|
RELEASE HAND/FINGER TENDON
|
Facility
|
IP
|
$4,105.13
|
|
|
Service Code
|
HCPCS 26455
|
| Hospital Charge Code |
40064146
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,858.61
|
|
|
RELEASE HAND/FINGER TENDON
|
Facility
|
OP
|
$4,105.13
|
|
|
Service Code
|
HCPCS 26455
|
| Hospital Charge Code |
40064146
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,301.03 |
| Max. Negotiated Rate |
$3,078.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,858.61
|
| Rate for Payer: Aetna Government |
$1,858.61
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,301.03
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,301.03
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,301.03
|
| Rate for Payer: Brighton Health Commercial |
$3,078.85
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,858.61
|
| 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 |
$1,858.61
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,579.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,654.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,858.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,654.16
|
| Rate for Payer: Group Health Inc Commercial |
$1,858.61
|
| Rate for Payer: Group Health Inc Medicare |
$1,858.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,052.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,858.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,579.82
|
| Rate for Payer: Healthfirst QHP |
$1,858.61
|
| Rate for Payer: Humana Medicare |
$1,895.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,858.61
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,858.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,858.61
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,486.89
|
| Rate for Payer: Wellcare Medicare |
$1,765.68
|
|
|
RELEASE OF FOOT CONTRACT
|
Facility
|
IP
|
$8,291.05
|
|
|
Service Code
|
HCPCS 28270
|
| Hospital Charge Code |
40084114
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$3,743.15
|
|
|
RELEASE OF FOOT CONTRACT
|
Facility
|
OP
|
$8,291.05
|
|
|
Service Code
|
HCPCS 28270
|
| Hospital Charge Code |
40084114
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,468.00 |
| Max. Negotiated Rate |
$6,218.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,743.15
|
| Rate for Payer: Aetna Government |
$3,743.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,620.20
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,620.20
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,620.20
|
| Rate for Payer: Brighton Health Commercial |
$6,218.29
|
| Rate for Payer: Cash Price |
$3,743.15
|
| Rate for Payer: Cash Price |
$3,743.15
|
| Rate for Payer: Cash Price |
$3,743.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,743.15
|
| 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 |
$3,743.15
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,181.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,331.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,743.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,331.40
|
| Rate for Payer: Group Health Inc Commercial |
$3,743.15
|
| Rate for Payer: Group Health Inc Medicare |
$3,743.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,145.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,743.15
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,181.68
|
| Rate for Payer: Healthfirst QHP |
$3,743.15
|
| Rate for Payer: Humana Medicare |
$3,818.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,743.15
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,743.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,743.15
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,994.52
|
| Rate for Payer: Wellcare Medicare |
$3,555.99
|
|
|
RELEASE OF TOE JOINT EACH
|
Facility
|
IP
|
$4,105.13
|
|
|
Service Code
|
HCPCS 28272
|
| Hospital Charge Code |
40029697
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,858.61
|
|
|
RELEASE OF TOE JOINT EACH
|
Facility
|
OP
|
$4,105.13
|
|
|
Service Code
|
HCPCS 28272
|
| Hospital Charge Code |
40029697
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,301.03 |
| Max. Negotiated Rate |
$3,078.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,858.61
|
| Rate for Payer: Aetna Government |
$1,858.61
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,301.03
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,301.03
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,301.03
|
| Rate for Payer: Brighton Health Commercial |
$3,078.85
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,858.61
|
| 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 |
$1,858.61
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,579.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,654.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,858.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,654.16
|
| Rate for Payer: Group Health Inc Commercial |
$1,858.61
|
| Rate for Payer: Group Health Inc Medicare |
$1,858.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,052.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,858.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,579.82
|
| Rate for Payer: Healthfirst QHP |
$1,858.61
|
| Rate for Payer: Humana Medicare |
$1,895.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,858.61
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,858.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,858.61
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,486.89
|
| Rate for Payer: Wellcare Medicare |
$1,765.68
|
|
|
RELEASE PALM CONTRACT EA. ADD DIG
|
Facility
|
OP
|
$825.90
|
|
|
Service Code
|
HCPCS 26125
|
| Hospital Charge Code |
40019893
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$282.33 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,485.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$282.33
|
| Rate for Payer: Aetna Government |
$282.33
|
| Rate for Payer: Brighton Health Commercial |
$619.42
|
| 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: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Group Health Inc Commercial |
$412.95
|
| Rate for Payer: Group Health Inc Medicare |
$289.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$412.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$412.95
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
|
|
RELEASE PALM CONTRACTURE
|
Facility
|
OP
|
$4,220.22
|
|
|
Service Code
|
HCPCS 26040
|
| Hospital Charge Code |
30300354
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,301.03 |
| Max. Negotiated Rate |
$3,165.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,485.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,858.61
|
| Rate for Payer: Aetna Government |
$1,858.61
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,301.03
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,301.03
