|
STYLET LEAD .016IN 59CML STRAIGHT
|
Facility
OP
|
$125.00
|
|
| Hospital Charge Code |
64902623
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$68.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$62.50
|
| Rate for Payer: Aetna Government |
$62.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$100.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$85.00
|
| Rate for Payer: Group Health Inc Commercial |
$62.50
|
| Rate for Payer: Group Health Inc Medicare |
$43.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$62.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$62.50
|
|
|
STYLETTE SLICK DISP
|
Facility
OP
|
$6.53
|
|
| Hospital Charge Code |
64903043
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$5.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.26
|
| Rate for Payer: Aetna Government |
$3.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.44
|
| Rate for Payer: Group Health Inc Commercial |
$3.26
|
| Rate for Payer: Group Health Inc Medicare |
$2.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.26
|
|
|
STYRKER SCREW LOCKING 3.5X12MM
|
Facility
IP
|
$247.80
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40205501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$123.90 |
| Max. Negotiated Rate |
$123.90 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$123.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$123.90
|
|
|
STYRKER SCREW LOCKING 3.5X12MM
|
Facility
OP
|
$247.80
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40205501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$86.73 |
| Max. Negotiated Rate |
$260.19 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$136.29
|
| 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 |
$123.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$142.48
|
| Rate for Payer: Fidelis Medicare Advantage |
$260.19
|
| Rate for Payer: Group Health Inc Commercial |
$123.90
|
| Rate for Payer: Group Health Inc Medicare |
$86.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$123.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$123.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$161.07
|
|
|
STYR SLF DRIL HLF PIN 6M 200X60M
|
Facility
IP
|
$165.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202635
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$82.88 |
| Max. Negotiated Rate |
$82.88 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$82.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$82.88
|
|
|
STYR SLF DRIL HLF PIN 6M 200X60M
|
Facility
OP
|
$165.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202635
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$58.01 |
| Max. Negotiated Rate |
$174.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$91.16
|
| 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 |
$82.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$95.31
|
| Rate for Payer: Fidelis Medicare Advantage |
$174.04
|
| Rate for Payer: Group Health Inc Commercial |
$82.88
|
| Rate for Payer: Group Health Inc Medicare |
$58.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$82.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$82.88
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$107.74
|
|
|
SUBC INJ FILLING MARTRL>10.0CC
|
Facility
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 11954
|
| Hospital Charge Code |
30307883
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$125.64 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$726.29
|
| Rate for Payer: Aetna Government |
$726.29
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$726.29
|
| 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 |
$726.29
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$125.64
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$617.35
|
| Rate for Payer: Fidelis Essential Plan QHP |
$646.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$726.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$646.40
|
| 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 |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$726.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$139.60
|
| Rate for Payer: Healthfirst Medicare Advantage |
$617.35
|
| Rate for Payer: Healthfirst QHP |
$726.29
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$726.29
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$726.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$726.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$581.03
|
| Rate for Payer: Wellcare Medicare |
$689.98
|
|
|
SUBCLAVIAN CATH INSERT TRAY
|
Facility
OP
|
$160.89
|
|
| Hospital Charge Code |
40200045
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$56.31 |
| Max. Negotiated Rate |
$128.71 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$88.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$80.44
|
| Rate for Payer: Aetna Government |
$80.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$128.71
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$109.41
|
| Rate for Payer: Group Health Inc Commercial |
$80.44
|
| Rate for Payer: Group Health Inc Medicare |
$56.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$80.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$80.44
|
|
|
SUBCLAVIAN CATH SET
|
Facility
OP
|
$129.20
|
|
| Hospital Charge Code |
40207630
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$45.22 |
| Max. Negotiated Rate |
$103.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$71.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$64.60
|
| Rate for Payer: Aetna Government |
$64.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$103.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$87.86
|
| Rate for Payer: Group Health Inc Commercial |
$64.60
|
| Rate for Payer: Group Health Inc Medicare |
$45.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$64.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$64.60
|
|
|
SUBCLAVIAN TRAY(RU)
|
Facility
OP
|
$57.76
|
|
| Hospital Charge Code |
40207805
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$20.22 |
| Max. Negotiated Rate |
$46.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$31.77
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$28.88
|
| Rate for Payer: Aetna Government |
$28.88
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$46.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$39.28
|
| Rate for Payer: Group Health Inc Commercial |
$28.88
|
| Rate for Payer: Group Health Inc Medicare |
$20.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$28.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$28.88
|
|
|
SUBCUTANEOUS INFUSION INITIAL
|
Facility
OP
|
$556.50
|
|
|
Service Code
|
HCPCS 96369
|
| Hospital Charge Code |
40509898
|
|
Hospital Revenue Code
|
269
|
| Min. Negotiated Rate |
$154.84 |
| Max. Negotiated Rate |
$445.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$306.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$247.87
|
| Rate for Payer: Aetna Government |
$247.87
|
| Rate for Payer: Cash Price |
$247.87
|
| Rate for Payer: Cash Price |
$247.87
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$247.87
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$445.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$378.42
|
| Rate for Payer: Elderplan Medicare Advantage |
$247.87
|
| Rate for Payer: EmblemHealth Commercial |
$247.87
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$154.84
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$210.69
|
| Rate for Payer: Fidelis Essential Plan QHP |
$220.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$247.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$220.60
|
| Rate for Payer: Group Health Inc Commercial |
$247.87
|
| Rate for Payer: Group Health Inc Medicare |
$247.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$278.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$247.87
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$172.05
|
| Rate for Payer: Healthfirst Medicare Advantage |
$210.69
|
| Rate for Payer: Healthfirst QHP |
$247.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$247.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$247.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$198.30
