
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$8,905.39
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$8,905.39
|
| Rate for Payer: Brighton Health Commercial |
$6,937.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$12,721.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,959.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4,215.78
|
| Rate for Payer: Elderplan Medicare Advantage |
$12,721.98
|
| Rate for Payer: EmblemHealth Commercial |
$12,721.98
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$10,813.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$11,322.56
|
| Rate for Payer: Fidelis Medicare Advantage |
$12,721.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$11,322.56
|
| Rate for Payer: Group Health Inc Commercial |
$12,721.98
|
| Rate for Payer: Group Health Inc Medicare |
$12,721.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12,721.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$10,813.68
|
| Rate for Payer: Healthfirst QHP |
$12,721.98
|
| Rate for Payer: Humana Medicare |
$12,976.42
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$12,721.98
|
| Rate for Payer: United Healthcare Commercial |
$2,546.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,721.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12,721.98
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$10,177.58
|
| Rate for Payer: Wellcare Medicare |
$12,085.88
|
|
|
Percutaneous transluminal coronary angioplasty; single major coronary artery or branch
|
Facility
|
OP
|
$6,937.00
|
|
|
Service Code
|
CPT 92920
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,546.00 |
| Max. Negotiated Rate |
$6,937.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,593.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,609.72
|
| Rate for Payer: Aetna Government |
$6,609.72
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$4,626.80
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$4,626.80
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$4,626.80
|
| Rate for Payer: Brighton Health Commercial |
$6,937.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,609.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,959.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4,215.78
|
| Rate for Payer: Elderplan Medicare Advantage |
$6,609.72
|
| Rate for Payer: EmblemHealth Commercial |
$6,609.72
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,618.26
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5,882.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,609.72
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5,882.65
|
| Rate for Payer: Group Health Inc Commercial |
$6,609.72
|
| Rate for Payer: Group Health Inc Medicare |
$6,609.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,609.72
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5,618.26
|
| Rate for Payer: Healthfirst QHP |
$6,609.72
|
| Rate for Payer: Humana Medicare |
$6,741.91
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,609.72
|
| Rate for Payer: United Healthcare Commercial |
$2,546.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,609.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,609.72
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,287.78
|
| Rate for Payer: Wellcare Medicare |
$6,279.23
|
|
|
PERFORATOR DISPOSABLE
|
Facility
|
OP
|
$672.50
|
|
| Hospital Charge Code |
64902731
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$235.38 |
| Max. Negotiated Rate |
$538.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$369.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$336.25
|
| Rate for Payer: Aetna Government |
$336.25
|
| Rate for Payer: Brighton Health Commercial |
$504.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$538.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$457.30
|
| Rate for Payer: Group Health Inc Commercial |
$336.25
|
| Rate for Payer: Group Health Inc Medicare |
$235.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$336.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$336.25
|
|
|
PERI-ARTICULAR PIN CLAMP
|
Facility
|
OP
|
$632.80
|
|
| Hospital Charge Code |
40201386
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$221.48 |
| Max. Negotiated Rate |
$506.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$348.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$316.40
|
| Rate for Payer: Aetna Government |
$316.40
|
| Rate for Payer: Brighton Health Commercial |
$474.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$506.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$430.30
|
| Rate for Payer: Group Health Inc Commercial |
$316.40
|
| Rate for Payer: Group Health Inc Medicare |
$221.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$316.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$316.40
|
|
|
PERICARDIAL WINDOW
|
Facility
|
OP
|
$2,690.56
|
|
|
Service Code
|
HCPCS 33025
|
| Hospital Charge Code |
40042130
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$891.90 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,479.81
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$891.90
|
| Rate for Payer: Aetna Government |
$891.90
|
| Rate for Payer: Brighton Health Commercial |
$2,017.92
|
