|
SINGLE ONLAY RES-BASED COMP 2SURF
|
Facility
OP
|
$1,169.44
|
|
|
Service Code
|
HCPCS D2662
|
| Hospital Charge Code |
42303289
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$584.72 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$643.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| 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 |
$584.72
|
| 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: Senior Whole Health 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
|
|
|
SINGLE ONLAY RES-BASED COMP 3SURF
|
Facility
OP
|
$1,169.44
|
|
|
Service Code
|
HCPCS D2663
|
| Hospital Charge Code |
42303290
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$584.72 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$643.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| 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 |
$584.72
|
| 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: Senior Whole Health 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
|
|
|
SINGLE STINGING INSECT,MLT DOSE V
|
Facility
OP
|
$115.43
|
|
|
Service Code
|
HCPCS 95145
|
| Hospital Charge Code |
30301418
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$63.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$54.93
|
| Rate for Payer: Aetna Government |
$54.93
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$54.93
|
| Rate for Payer: Cash Price |
$54.93
|
| Rate for Payer: Cash Price |
$54.93
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$54.93
|
| 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 |
$54.93
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$46.69
|
| Rate for Payer: Fidelis Essential Plan QHP |
$48.89
|
| Rate for Payer: Fidelis Medicare Advantage |
$54.93
|
| Rate for Payer: Fidelis Qualified Health Plan |
$48.89
|
| 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 |
$57.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$54.93
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3.75
|
| Rate for Payer: Healthfirst Medicare Advantage |
$46.69
|
| Rate for Payer: Healthfirst QHP |
$54.93
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$54.93
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$54.93
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$54.93
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$43.94
|
| Rate for Payer: Wellcare Medicare |
$52.18
|
|
|
SINUS AND MASTOID PROCEDURES WITH CC/MCC
|
Facility
IP
|
$45,799.11
|
|
|
Service Code
|
MS-DRG 135
|
| Min. Negotiated Rate |
$20,509.07 |
| Max. Negotiated Rate |
$45,799.11 |
| Rate for Payer: Senior Whole Health Medicare Advantage |
$44,105.53
|
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$39,105.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44,105.53
|
| Rate for Payer: Aetna Government |
$44,105.53
|
| Rate for Payer: Brighton Health Commercial |
$38,455.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$44,987.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$45,799.11
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$37,795.40
|
| Rate for Payer: Elderplan Medicare Advantage |
$41,900.25
|
| Rate for Payer: EmblemHealth Commercial |
$22,741.80
|
| Rate for Payer: Fidelis Medicare Advantage |
$44,105.53
|
| Rate for Payer: Group Health Inc Commercial |
$44,105.53
|
| Rate for Payer: Group Health Inc Medicare |
$44,105.53
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$44,105.53
|
| Rate for Payer: Healthfirst Medicare Advantage |
$20,509.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$44,105.53
|
| Rate for Payer: Wellcare Medicare |
$41,900.25
|
|
|
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC
|
Facility
IP
|
$22,245.75
|
|
|
Service Code
|
MS-DRG 136
|
| Min. Negotiated Rate |
$8,052.78 |
| Max. Negotiated Rate |
$22,245.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13,847.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$21,809.56
|
| Rate for Payer: Aetna Government |
$21,809.56
|
| Rate for Payer: Brighton Health Commercial |
$13,616.95
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$22,245.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18,034.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$14,882.44
|
| Rate for Payer: Elderplan Medicare Advantage |
$20,719.08
|
| Rate for Payer: EmblemHealth Commercial |
$8,052.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$21,809.56
|
| Rate for Payer: Group Health Inc Commercial |
$21,809.56
|
| Rate for Payer: Group Health Inc Medicare |
$21,809.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$21,809.56
|
| Rate for Payer: Healthfirst Medicare Advantage |
$10,141.45
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$21,809.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21,809.56
|
| Rate for Payer: Wellcare Medicare |
$20,719.08
|
|
|
SINUS AUG VIA A VERTICAL APPROACH
|
Facility
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS D7952
|
| Hospital Charge Code |
42300749
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$476.08 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,100.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$476.08
|
| Rate for Payer: Aetna Government |
$476.08
|
| 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 |
$1,000.00
|
| Rate for Payer: Group Health Inc Medicare |
$700.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,000.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,000.00
|
|
|
SINUS AUG W BONE/BONE SUP
