|
TITANIUM ADAPTER
|
Facility
OP
|
$26.58
|
|
| Hospital Charge Code |
42905245
|
|
Hospital Revenue Code
|
801
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$21.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$13.29
|
| Rate for Payer: Aetna Government |
$13.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$21.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$18.07
|
| Rate for Payer: Group Health Inc Commercial |
$13.29
|
| Rate for Payer: Group Health Inc Medicare |
$9.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.29
|
|
|
TITANIUM HEMOSTATIC MIRCOCLIP
|
Facility
OP
|
$4.31
|
|
| Hospital Charge Code |
64905476
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.37
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.16
|
| Rate for Payer: Aetna Government |
$2.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.93
|
| Rate for Payer: Group Health Inc Commercial |
$2.16
|
| Rate for Payer: Group Health Inc Medicare |
$1.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.16
|
|
|
TITAN OFW MTB RIGHT
|
Facility
OP
|
$3,262.50
|
|
| Hospital Charge Code |
64905370
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,141.88 |
| Max. Negotiated Rate |
$2,610.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,794.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,631.25
|
| Rate for Payer: Aetna Government |
$1,631.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,610.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,218.50
|
| Rate for Payer: Group Health Inc Commercial |
$1,631.25
|
| Rate for Payer: Group Health Inc Medicare |
$1,141.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,631.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,631.25
|
|
|
TI UNIVERSAL PLATE 8 HOLES
|
Facility
OP
|
$1,700.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40209498
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$1,785.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$935.00
|
| 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 |
$850.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$977.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,785.00
|
| Rate for Payer: Group Health Inc Commercial |
$850.00
|
| Rate for Payer: Group Health Inc Medicare |
$595.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$850.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$850.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,105.00
|
|
|
TI UNIVERSAL PLATE 8 HOLES
|
Facility
IP
|
$1,700.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40209498
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$850.00 |
| Max. Negotiated Rate |
$850.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$850.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$850.00
|
|
|
TIXAGEVIMAB + CILGAVIMAB-EVUSHELD
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41650326
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
TIXAGEVIMAB + CILGAVIMAB-EVUSHELD
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41640326
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
TIXAGEVIMAB + CILGAVIMAB-EVUSHELD
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41640326
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
TIXAGEVIMAB + CILGAVIMAB-EVUSHELD
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41650326
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
T-LYMPHOCYTE HELPER/SUPPRESSOR
|
Facility
OP
|
$94.33
|
|
|
Service Code
|
HCPCS 86359
|
| Hospital Charge Code |
40629228
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.18 |
| Max. Negotiated Rate |
$59.96 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$51.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$37.73
|
| Rate for Payer: Aetna Government |
$37.73
|
| Rate for Payer: Cash Price |
$37.73
|
| Rate for Payer: Cash Price |
$37.73
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$37.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$59.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$50.73
|
| Rate for Payer: Elderplan Medicare Advantage |
$37.73
|
| Rate for Payer: EmblemHealth Commercial |
$37.73
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$33.96
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$32.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$33.58
|
| Rate for Payer: Fidelis Medicare Advantage |
$37.73
|
| Rate for Payer: Fidelis Qualified Health Plan |
$33.58
|
| Rate for Payer: Group Health Inc Commercial |
$37.73
|
| Rate for Payer: Group Health Inc Medicare |
$37.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$47.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.73
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$37.73
|
| Rate for Payer: Healthfirst Medicare Advantage |
$37.73
|
| Rate for Payer: Healthfirst QHP |
$37.73
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$37.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$37.73
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$30.18
|
| Rate for Payer: Wellcare Medicare |
$33.96
|
|
|
TM CR FEMORAL 62.5MM RT-INTERLOCK
|
Facility
IP
|
$4,640.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40209908
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,320.00 |
| Max. Negotiated Rate |
$2,320.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,320.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,320.00
|
|
|
TM CR FEMORAL 62.5MM RT-INTERLOCK
|
Facility
OP
|
$4,640.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40209908
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$4,872.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,552.00
|
| 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 |
