|
POLYETHYLENE GLYCOL (NULYTELY) POWDER
|
Facility
|
OP
|
$12.00
|
|
| Hospital Charge Code |
41650121
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.00
|
| Rate for Payer: Aetna Government |
$6.00
|
| Rate for Payer: Brighton Health Commercial |
$9.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.16
|
| Rate for Payer: Group Health Inc Commercial |
$6.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.80
|
|
|
POLYETHYLENE GLYCOL (NULYTELY) POWDER
|
Facility
|
OP
|
$12.00
|
|
| Hospital Charge Code |
41640121
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.00
|
| Rate for Payer: Aetna Government |
$6.00
|
| Rate for Payer: Brighton Health Commercial |
$9.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.16
|
| Rate for Payer: Group Health Inc Commercial |
$6.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.80
|
|
|
POLYETHYLENE GLYCOL POWDER (MIRALAX)
|
Facility
|
OP
|
$1.90
|
|
| Hospital Charge Code |
41654998
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.95
|
| Rate for Payer: Aetna Government |
$0.95
|
| Rate for Payer: Brighton Health Commercial |
$1.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.29
|
| Rate for Payer: Group Health Inc Commercial |
$0.95
|
| Rate for Payer: Group Health Inc Medicare |
$0.67
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.24
|
|
|
POLYETHYLENE GLYCOL POWDER (MIRALAX)
|
Facility
|
OP
|
$1.90
|
|
| Hospital Charge Code |
41644998
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.95
|
| Rate for Payer: Aetna Government |
$0.95
|
| Rate for Payer: Brighton Health Commercial |
$1.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.29
|
| Rate for Payer: Group Health Inc Commercial |
$0.95
|
| Rate for Payer: Group Health Inc Medicare |
$0.67
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.24
|
|
|
POLYMER I/A CURVED CANNULA
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
64907114
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
|
|
POLYMYXIN B SULFATE 500000 UNITS IJ SOLR [6393]
|
Facility
|
OP
|
$17.50
|
|
|
Service Code
|
NDC 55150023410
|
| Hospital Charge Code |
55150023410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.75
|
| Rate for Payer: Aetna Government |
$8.75
|
| Rate for Payer: Brighton Health Commercial |
$13.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.90
|
| Rate for Payer: Group Health Inc Commercial |
$8.75
|
| Rate for Payer: Group Health Inc Medicare |
$6.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.38
|
|
|
POLYMYXIN B SULFATE 500000 UNITS IJ SOLR [6393]
|
Facility
|
OP
|
$11.99
|
|
|
Service Code
|
NDC 63323032110
|
| Hospital Charge Code |
63323032110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$9.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.99
|
| Rate for Payer: Aetna Government |
$5.99
|
| Rate for Payer: Brighton Health Commercial |
$8.99
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.59
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.15
|
| Rate for Payer: Group Health Inc Commercial |
$5.99
|
| Rate for Payer: Group Health Inc Medicare |
$4.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.99
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.79
|
|
|
POLYMYXIN B SULFATE 500,000 UNITS INJ
|
Facility
|
OP
|
$12.48
|
|
| Hospital Charge Code |
41654778
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$9.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.24
|
| Rate for Payer: Aetna Government |
$6.24
|
| Rate for Payer: Brighton Health Commercial |
$9.36
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.98
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.49
|
| Rate for Payer: Group Health Inc Commercial |
$6.24
|
| Rate for Payer: Group Health Inc Medicare |
$4.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.24
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.24
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8.11
|
|
|
POLYMYXIN B SULFATE 500,000 UNITS INJ
|
Facility
|
OP
|
$12.48
|
|
| Hospital Charge Code |
41644778
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$9.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.24
|
| Rate for Payer: Aetna Government |
$6.24
|
| Rate for Payer: Brighton Health Commercial |
$9.36
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.98
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.49
|
| Rate for Payer: Group Health Inc Commercial |
$6.24
|
| Rate for Payer: Group Health Inc Medicare |
$4.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.24
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.24
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8.11
|
|
|
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN [11596]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 24208031510
|
| Hospital Charge Code |
24208031510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.67
|
| Rate for Payer: Aetna Government |
$0.67
|
| Rate for Payer: Brighton Health Commercial |
$1.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.91
|
| Rate for Payer: Group Health Inc Commercial |
$0.67
|
| Rate for Payer: Group Health Inc Medicare |
$0.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.67
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.87
|
|
|
POLYMYXIN B + TRIMETHOPRIM OPHTHALMIC DR
|
Facility
|
OP
|
$12.00
|
|
| Hospital Charge Code |
41641005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.00