|
Facility
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS D7951
|
| Hospital Charge Code |
42303429
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$700.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,100.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$837.26
|
| Rate for Payer: Aetna Government |
$837.26
|
| 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 |
$1,000.00
|
| Rate for Payer: Group Health Inc Medicare |
$700.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,000.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,000.00
|
|
|
SINUS IMPLANT
|
Facility
OP
|
$3,160.00
|
|
| Hospital Charge Code |
40203105
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,106.00 |
| Max. Negotiated Rate |
$2,528.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,738.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,580.00
|
| Rate for Payer: Aetna Government |
$1,580.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,528.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,148.80
|
| Rate for Payer: Group Health Inc Commercial |
$1,580.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,106.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,580.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,580.00
|
|
|
SINUS IRRIGATION
|
Facility
OP
|
$616.78
|
|
|
Service Code
|
HCPCS 31000
|
| Hospital Charge Code |
30304092
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$123.02 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$282.47
|
| Rate for Payer: Aetna Government |
$282.47
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| 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: Fidelis CHP/HARP/Medicaid |
$123.02
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$240.10
|
| Rate for Payer: Fidelis Essential Plan QHP |
$251.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$282.47
|
| Rate for Payer: Fidelis Qualified Health Plan |
$251.40
|
| 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 |
$308.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$282.47
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$136.69
|
| Rate for Payer: Healthfirst Medicare Advantage |
$240.10
|
| Rate for Payer: Healthfirst QHP |
$282.47
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$282.47
|
| Rate for Payer: Senior Whole Health 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
|
|
|
SINUS LIFT WITH BONE GRAFT
|
Facility
OP
|
$2,126.00
|
|
|
Service Code
|
HCPCS D7950
|
| Hospital Charge Code |
42303385
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,063.00 |
| Max. Negotiated Rate |
$6,772.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,169.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,772.21
|
| Rate for Payer: Aetna Government |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,772.21
|
| 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 |
$6,772.21
|
| Rate for Payer: EmblemHealth Commercial |
$6,772.21
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,756.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6,027.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,772.21
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6,027.27
|
| Rate for Payer: Group Health Inc Commercial |
$6,772.21
|
| Rate for Payer: Group Health Inc Medicare |
$6,772.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,063.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,772.21
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5,756.38
|
| Rate for Payer: Healthfirst QHP |
$6,772.21
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,772.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,772.21
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,417.77
|
| Rate for Payer: Wellcare Medicare |
$6,433.60
|
|
|
SITAGLIPTIN 100 MG TAB - NF
|
Facility
OP
|
$14.05
|
|
| Hospital Charge Code |
41654866
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$11.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.73
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.02
|
| Rate for Payer: Aetna Government |
$7.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.55
|
| Rate for Payer: Group Health Inc Commercial |
$7.02
|
| Rate for Payer: Group Health Inc Medicare |
$4.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.13
|
|
|
SITAGLIPTIN 100 MG TAB - NF
|
Facility
OP
|
$14.05
|
|
| Hospital Charge Code |
41644866
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$11.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.73
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.02
|
| Rate for Payer: Aetna Government |
$7.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.55
|
| Rate for Payer: Group Health Inc Commercial |
$7.02
|
| Rate for Payer: Group Health Inc Medicare |
$4.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.13
|
|
|
SITAGLIPTIN 25 MG TAB - NF
|
Facility
OP
|
$13.00
|
|
| Hospital Charge Code |
41654864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.50
|
| Rate for Payer: Aetna Government |
$6.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.84
|
| Rate for Payer: Group Health Inc Commercial |
$6.50
|
| Rate for Payer: Group Health Inc Medicare |
$4.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8.45
|
|
|
SITAGLIPTIN 25 MG TAB - NF
|
Facility
OP
|
$13.00
|
|
| Hospital Charge Code |
41644864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.50
|
| Rate for Payer: Aetna Government |