| 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: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,345.28
|
| Rate for Payer: Group Health Inc Medicare |
$941.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,345.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,345.28
|
| Rate for Payer: United Healthcare Commercial |
$1,496.00
|
|
|
PERICARDIOCENTESIS
|
Facility
|
OP
|
$4,940.28
|
|
|
Service Code
|
HCPCS 33016 TC
|
| Hospital Charge Code |
30300250
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,852.05
|
| Rate for Payer: Aetna Government |
$1,852.05
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,296.44
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,296.44
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,296.44
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$1,852.05
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$1,852.05
|
| Rate for Payer: Cash Price |
$1,852.05
|
| Rate for Payer: Cash Price |
$1,852.05
|
| Rate for Payer: Cash Price |
$1,852.05
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,852.05
|
| 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 |
$1,852.05
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,574.24
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,648.32
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,852.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,648.32
|
| 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 |
$2,470.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,852.05
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$1,852.05
|
| Rate for Payer: Humana Medicare |
$1,889.09
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,852.05
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,852.05
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,852.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,852.05
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,481.64
|
| Rate for Payer: Wellcare Medicare |
$1,759.45
|
|
|
PERICARDIOCENTESIS
|
Facility
|
IP
|
$4,940.28
|
|
|
Service Code
|
HCPCS 33016 TC
|
| Hospital Charge Code |
30300250
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$1,852.05
|
|
|
PERICARDIOCENTESIS W/IMAGE
|
Facility
|
IP
|
$4,940.28
|
|
|
Service Code
|
HCPCS 33016
|
| Hospital Charge Code |
41103732
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,852.05
|
|
|
PERICARDIOCENTESIS W/IMAGE
|
Facility
|
OP
|
$4,940.28
|
|
|
Service Code
|
HCPCS 33016
|
| Hospital Charge Code |
41103732
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,188.00 |
| Max. Negotiated Rate |
$3,705.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,852.05
|
| Rate for Payer: Aetna Government |
$1,852.05
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,296.44
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,296.44
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,296.44
|
| Rate for Payer: Brighton Health Commercial |
$3,705.21
|
| Rate for Payer: Cash Price |
$1,852.05
|
| Rate for Payer: Cash Price |
$1,852.05
|
| Rate for Payer: Cash Price |
$1,852.05
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,852.05
|
| 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 |
$1,852.05
|
| Rate for Payer: EmblemHealth Commercial |
$1,852.05
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,574.24
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,648.32
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,852.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,648.32
|
| Rate for Payer: Group Health Inc Commercial |
$1,852.05
|
| Rate for Payer: Group Health Inc Medicare |
$1,852.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,470.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,852.05
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,574.24
|
| Rate for Payer: Healthfirst QHP |
$1,852.05
|
| Rate for Payer: Humana Medicare |
$1,889.09
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,852.05
|
| Rate for Payer: United Healthcare Commercial |
$1,188.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,852.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,852.05
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,481.64
|
| Rate for Payer: Wellcare Medicare |
$1,759.45
|
|
|
Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents
|
Facility
|
OP
|
$4,496.14
|
|
|
Service Code
|
CPT 19371
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$4,496.14 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,485.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,407.98
|
| Rate for Payer: Aetna Government |
$4,407.98
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,085.59
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,085.59
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,085.59
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4,407.98
|
| 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 |
$4,407.98
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,746.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,923.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,407.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,923.10
|
| Rate for Payer: Group Health Inc Commercial |
$4,407.98
|
| Rate for Payer: Group Health Inc Medicare |
