|
SOUNDS UTERINE DISPOSABLE SIMS
|
Facility
OP
|
$4.70
|
|
| Hospital Charge Code |
64903367
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$3.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.35
|
| Rate for Payer: Aetna Government |
$2.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.76
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.20
|
| Rate for Payer: Group Health Inc Commercial |
$2.35
|
| Rate for Payer: Group Health Inc Medicare |
$1.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.35
|
|
|
SP ABCESS CATH. CHANGE
|
Facility
OP
|
$711.45
|
|
|
Service Code
|
HCPCS 43762 TC
|
| Hospital Charge Code |
41547458
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$249.01 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$391.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$355.72
|
| Rate for Payer: Aetna Government |
$355.72
|
| Rate for Payer: Cash Price |
$285.81
|
| Rate for Payer: Cash Price |
$285.81
|
| 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 |
$355.72
|
| Rate for Payer: Group Health Inc Medicare |
$249.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$355.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$355.72
|
|
|
SP ABCESS CATH. CHECK
|
Facility
OP
|
$127.89
|
|
|
Service Code
|
HCPCS 20501 TC
|
| Hospital Charge Code |
41547457
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$44.76 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$70.34
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$63.94
|
| Rate for Payer: Aetna Government |
$63.94
|
| 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 |
$63.94
|
| Rate for Payer: Group Health Inc Medicare |
$44.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$63.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$63.94
|
|
|
SP ABCESSOGRAM (VIA CATHETER)
|
Facility
OP
|
$4,542.00
|
|
|
Service Code
|
HCPCS 49424 TC
|
| Hospital Charge Code |
41547628
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,589.70 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,498.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,271.00
|
| Rate for Payer: Aetna Government |
$2,271.00
|
| 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 |
$2,271.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,589.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,271.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,271.00
|
|
|
SP ABD PARACENTESIS W/IMAGING
|
Facility
OP
|
$2,380.35
|
|
|
Service Code
|
HCPCS 49083 TC
|
| Hospital Charge Code |
41542788
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$833.12 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,309.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,190.18
|
| Rate for Payer: Aetna Government |
$1,190.18
|
| Rate for Payer: Cash Price |
$1,048.28
|
| Rate for Payer: Cash Price |
$1,048.28
|
| 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 |
$1,190.18
|
| Rate for Payer: Group Health Inc Medicare |
$833.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,190.18
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,190.18
|
|
|
SP ABD/RETRO PERCUTANEOUS
|
Facility
OP
|
$4,157.25
|
|
|
Service Code
|
HCPCS 49180 TC
|
| Hospital Charge Code |
41542795
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,455.04 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,286.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,078.62
|
| Rate for Payer: Aetna Government |
$2,078.62
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Cash Price |
$1,874.89
|
| 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 |
$2,078.62
|
| Rate for Payer: Group Health Inc Medicare |
$1,455.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,078.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,078.62
|
|
|
SP ABI AT REST/LASER DOPPL
|
Facility
OP
|
$330.23
|
|
|
Service Code
|
HCPCS 93922 TC
|
| Hospital Charge Code |
41201164
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$78.29 |
| Max. Negotiated Rate |
$264.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$181.63
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$165.12
|
| Rate for Payer: Aetna Government |
$165.12
|
| Rate for Payer: Cash Price |
$147.72
|
| Rate for Payer: Cash Price |
$147.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$264.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$224.56
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$78.29
|
| Rate for Payer: Group Health Inc Commercial |
$165.12
|
| Rate for Payer: Group Health Inc Medicare |
$115.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$165.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$165.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$86.99
|
|
|
SP ABI WITH EXERCISE
|
Facility
OP
|
$419.03
|
|
|
Service Code
|
HCPCS 93923 TC
|
| Hospital Charge Code |
41201165
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$118.95 |
| Max. Negotiated Rate |
$335.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$230.47
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$209.52
|
| Rate for Payer: Aetna Government |
$209.52
|
| Rate for Payer: Cash Price |
$180.64
|
| Rate for Payer: Cash Price |
$180.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$335.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$284.94
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$118.95
|
| Rate for Payer: Group Health Inc Commercial |
$209.52
|
| Rate for Payer: Group Health Inc Medicare |
$146.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$209.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$209.52