$6.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.84
|
| Rate for Payer: Group Health Inc Commercial |
$6.50
|
| Rate for Payer: Group Health Inc Medicare |
$4.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8.45
|
|
|
SITAGLIPTIN 50 MG TAB - NF
|
Facility
OP
|
$14.07
|
|
| Hospital Charge Code |
41654865
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.04
|
| Rate for Payer: Aetna Government |
$7.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.57
|
| Rate for Payer: Group Health Inc Commercial |
$7.04
|
| Rate for Payer: Group Health Inc Medicare |
$4.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.15
|
|
|
SITAGLIPTIN 50 MG TAB - NF
|
Facility
OP
|
$14.07
|
|
| Hospital Charge Code |
41644865
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.04
|
| Rate for Payer: Aetna Government |
$7.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.57
|
| Rate for Payer: Group Health Inc Commercial |
$7.04
|
| Rate for Payer: Group Health Inc Medicare |
$4.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.15
|
|
|
SITZ BATH
|
Facility
OP
|
$7.80
|
|
| Hospital Charge Code |
40207626
|
|
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: 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
|
|
|
SIZE 3-4 21MM CONSTRAINED INSERT
|
Facility
IP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64904173
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,350.00 |
| Max. Negotiated Rate |
$2,350.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,350.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,350.00
|
|
|
SIZE 3-4 21MM CONSTRAINED INSERT
|
Facility
OP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64904173
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$4,935.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,585.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,350.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,702.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,935.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,350.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,645.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,350.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,350.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,055.00
|
|
|
SIZE 3 RIGHT REVISION TIB
|
Facility
IP
|
$97,187.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904175
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$48,593.75 |
| Max. Negotiated Rate |
$48,593.75 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$48,593.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$48,593.75
|
|
|
SIZE 3 RIGHT REVISION TIB
|
Facility
OP
|
$97,187.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904175
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$102,046.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$53,453.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$48,593.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$55,882.81
|
| Rate for Payer: Fidelis Medicare Advantage |
$102,046.88
|
| Rate for Payer: Group Health Inc Commercial |
$48,593.75
|
| Rate for Payer: Group Health Inc Medicare |
$34,015.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$48,593.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$48,593.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$63,171.88
|
|
|
SIZE 4 RIGHT OX REV FEMUR
|
Facility
OP
|
$24,211.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904170
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$25,421.81 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13,316.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12,105.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13,921.47
|
| Rate for Payer: Fidelis Medicare Advantage |
$25,421.81
|
| Rate for Payer: Group Health Inc Commercial |
$12,105.62
|
| Rate for Payer: Group Health Inc Medicare |
$8,473.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12,105.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12,105.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15,737.31
|
|
|
SIZE 4 RIGHT OX REV FEMUR
|
Facility
IP
|
$24,211.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904170
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,105.62 |
| Max. Negotiated Rate |
$12,105.62 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12,105.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12,105.62
|
|
|
SIZE II SYN POROUS HO STEM
|
Facility
OP
|
$9,329.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904385
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$9,795.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,131.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,664.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5,364.46
|
| Rate for Payer: Fidelis Medicare Advantage |
$9,795.98
|
| Rate for Payer: Group Health Inc Commercial |
$4,664.75
|
| Rate for Payer: Group Health Inc Medicare |
$3,265.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,664.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,664.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,064.18
|
|
|
SIZE II SYN POROUS HO STEM
|
Facility
IP
|
$9,329.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904385
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,664.75 |
| Max. Negotiated Rate |
$4,664.75 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,664.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,664.75
|
|