$2,320.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,668.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,872.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,320.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,624.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,320.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,320.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,016.00
|
|
|
TMJ ARTHROCENTESIS
|
Facility
OP
|
$786.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
30302001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$40.76 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$342.51
|
| Rate for Payer: Aetna Government |
$342.51
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$342.51
|
| 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 |
$342.51
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$40.76
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$291.13
|
| Rate for Payer: Fidelis Essential Plan QHP |
$304.83
|
| Rate for Payer: Fidelis Medicare Advantage |
$342.51
|
| Rate for Payer: Fidelis Qualified Health Plan |
$304.83
|
| 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 |
$393.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$342.51
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$45.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$291.13
|
| Rate for Payer: Healthfirst QHP |
$342.51
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$342.51
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$342.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$342.51
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$274.01
|
| Rate for Payer: Wellcare Medicare |
$325.38
|
|
|
TMJ ARTHROCENTESIS
|
Facility
OP
|
$786.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
30103025
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$40.76 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$342.51
|
| Rate for Payer: Aetna Government |
$342.51
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$342.51
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$342.51
|
| 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 |
$342.51
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$40.76
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$291.13
|
| Rate for Payer: Fidelis Essential Plan QHP |
$304.83
|
| Rate for Payer: Fidelis Medicare Advantage |
$342.51
|
| Rate for Payer: Fidelis Qualified Health Plan |
$304.83
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$393.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$342.51
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$342.51
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$342.51
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$342.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$342.51
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$274.01
|
| Rate for Payer: Wellcare Medicare |
$325.38
|
|
|
TMJ ARTHROCENTESIS
|
Facility
OP
|
$786.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
40029631
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$40.76 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$342.51
|
| Rate for Payer: Aetna Government |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$342.51
|
| 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 |
$342.51
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$40.76
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$291.13
|
| Rate for Payer: Fidelis Essential Plan QHP |
$304.83
|
| Rate for Payer: Fidelis Medicare Advantage |
$342.51
|
| Rate for Payer: Fidelis Qualified Health Plan |
$304.83
|
| Rate for Payer: Group Health Inc Commercial |
$342.51
|
| Rate for Payer: Group Health Inc Medicare |
$342.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$393.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$342.51
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$45.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$291.13
|
| Rate for Payer: Healthfirst QHP |
$342.51
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$342.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$342.51
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$274.01
|
| Rate for Payer: Wellcare Medicare |
$325.38
|
|
|
TMJ ARTHROGRAM, INCLUDING INJECTI
|
Facility
OP
|
$435.00
|
|
|
Service Code
|
HCPCS D0320
|
| Hospital Charge Code |
42300170
|
|
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 |
$283.37
|
| Rate for Payer: Aetna Government |
$283.37
|
| Rate for Payer: Cash Price |
$283.37
|
| Rate for Payer: Cash Price |
$283.37
|
| Rate for Payer: Cash Price |
$283.37
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$283.37
|
| 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 |
$283.37
|
| Rate for Payer: EmblemHealth Commercial |
$283.37
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$240.86
|
| Rate for Payer: Fidelis Essential Plan QHP |
$252.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$283.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$252.20
|
| Rate for Payer: Group Health Inc Commercial |
$283.37
|
| Rate for Payer: Group Health Inc Medicare |
$283.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$217.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$283.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$240.86
|
| Rate for Payer: Healthfirst QHP |
$283.37
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$283.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$283.37
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$226.70
|
| Rate for Payer: Wellcare Medicare |
$269.20
|
|
|
TMJ ARTHROSC LAT RELEASE
|
Facility
OP
|
$8,291.05
|
|
|
Service Code
|
HCPCS 29804
|
| Hospital Charge Code |
40029630
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$644.48 |
| Max. Negotiated Rate |
$4,145.52 |
| 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: 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 CHP/HARP/Medicaid |