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$132.17
|
|
|
SP ABSC DRAINAGE,APPENDIX(PERCUT)
|
Facility
OP
|
$4,157.25
|
|
|
Service Code
|
HCPCS 49406 TC
|
| Hospital Charge Code |
41547607
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,455.04 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,286.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,078.62
|
| Rate for Payer: Aetna Government |
$2,078.62
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Cash Price |
$1,874.89
|
| 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 |
$2,078.62
|
| Rate for Payer: Group Health Inc Medicare |
$1,455.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,078.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,078.62
|
|
|
SP ABSC DRAINAGE PELVIC TRANSRECT
|
Facility
OP
|
$3,041.53
|
|
|
Service Code
|
HCPCS 45000 TC
|
| Hospital Charge Code |
41547608
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,064.54 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,672.84
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,520.76
|
| Rate for Payer: Aetna Government |
$1,520.76
|
| Rate for Payer: Cash Price |
$1,364.66
|
| Rate for Payer: Cash Price |
$1,364.66
|
| 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 |
$1,520.76
|
| Rate for Payer: Group Health Inc Medicare |
$1,064.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,520.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,520.76
|
|
|
SP ABSCESS DRAINAGE LIVER C
|
Facility
OP
|
$4,157.25
|
|
|
Service Code
|
HCPCS 49405 TC
|
| Hospital Charge Code |
41542782
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,455.04 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,286.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,078.62
|
| Rate for Payer: Aetna Government |
$2,078.62
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Cash Price |
$1,874.89
|
| 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 |
$2,078.62
|
| Rate for Payer: Group Health Inc Medicare |
$1,455.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,078.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,078.62
|
|
|
SP ABSCESS DRAINAGE, PELVIC
|
Facility
OP
|
$7,099.93
|
|
|
Service Code
|
HCPCS 45020
|
| Hospital Charge Code |
41547609
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$651.93 |
| Max. Negotiated Rate |
$3,549.96 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,246.99
|
| Rate for Payer: Aetna Government |
$3,246.99
|
| Rate for Payer: Cash Price |
$3,246.99
|
| Rate for Payer: Cash Price |
$3,246.99
|
| Rate for Payer: Cash Price |
$3,246.99
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,246.99
|
| 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 |
$3,246.99
|
| Rate for Payer: EmblemHealth Commercial |
$3,246.99
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$651.93
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2,759.94
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2,889.82
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,246.99
|
| Rate for Payer: Fidelis Qualified Health Plan |
$2,889.82
|
| Rate for Payer: Group Health Inc Commercial |
$3,246.99
|
| Rate for Payer: Group Health Inc Medicare |
$3,246.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,549.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,246.99
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$724.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2,759.94
|
| Rate for Payer: Healthfirst QHP |
$3,246.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,246.99
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,246.99
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,597.59
|
| Rate for Payer: Wellcare Medicare |
$3,084.64
|
|
|
SP ABSCESS DRAINAGE PERIVESICAL
|
Facility
OP
|
$5,365.58
|
|
|
Service Code
|
HCPCS 51060 TC
|
| Hospital Charge Code |
41547610
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,877.95 |
| Max. Negotiated Rate |
$2,951.07 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,951.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,682.79
|
| Rate for Payer: Aetna Government |
$2,682.79
|
| Rate for Payer: Cash Price |
$2,355.42
|
| Rate for Payer: Cash Price |
$2,355.42
|
| 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 |
$2,682.79
|
| Rate for Payer: Group Health Inc Medicare |
$1,877.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,682.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,682.79
|
|
|
SP ABSCESS DRAINAGE, SUBUTANEOUS
|
Facility
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 10160 TC
|
| Hospital Charge Code |
41546555
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$338.71 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$532.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$483.86
|
| Rate for Payer: Aetna Government |
$483.86
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| 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 |
$483.86
|
| Rate for Payer: Group Health Inc Medicare |
$338.71
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$483.86
|
|
|
SP ABSCESS DRAIN EMP/HEM
|
Facility
OP
|
$4,940.28
|
|
|
Service Code
|
HCPCS 32551 TC
|
| Hospital Charge Code |
41542783
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,729.10 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,717.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,470.14
|
| Rate for Payer: Aetna Government |
$2,470.14
|
| Rate for Payer: Cash Price |
$1,852.05
|
| Rate for Payer: Cash Price |
$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: Group Health Inc Commercial |