$4,407.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,407.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,746.78
|
| Rate for Payer: Healthfirst QHP |
$4,407.98
|
| Rate for Payer: Humana Medicare |
$4,496.14
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4,407.98
|
| Rate for Payer: United Healthcare Commercial |
$1,835.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,407.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4,407.98
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3,526.38
|
| Rate for Payer: Wellcare Medicare |
$4,187.58
|
|
|
PERINUCLEAR (P-ANCA)
|
Facility
|
IP
|
$30.13
|
|
|
Service Code
|
HCPCS 86037
|
| Hospital Charge Code |
40729916
|
|
Hospital Revenue Code
|
302
|
| Rate for Payer: Cash Price |
$12.05
|
|
|
PERINUCLEAR (P-ANCA)
|
Facility
|
OP
|
$30.13
|
|
|
Service Code
|
HCPCS 86037
|
| Hospital Charge Code |
40729916
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.44 |
| Max. Negotiated Rate |
$24.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.05
|
| Rate for Payer: Aetna Government |
$12.05
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$8.44
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$8.44
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$8.44
|
| Rate for Payer: Brighton Health Commercial |
$22.60
|
| Rate for Payer: Cash Price |
$12.05
|
| Rate for Payer: Cash Price |
$12.05
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$12.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$20.49
|
| Rate for Payer: Elderplan Medicare Advantage |
$12.05
|
| Rate for Payer: EmblemHealth Commercial |
$12.05
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$10.24
|
| Rate for Payer: Fidelis Essential Plan QHP |
$10.72
|
| Rate for Payer: Fidelis Medicare Advantage |
$12.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$10.72
|
| Rate for Payer: Group Health Inc Commercial |
$12.05
|
| Rate for Payer: Group Health Inc Medicare |
$12.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.05
|
| Rate for Payer: Healthfirst Medicare Advantage |
$12.05
|
| Rate for Payer: Healthfirst QHP |
$12.05
|
| Rate for Payer: Humana Medicare |
$12.29
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare Commercial |
$10.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12.05
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$9.64
|
| Rate for Payer: Wellcare Medicare |
$10.84
|
|
|
PERIODIC ORAL EXAMINATION
|
Facility
|
OP
|
$62.50
|
|
|
Service Code
|
HCPCS D0120
|
| Hospital Charge Code |
42300095
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$31.25 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$152.87
|
| Rate for Payer: Aetna Government |
$152.87
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$107.01
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$107.01
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$107.01
|
| Rate for Payer: Brighton Health Commercial |
$46.88
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$152.87
|
| 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 |
$152.87
|
| Rate for Payer: EmblemHealth Commercial |
$152.87
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$129.94
|
| Rate for Payer: Fidelis Essential Plan QHP |
$136.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$152.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$136.05
|
| Rate for Payer: Group Health Inc Commercial |
$152.87
|
| Rate for Payer: Group Health Inc Medicare |
$152.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$152.87
|
| Rate for Payer: Healthfirst Medicare Advantage |
$129.94
|
| Rate for Payer: Healthfirst QHP |
$152.87
|
| Rate for Payer: Humana Medicare |
$155.93
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$152.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$152.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$152.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$122.30
|
| Rate for Payer: Wellcare Medicare |
$145.23
|
|
|
PERIODIC ORAL EXAMINATION
|
Facility
|
IP
|
$62.50
|
|
|
Service Code
|
HCPCS D0120
|
| Hospital Charge Code |
42300095
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$152.87
|
|
|
PERIO MAINTENANCE PROC FOLLOWING
|
Facility
|
OP
|
$112.50
|
|
|
Service Code
|
HCPCS D4910
|
| Hospital Charge Code |
42300945
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$56.25 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$61.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$84.38
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
PERIO MAINTENANCE PROC FOLLOWING
|
Facility
|
IP
|
$112.50
|
|
|
Service Code
|
HCPCS D4910
|
| Hospital Charge Code |
42300945
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
PERIO SCALING AND ROOT PLANING-PE
|
Facility
|
OP
|
$112.50
|
|
|
Service Code
|
HCPCS D4341
|
| Hospital Charge Code |
42300930
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$56.25 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$61.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$84.38
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
PERIO SCALING AND ROOT PLANING-PE
|
Facility
|
IP
|
$112.50
|
|
|
Service Code
|
HCPCS D4341
|
| Hospital Charge Code |
42300930
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
PERIO SC/RP, 1-3 TEETH/QUAD