|
| Rate for Payer: Aetna Government |
$6.00
|
| Rate for Payer: Brighton Health Commercial |
$9.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.16
|
| Rate for Payer: Group Health Inc Commercial |
$6.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.80
|
|
|
POLYMYXIN B + TRIMETHOPRIM OPHTHALMIC DR
|
Facility
|
OP
|
$12.00
|
|
| Hospital Charge Code |
41651005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.00
|
| Rate for Payer: Aetna Government |
$6.00
|
| Rate for Payer: Brighton Health Commercial |
$9.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.16
|
| Rate for Payer: Group Health Inc Commercial |
$6.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.80
|
|
|
POLYPATELLA STAN SZ29 8.0MM THCK
|
Facility
|
OP
|
$1,580.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40200254
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$1,659.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$869.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$948.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$790.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$908.50
|
| Rate for Payer: EmblemHealth Commercial |
$790.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,659.00
|
| Rate for Payer: Group Health Inc Commercial |
$790.00
|
| Rate for Payer: Group Health Inc Medicare |
$553.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$790.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$790.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,027.00
|
|
|
POLYPATELLA STAN SZ29 8.0MM THCK
|
Facility
|
IP
|
$1,580.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40200254
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$790.00 |
| Max. Negotiated Rate |
$790.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$790.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$790.00
|
|
|
POLYPECTOMY,ETHMOIDECTOMY
|
Facility
|
OP
|
$16,477.50
|
|
|
Service Code
|
HCPCS 31255
|
| Hospital Charge Code |
40108900
|
|
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
|
|
|
POLYPECTOMY,ETHMOIDECTOMY
|
Facility
|
IP
|
$16,477.50
|
|
|
Service Code
|
HCPCS 31255
|
| Hospital Charge Code |
40108900
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$7,914.90
|
|
|
POLY SCREW 5X40MM
|
Facility
|
OP
|
$3,550.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$3,727.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,952.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$2,130.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,775.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,041.25
|
| Rate for Payer: EmblemHealth Commercial |
$1,775.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,727.50
|
| Rate for Payer: Group Health Inc Commercial |
$1,775.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,242.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,775.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,775.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,307.50
|
|
|
POLY SCREW 5X40MM
|
Facility
|
IP
|
$3,550.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.00 |
| Max. Negotiated Rate |
$1,775.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,775.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,775.00
|
|
|
POLY SCREW 5X45MM
|
Facility
|
OP
|
$3,550.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202054
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$3,727.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,952.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$2,130.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,775.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,041.25
|
| Rate for Payer: EmblemHealth Commercial |
$1,775.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,727.50
|
| Rate for Payer: Group Health Inc Commercial |
$1,775.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,242.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,775.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,775.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,307.50
|
|
|
POLY SCREW 5X45MM
|
Facility
|
IP
|
$3,550.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202054
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.00 |
| Max. Negotiated Rate |
$1,775.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,775.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,775.00
|
|
|
POLYSOM <6 YRS 4/> PARAMTRS
|
Facility
|
IP
|
$2,752.98
|
|
|
Service Code
|
HCPCS 95782 TC
|
| Hospital Charge Code |
40401401
|
|
Hospital Revenue Code
|
922
|
| Rate for Payer: Cash Price |
$1,209.08
|
|
|
POLYSOM <6 YRS 4/> PARAMTRS
|
Facility
|
OP
|
$2,752.98
|
|
|
Service Code
|
HCPCS 95782 TC
|
| Hospital Charge Code |
40401401
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$822.00 |
| Max. Negotiated Rate |
$2,342.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,514.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,209.08
|
| Rate for Payer: Aetna Government |
$1,209.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$846.36
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$846.36
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$846.36
|
| Rate for Payer: Brighton Health Commercial |
$2,342.00
|
| Rate for Payer: Cash Price |
$1,209.08
|
| Rate for Payer: Cash Price |
$1,209.08
|
| Rate for Payer: Cash Price |
$1,209.08