$2,470.14
|
| Rate for Payer: Group Health Inc Medicare |
$1,729.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,470.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,470.14
|
|
|
SP ABSCESS DRAIN PERITON
|
Facility
OP
|
$4,157.25
|
|
|
Service Code
|
HCPCS 49405 TC
|
| Hospital Charge Code |
41542784
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,455.04 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,286.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,078.62
|
| Rate for Payer: Aetna Government |
$2,078.62
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Cash Price |
$1,874.89
|
| 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 |
$2,078.62
|
| Rate for Payer: Group Health Inc Medicare |
$1,455.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,078.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,078.62
|
|
|
SP ABSCESS DRAIN RENAL
|
Facility
OP
|
$4,157.25
|
|
|
Service Code
|
HCPCS 49406 TC
|
| Hospital Charge Code |
41542787
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,455.04 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,286.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,078.62
|
| Rate for Payer: Aetna Government |
$2,078.62
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Cash Price |
$1,874.89
|
| 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 |
$2,078.62
|
| Rate for Payer: Group Health Inc Medicare |
$1,455.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,078.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,078.62
|
|
|
SP ABSCESS DRAIN RETROPERI
|
Facility
OP
|
$4,157.25
|
|
|
Service Code
|
HCPCS 49406 TC
|
| Hospital Charge Code |
41542785
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,455.04 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,286.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,078.62
|
| Rate for Payer: Aetna Government |
$2,078.62
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Cash Price |
$1,874.89
|
| 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 |
$2,078.62
|
| Rate for Payer: Group Health Inc Medicare |
$1,455.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,078.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,078.62
|
|
|
SP ABSCESS DRAIN SUB/DIAPH
|
Facility
OP
|
$4,157.25
|
|
|
Service Code
|
HCPCS 49405 TC
|
| Hospital Charge Code |
41542786
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,455.04 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,286.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,078.62
|
| Rate for Payer: Aetna Government |
$2,078.62
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Cash Price |
$1,874.89
|
| 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 |
$2,078.62
|
| Rate for Payer: Group Health Inc Medicare |
$1,455.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,078.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,078.62
|
|
|
SPACE MAINTAINER-FIXED-UNILATERAL
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS D1510
|
| Hospital Charge Code |
42300295
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$145.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$159.50
|
| 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 |
$145.00
|
| 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
|
|
|
SPACE MAINTAINER-REMOVABLE-UNILAT
|
Facility
OP
|
$508.88
|
|
|
Service Code
|
HCPCS D1520
|
| Hospital Charge Code |
42300305
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$254.44 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$279.88
|
| 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 |
$254.44
|
| 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
|
|
|
SPACE MAINT FIXED BILAT MANDIBULA
|
Facility
OP
|
$435.00
|
|
|
Service Code
|
HCPCS D1517
|
| Hospital Charge Code |
42300737
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$217.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$239.25
|
| 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 |
$217.50
|
| 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: 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
|
|
|
SPACE MAINT-FIXED BILAT MAXILLARY
|
Facility
OP
|
$435.00
|
|
|
Service Code
|
HCPCS D1516
|
| Hospital Charge Code |
42300736
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$217.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$239.25
|
| 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 |
$217.50
|
| 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: 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
|
|
|
SPACER, 15X13MM 6MM HEIGHT
|
Facility
OP
|
$5,812.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904761
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$6,103.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3,196.88
|
| 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 |
$2,906.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,342.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,103.12
|
| Rate for Payer: Group Health Inc Commercial |
$2,906.25
|
| Rate for Payer: Group Health Inc Medicare |
$2,034.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,906.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,906.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,778.12
|
|
|
SPACER, 15X13MM 6MM HEIGHT
|
Facility
IP
|
$5,812.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904761
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,906.25 |
| Max. Negotiated Rate |
$2,906.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,906.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,906.25
|
|