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
HCPCS D4342
|
| Hospital Charge Code |
42303395
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
PERIO SC/RP, 1-3 TEETH/QUAD
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
HCPCS D4342
|
| Hospital Charge Code |
42303395
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$37.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$41.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$56.25
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
PERI PATCH REP. KIT
|
Facility
|
OP
|
$112.50
|
|
| Hospital Charge Code |
64902937
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$39.38 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$61.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$56.25
|
| Rate for Payer: Aetna Government |
$56.25
|
| Rate for Payer: Brighton Health Commercial |
$84.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.50
|
| Rate for Payer: Group Health Inc Commercial |
$56.25
|
| Rate for Payer: Group Health Inc Medicare |
$39.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$56.25
|
|
|
PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR
|
Facility
|
IP
|
$52,610.00
|
|
|
Service Code
|
MSDRG 041
|
| Min. Negotiated Rate |
$17,791.75 |
| Max. Negotiated Rate |
$52,610.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$32,891.67
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$38,261.82
|
| Rate for Payer: Aetna Government |
$38,261.82
|
| Rate for Payer: Brighton Health Commercial |
$32,345.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$39,027.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$38,521.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$31,789.97
|
| Rate for Payer: Elderplan Medicare Advantage |
$36,348.73
|
| Rate for Payer: EmblemHealth Commercial |
$19,128.30
|
| Rate for Payer: Fidelis Medicare Advantage |
$38,261.82
|
| Rate for Payer: Group Health Inc Commercial |
$38,261.82
|
| Rate for Payer: Group Health Inc Medicare |
$38,261.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$38,261.82
|
| Rate for Payer: Healthfirst Medicare Advantage |
$17,791.75
|
| Rate for Payer: Humana Medicare |
$52,610.00
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$38,261.82
|
| Rate for Payer: United Healthcare Commercial |
$44,361.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38,261.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$38,261.82
|
| Rate for Payer: Wellcare Medicare |
$36,348.73
|
|
|
PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC
|
Facility
|
IP
|
$83,495.78
|
|
|
Service Code
|
MSDRG 040
|
| Min. Negotiated Rate |
$28,236.75 |
| Max. Negotiated Rate |
$83,495.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$56,775.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$60,724.20
|
| Rate for Payer: Aetna Government |
$60,724.20
|
| Rate for Payer: Brighton Health Commercial |
$55,832.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$61,938.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$66,494.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$54,873.94
|
| Rate for Payer: Elderplan Medicare Advantage |
$57,687.99
|
| Rate for Payer: EmblemHealth Commercial |
$33,018.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$60,724.20
|
| Rate for Payer: Group Health Inc Commercial |
$60,724.20
|
| Rate for Payer: Group Health Inc Medicare |
$60,724.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$60,724.20
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28,236.75
|
| Rate for Payer: Humana Medicare |
$83,495.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$60,724.20
|
| Rate for Payer: United Healthcare Commercial |
$76,574.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60,724.20
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$60,724.20
|
| Rate for Payer: Wellcare Medicare |
$57,687.99
|
|
|
PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$43,249.69
|
|
|
Service Code
|
MSDRG 042
|
| Min. Negotiated Rate |
$14,626.26 |
| Max. Negotiated Rate |
$43,249.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25,653.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$31,454.32
|
| Rate for Payer: Aetna Government |
$31,454.32
|
| Rate for Payer: Brighton Health Commercial |
$25,227.10
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$32,083.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$30,044.61
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24,794.10
|
| Rate for Payer: Elderplan Medicare Advantage |
$29,881.60
|
| Rate for Payer: EmblemHealth Commercial |
$14,918.80
|
| Rate for Payer: Fidelis Medicare Advantage |
$31,454.32
|
| Rate for Payer: Group Health Inc Commercial |
$31,454.32
|
| Rate for Payer: Group Health Inc Medicare |
$31,454.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31,454.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$14,626.26
|
| Rate for Payer: Humana Medicare |
$43,249.69
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$31,454.32
|
| Rate for Payer: United Healthcare Commercial |
$34,599.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$31,454.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$31,454.32
|
| Rate for Payer: Wellcare Medicare |
$29,881.60
|
|