$644.48
|
| 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 CHP/FHP/Medicaid |
$716.09
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,181.68
|
| Rate for Payer: Healthfirst QHP |
$3,743.15
|
| Rate for Payer: Senior Whole Health 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
|
|
|
TOBACCO CESS >10 MIN
|
Facility
OP
|
$82.75
|
|
|
Service Code
|
HCPCS 99407
|
| Hospital Charge Code |
30400125
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$26.31 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$45.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$33.18
|
| Rate for Payer: Aetna Government |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$33.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$66.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$56.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26.31
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$28.20
|
| Rate for Payer: Fidelis Essential Plan QHP |
$29.53
|
| Rate for Payer: Fidelis Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$29.53
|
| 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 |
$41.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$33.18
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$29.23
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.20
|
| Rate for Payer: Healthfirst QHP |
$33.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$33.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$33.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.54
|
| Rate for Payer: Wellcare Medicare |
$31.52
|
|
|
TOBACCO CESS,>10 MIN
|
Facility
OP
|
$82.75
|
|
|
Service Code
|
HCPCS 99407
|
| Hospital Charge Code |
30301260
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$26.31 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$45.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$33.18
|
| Rate for Payer: Aetna Government |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$33.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$66.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$56.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26.31
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$28.20
|
| Rate for Payer: Fidelis Essential Plan QHP |
$29.53
|
| Rate for Payer: Fidelis Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$29.53
|
| 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 |
$41.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$33.18
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$29.23
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.20
|
| Rate for Payer: Healthfirst QHP |
$33.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$33.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$33.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.54
|
| Rate for Payer: Wellcare Medicare |
$31.52
|
|
|
TOBACCO CESS>10 MIN
|
Facility
OP
|
$82.75
|
|
|
Service Code
|
HCPCS 99407
|
| Hospital Charge Code |
32401260
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.31 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$45.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$33.18
|
| Rate for Payer: Aetna Government |
$33.18
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$33.18
|
| 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 |
$33.18
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26.31
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$28.20
|
| Rate for Payer: Fidelis Essential Plan QHP |
$29.53
|
| Rate for Payer: Fidelis Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$29.53
|
| 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 |
$41.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$33.18
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$29.23
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.20
|
| Rate for Payer: Healthfirst QHP |
$33.18
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$33.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$33.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$33.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.54
|
| Rate for Payer: Wellcare Medicare |
$31.52
|
|
|
TOBACCO COUN. & PREV. OF ORAL DIS
|
Facility
OP
|
$25.00
|
|
|
Service Code
|
HCPCS D1320
|
| Hospital Charge Code |
42303280
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$13.72
|
| Rate for Payer: Aetna Government |
$13.72
|
| 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 |
$12.50
|
| Rate for Payer: Group Health Inc Medicare |
$8.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.50
|
|
|
TOBACCO NON-USER
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 1036F
|
| Hospital Charge Code |
30307887
|
|
Hospital Revenue Code
|
969
|
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| 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 |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
TOBRAMYCIN 0.3% OPHTHALMIC OINT 3.5 GRAM
|
Facility
OP
|
$125.00
|
|
| Hospital Charge Code |
41650610
|
|
Hospital Revenue Code
|
250
|
| 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
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$81.25
|
|
|
TOBRAMYCIN 0.3% OPHTHALMIC OINT 3.5 GRAM
|
Facility
OP
|
$125.00
|
|
| Hospital Charge Code |
41640610
|
|
Hospital Revenue Code
|
250
|
| 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
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$81.25
|
|
|
TOBRAMYCIN 0.3% OPHTHALMIC SOLN
|
Facility
OP
|
$2.00
|
|
| Hospital Charge Code |
41650461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.00
|
| Rate for Payer: Aetna Government |
$1.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.36
|
| Rate for Payer: Group Health Inc Commercial |
$1.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.30
|
|