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,301.03
|
| Rate for Payer: Brighton Health Commercial |
$3,165.16
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,858.61
|
| 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 |
$1,858.61
|
| Rate for Payer: EmblemHealth Commercial |
$1,858.61
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,579.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,654.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,858.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,654.16
|
| Rate for Payer: Group Health Inc Commercial |
$1,858.61
|
| Rate for Payer: Group Health Inc Medicare |
$1,858.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,110.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,858.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,579.82
|
| Rate for Payer: Healthfirst QHP |
$1,858.61
|
| Rate for Payer: Humana Medicare |
$1,895.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,858.61
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,858.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,858.61
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,486.89
|
| Rate for Payer: Wellcare Medicare |
$1,765.68
|
|
|
RELEASE PALM CONTRACTURE
|
Facility
|
IP
|
$4,220.22
|
|
|
Service Code
|
HCPCS 26040
|
| Hospital Charge Code |
30300354
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,858.61
|
|
|
RELEASE PALM CONTRACTURE 1ST DIGI
|
Facility
|
IP
|
$8,291.05
|
|
|
Service Code
|
HCPCS 26123
|
| Hospital Charge Code |
40019892
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$3,743.15
|
|
|
RELEASE PALM CONTRACTURE 1ST DIGI
|
Facility
|
OP
|
$8,291.05
|
|
|
Service Code
|
HCPCS 26123
|
| Hospital Charge Code |
40019892
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$6,218.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,485.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,743.15
|
| Rate for Payer: Aetna Government |
$3,743.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,620.20
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,620.20
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,620.20
|
| Rate for Payer: Brighton Health Commercial |
$6,218.29
|
| Rate for Payer: Cash Price |
$3,743.15
|
| Rate for Payer: Cash Price |
$3,743.15
|
| Rate for Payer: Cash Price |
$3,743.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,743.15
|
| 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 |
$3,743.15
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,181.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,331.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,743.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,331.40
|
| Rate for Payer: Group Health Inc Commercial |
$3,743.15
|
| Rate for Payer: Group Health Inc Medicare |
$3,743.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,145.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,743.15
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,181.68
|
| Rate for Payer: Healthfirst QHP |
$3,743.15
|
| Rate for Payer: Humana Medicare |
$3,818.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,743.15
|
| Rate for Payer: United Healthcare Commercial |
$1,835.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,743.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,743.15
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,994.52
|
| Rate for Payer: Wellcare Medicare |
$3,555.99
|
|
|
RELEASE PALM/FINGER TENDON
|
Facility
|
OP
|
$4,105.13
|
|
|
Service Code
|
HCPCS 26440
|
| Hospital Charge Code |
40019895
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,301.03 |
| Max. Negotiated Rate |
$3,078.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,858.61
|
| Rate for Payer: Aetna Government |
$1,858.61
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,301.03
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,301.03
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,301.03
|
| Rate for Payer: Brighton Health Commercial |
$3,078.85
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,858.61
|
| 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 |
$1,858.61
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,579.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,654.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,858.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,654.16
|
| Rate for Payer: Group Health Inc Commercial |
$1,858.61
|
| Rate for Payer: Group Health Inc Medicare |
$1,858.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,052.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,858.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,579.82
|
| Rate for Payer: Healthfirst QHP |
$1,858.61
|
| Rate for Payer: Humana Medicare |
$1,895.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,858.61
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,858.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,858.61
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,486.89
|
| Rate for Payer: Wellcare Medicare |
$1,765.68
|
|
|
RELEASE PALM/FINGER TENDON
|
Facility
|
IP
|
$4,105.13
|
|
|
Service Code
|
HCPCS 26440
|
| Hospital Charge Code |
40019895
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,858.61
|
|
|
RELEASE TRIGGER FINGER
|
Facility
|
OP
|
$4,105.13
|
|
|
Service Code
|
HCPCS 26055
|
| Hospital Charge Code |
40021615
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,301.03 |
| Max. Negotiated Rate |
$3,078.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,858.61
|
| Rate for Payer: Aetna Government |
$1,858.61
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,301.03
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,301.03
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,301.03
|
| Rate for Payer: Brighton Health Commercial |
$3,078.85
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Cash Price |
$1,858.61
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,858.61
|
| 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 |
$1,858.61
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,579.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,654.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,858.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,654.16
|
| Rate for Payer: Group Health Inc Commercial |
$1,858.61
|
| Rate for Payer: Group Health Inc Medicare |
$1,858.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,052.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,858.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,579.82
|
| Rate for Payer: Healthfirst QHP |
$1,858.61
|
| Rate for Payer: Humana Medicare |
$1,895.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,858.61
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,858.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,858.61