|
| Rate for Payer: Cash Price |
$1,209.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,209.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,202.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,872.03
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,209.08
|
| Rate for Payer: EmblemHealth Commercial |
$1,209.08
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,027.72
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,076.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,209.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,076.08
|
| Rate for Payer: Group Health Inc Commercial |
$1,209.08
|
| Rate for Payer: Group Health Inc Medicare |
$1,209.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,376.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,209.08
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,027.72
|
| Rate for Payer: Healthfirst QHP |
$1,209.08
|
| Rate for Payer: Humana Medicare |
$1,233.26
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,209.08
|
| Rate for Payer: United Healthcare Commercial |
$822.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,209.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,209.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$967.26
|
| Rate for Payer: Wellcare Medicare |
$1,148.63
|
|
|
POLYSOM/6>YRS COAO 4>PARM
|
Facility
|
IP
|
$2,752.98
|
|
|
Service Code
|
HCPCS 95811 TC
|
| Hospital Charge Code |
30307885
|
|
Hospital Revenue Code
|
519
|
| Rate for Payer: Cash Price |
$1,209.08
|
|
|
POLYSOM/6>YRS COAO 4>PARM
|
Facility
|
OP
|
$2,752.98
|
|
|
Service Code
|
HCPCS 95811 TC
|
| Hospital Charge Code |
30307885
|
|
Hospital Revenue Code
|
519
|
| Min. Negotiated Rate |
$173.89 |
| Max. Negotiated Rate |
$1,514.14 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,514.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,209.08
|
| Rate for Payer: Aetna Government |
$1,209.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$846.36
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$846.36
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$846.36
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$1,209.08
|
| Rate for Payer: Cash Price |
$1,209.08
|
| Rate for Payer: Cash Price |
$1,209.08
|
| Rate for Payer: Cash Price |
$1,209.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,209.08
|
| 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 |
$1,209.08
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,027.72
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,076.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,209.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,076.08
|
| 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 |
$1,376.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,209.08
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,027.72
|
| Rate for Payer: Healthfirst QHP |
$1,209.08
|
| Rate for Payer: Humana Medicare |
$1,233.26
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,209.08
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,209.08
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,209.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,209.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$967.26
|
| Rate for Payer: Wellcare Medicare |
$1,148.63
|
|
|
POLYSOM < 6 YRS CPAP/BILVL
|
Facility
|
OP
|
$2,752.98
|
|
|
Service Code
|
HCPCS 95783 TC
|
| Hospital Charge Code |
40401402
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$822.00 |
| Max. Negotiated Rate |
$2,342.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,514.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,209.08
|
| Rate for Payer: Aetna Government |
$1,209.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$846.36
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$846.36
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$846.36
|
| Rate for Payer: Brighton Health Commercial |
$2,342.00
|
| Rate for Payer: Cash Price |
$1,209.08
|
| Rate for Payer: Cash Price |
$1,209.08
|
| Rate for Payer: Cash Price |
$1,209.08
|
| Rate for Payer: Cash Price |
$1,209.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,209.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,202.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,872.03
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,209.08
|
| Rate for Payer: EmblemHealth Commercial |
$1,209.08
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,027.72
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,076.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,209.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,076.08
|
| Rate for Payer: Group Health Inc Commercial |
$1,209.08
|
| Rate for Payer: Group Health Inc Medicare |
$1,209.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,376.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,209.08
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,027.72
|
| Rate for Payer: Healthfirst QHP |
$1,209.08
|
| Rate for Payer: Humana Medicare |
$1,233.26
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,209.08
|
| Rate for Payer: United Healthcare Commercial |
$822.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,209.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,209.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$967.26
|
| Rate for Payer: Wellcare Medicare |
$1,148.63
|
|