|
| Rate for Payer: Wellcare Medicare |
$235.48
|
|
|
SUBEPITHELIAL CONN. TISSUE GRAFT
|
Facility
OP
|
$750.00
|
|
|
Service Code
|
HCPCS D4273
|
| Hospital Charge Code |
42303311
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$375.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$412.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,763.60
|
| Rate for Payer: Aetna Government |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,763.60
|
| 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 |
$1,763.60
|
| Rate for Payer: EmblemHealth Commercial |
$1,763.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,499.06
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,569.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,763.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,569.60
|
| Rate for Payer: Group Health Inc Commercial |
$1,763.60
|
| Rate for Payer: Group Health Inc Medicare |
$1,763.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$375.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,763.60
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,499.06
|
| Rate for Payer: Healthfirst QHP |
$1,763.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,763.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,763.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,410.88
|
| Rate for Payer: Wellcare Medicare |
$1,675.42
|
|
|
SUBPERIOSTEAL IMPLANT
|
Facility
OP
|
$10,302.00
|
|
|
Service Code
|
HCPCS D6040
|
| Hospital Charge Code |
42301420
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,313.78 |
| Max. Negotiated Rate |
$5,666.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,666.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,313.78
|
| Rate for Payer: Aetna Government |
$2,313.78
|
| 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 |
$5,151.00
|
| Rate for Payer: Group Health Inc Medicare |
$3,605.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5,151.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5,151.00
|
|
|
SUBSEQUENT ADMIN IM/SQ
|
Facility
OP
|
$17.50
|
|
|
Service Code
|
HCPCS 90461
|
| Hospital Charge Code |
30301291
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.00
|
| Rate for Payer: Aetna Government |
$5.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.90
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$10.57
|
| 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 |
$8.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.75
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$11.74
|
|
|
SUBTALAR 9MM HERIZON TITANIUM
|
Facility
IP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,312.50 |
| Max. Negotiated Rate |
$2,312.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,312.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,312.50
|
|
|
SUBTALAR 9MM HERIZON TITANIUM
|
Facility
OP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$4,856.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,543.75
|
| 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 |
$2,312.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,659.38
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,856.25
|
| Rate for Payer: Group Health Inc Commercial |
$2,312.50
|
| Rate for Payer: Group Health Inc Medicare |
$1,618.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,312.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,312.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,006.25
|
|
|
SUBTALAR HERIZON TITANIUM 10MM
|
Facility
IP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901834
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,312.50 |
| Max. Negotiated Rate |
$2,312.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,312.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,312.50
|
|
|
SUBTALAR HERIZON TITANIUM 10MM
|
Facility
OP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901834
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$4,856.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,543.75
|
| 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 |
$2,312.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,659.38
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,856.25
|
| Rate for Payer: Group Health Inc Commercial |
$2,312.50
|
| Rate for Payer: Group Health Inc Medicare |
$1,618.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,312.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,312.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,006.25
|
|
|
SUBTALAR IMPLANT
|
Facility
OP
|
$4,326.00
|
|
| Hospital Charge Code |
40203017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,514.10 |
| Max. Negotiated Rate |
$3,460.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,379.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,163.00
|
| Rate for Payer: Aetna Government |
$2,163.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,460.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,941.68
|
| Rate for Payer: Group Health Inc Commercial |
$2,163.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,514.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,163.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,163.00
|
|
|
SUBTALAR MBA IMPLANT 10MM
|
Facility
OP
|
$2,720.00
|
|
| Hospital Charge Code |
40209713
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$952.00 |
| Max. Negotiated Rate |
$2,176.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,496.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,360.00
|
| Rate for Payer: Aetna Government |
$1,360.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,176.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,849.60
|
| Rate for Payer: Group Health Inc Commercial |
$1,360.00
|
| Rate for Payer: Group Health Inc Medicare |
$952.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,360.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,360.00
|
|
|
SUBTOT TO HYSTO AFTER CESAR
|
Facility
OP
|
$1,341.63
|
|
|
Service Code
|
HCPCS 59525
|
| Hospital Charge Code |
40052239
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$469.57 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$737.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$585.73
|
| Rate for Payer: Aetna Government |
$585.73
|
| 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: Fidelis CHP/HARP/Medicaid |
$575.75
|
| Rate for Payer: Group Health Inc Commercial |
$670.82
|
| Rate for Payer: Group Health Inc Medicare |
$469.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$670.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$670.82
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$639.72
|
|
|
SUCCIMER 100 MG CAP
|
Facility
OP
|
$14.18
|
|
| Hospital Charge Code |
41644010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$11.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.09
|
| Rate for Payer: Aetna Government |
$7.09
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.64
|
| Rate for Payer: Group Health Inc Commercial |
$7.09
|
| Rate for Payer: Group Health Inc Medicare |
$4.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.09
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.22
|
|
|
SUCCIMER 100 MG CAP
|
Facility
OP
|
$14.18
|
|
| Hospital Charge Code |
41654010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$11.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.09
|
| Rate for Payer: Aetna Government |
$7.09
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.64
|
| Rate for Payer: Group Health Inc Commercial |
$7.09
|
| Rate for Payer: Group Health Inc Medicare |
$4.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.09
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.22
|
|
|
SUCCINYLCHOLINE 100MG/5ML PFS
|
Facility
IP
|
$31.25
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
41650231
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.62 |
| Max. Negotiated Rate |
$15.62 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.62
|
|
|
SUCCINYLCHOLINE 100MG/5ML PFS
|
Facility
IP
|
$31.25
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
41640231
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.62 |
| Max. Negotiated Rate |
$15.62 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.62
|
|