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,486.89
|
| Rate for Payer: Wellcare Medicare |
$1,765.68
|
|
|
RELEASE TRIGGER FINGER
|
Facility
|
IP
|
$4,105.13
|
|
|
Service Code
|
HCPCS 26055
|
| Hospital Charge Code |
40021615
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,858.61
|
|
|
RELIANCE SG SINGLE COIL 64CM
|
Facility
|
OP
|
$11,200.00
|
|
|
Service Code
|
HCPCS C1777
|
| Hospital Charge Code |
66526903
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$988.18 |
| Max. Negotiated Rate |
$11,760.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6,160.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$988.18
|
| Rate for Payer: Aetna Government |
$988.18
|
| Rate for Payer: Brighton Health Commercial |
$6,720.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5,600.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6,440.00
|
| Rate for Payer: EmblemHealth Commercial |
$5,600.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$11,760.00
|
| Rate for Payer: Group Health Inc Commercial |
$5,600.00
|
| Rate for Payer: Group Health Inc Medicare |
$3,920.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5,600.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5,600.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7,280.00
|
|
|
RELINE 0 TI ROD 5.5X40 LOR
|
Facility
|
IP
|
$937.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904806
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$468.75 |
| Max. Negotiated Rate |
$468.75 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$468.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$468.75
|
|
|
RELINE 0 TI ROD 5.5X40 LOR
|
Facility
|
OP
|
$937.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904806
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$984.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$515.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$562.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$468.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$539.06
|
| Rate for Payer: EmblemHealth Commercial |
$468.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$984.38
|
| Rate for Payer: Group Health Inc Commercial |
$468.75
|
| Rate for Payer: Group Health Inc Medicare |
$328.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$468.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$468.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$609.38
|
|
|
RELINE COMPLETE LOWER DENTURE (CH
|
Facility
|
OP
|
$312.50
|
|
|
Service Code
|
HCPCS D5731
|
| Hospital Charge Code |
42301125
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$92.21 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$171.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$92.21
|
| Rate for Payer: Aetna Government |
$92.21
|
| Rate for Payer: Brighton Health Commercial |
$234.38
|
| 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 |
$156.25
|
| Rate for Payer: Group Health Inc Medicare |
$109.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$156.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$156.25
|
|
|
RELINE COMPLETE LOWER DENTURE (LA
|
Facility
|
OP
|
$425.00
|
|
|
Service Code
|
HCPCS D5751
|
| Hospital Charge Code |
42301145
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$123.05 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$233.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$123.05
|
| Rate for Payer: Aetna Government |
$123.05
|
| Rate for Payer: Brighton Health Commercial |
$318.75
|
| 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 |
$212.50
|
| Rate for Payer: Group Health Inc Medicare |
$148.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$212.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$212.50
|
|
|
RELINE COMPLETE UPPER DENTURE (CH
|
Facility
|
OP
|
$312.50
|
|
|
Service Code
|
HCPCS D5730
|
| Hospital Charge Code |
42301120
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$92.21 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$171.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$92.21
|
| Rate for Payer: Aetna Government |
$92.21
|
| Rate for Payer: Brighton Health Commercial |
$234.38
|
| 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 |
$156.25
|
| Rate for Payer: Group Health Inc Medicare |
$109.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$156.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$156.25
|
|
|
RELINE COMPLETE UPPER DENTURE (LA
|
Facility
|
OP
|
$425.00
|
|
|
Service Code
|
HCPCS D5750
|
| Hospital Charge Code |
42301140
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$123.05 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$233.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$123.05
|
| Rate for Payer: Aetna Government |
$123.05
|
| Rate for Payer: Brighton Health Commercial |
$318.75
|
| 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 |
$212.50
|
| Rate for Payer: Group Health Inc Medicare |
$148.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$212.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$212.50
|
|
|
RELINE LOCK SCREW, 5.5MM OPENT
|
Facility
|
IP
|
$662.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64905570
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$331.25 |
| Max. Negotiated Rate |
$331.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$331.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$331.25
|
|
|
RELINE LOCK SCREW, 5.5MM OPENT
|
Facility
|
OP
|
$662.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64905570
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$695.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$364.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$397.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$331.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$380.94
|
| Rate for Payer: EmblemHealth Commercial |
$331.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$695.62
|
| Rate for Payer: Group Health Inc Commercial |
$331.25
|
| Rate for Payer: Group Health Inc Medicare |
$231.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$331.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$331.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$430.62
|
|
|
RELINE LOWER PARTIAL DENTURE (CHA
|
Facility
|
OP
|
$212.50
|
|
|
Service Code
|
HCPCS D5741
|
| Hospital Charge Code |
42301135
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$74.38 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$116.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$84.72
|
| Rate for Payer: Aetna Government |
$84.72
|
| Rate for Payer: Brighton Health Commercial |
$159.38
|
| 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 |
$106.25
|
| Rate for Payer: Group Health Inc Medicare |
$74.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$106.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$106.25
|
|
