|
REP LAYERED N,H,F,E,G 2.5
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 12041
|
| Hospital Charge Code |
42201660
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
REP LAYERED N,H,F,E,G 2.5
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 12041
|
| Hospital Charge Code |
30305075
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
REP LAYERED N,H,F,E,G 2.5
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 12041
|
| Hospital Charge Code |
30103020
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$461.12
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$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: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| 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 |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$461.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
REP LAYERED N,H,F,E,G 2.6 - 7.5CM
|
Facility
|
OP
|
$934.02
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
42201670
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$322.78 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$700.52
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$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: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: EmblemHealth Commercial |
$461.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$461.12
|
| Rate for Payer: Group Health Inc Medicare |
$461.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$467.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$391.95
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
REP LAYERED N,H,F,E,G 2.6 - 7.5CM
|
Facility
|
IP
|
$934.02
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
42201670
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
REP LAYERED S,A,T,E 2.5
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
30305950
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$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: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| 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 |
$461.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$391.95
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$461.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
REP LAYERED S,A,T,E 2.5
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
30103218
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$461.12
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$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: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| 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 |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$461.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
REP LAYERED S,A,T,E 2.5
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
42201640
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
REP LAYERED S,A,T,E 2.5
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
30103218
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
REP LAYERED S,A,T,E 2.5
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
30305950
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
REP LAYERED S,A,T,E 2.5
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
42201640
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$322.78 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$725.80
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$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: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: EmblemHealth Commercial |
$461.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$461.12
|
| Rate for Payer: Group Health Inc Medicare |
$461.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$391.95
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
REP LAYERED S,A,T,E 2.6-7.5 CM
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 12032
|
| Hospital Charge Code |
30103219
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$461.12
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$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: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| 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 |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$461.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
REP LAYERED S,A,T,E 2.6-7.5 CM
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 12032
|
| Hospital Charge Code |
30103219
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
REP LAYERED S,A,T,E 2.6 - 7.5CM
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 12032
|
| Hospital Charge Code |
42201650
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$322.78 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$725.80
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$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: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: EmblemHealth Commercial |
$461.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$461.12
|
| Rate for Payer: Group Health Inc Medicare |
$461.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$391.95
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
REP LAYERED S,A,T,E 2.6 - 7.5CM
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 12032
|
| Hospital Charge Code |
42201650
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
REP LAYRED S,A,T,E 2.6-7.5CM
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 12032
|
| Hospital Charge Code |
30305951
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$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: Elderplan Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| 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 |
$461.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$391.95
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$461.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
REP LAYRED S,A,T,E 2.6-7.5CM
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 12032
|
| Hospital Charge Code |
30305951
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
REPLCEMT OF LOST/BROKEN RET-MAXIL
|
Facility
|
OP
|
$181.25
|
|
|
Service Code
|
HCPCS D8703
|
| Hospital Charge Code |
42300727
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$63.44 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$99.69
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$85.88
|
| Rate for Payer: Aetna Government |
$85.88
|
| Rate for Payer: Brighton Health Commercial |
$135.94
|
| 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 |
$90.62
|
| Rate for Payer: Group Health Inc Medicare |
$63.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$90.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$90.62
|
|
|
REPLCE SPINAL CRD STIMULATOR
|
Facility
|
OP
|
$18,739.28
|
|
|
Service Code
|
HCPCS 63650
|
| Hospital Charge Code |
40000460
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$406,911.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7,908.94
|
| Rate for Payer: Aetna Government |
$7,908.94
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$9,155.50
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$9,155.50
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$4,069.11
|
| Rate for Payer: Amida Care Medicaid |
$4,069.11
|
| Rate for Payer: Brighton Health Commercial |
$14,054.46
|
| Rate for Payer: Cash Price |
$7,908.94
|
| Rate for Payer: Cash Price |
$7,908.94
|
| Rate for Payer: Cash Price |
$7,908.94
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$7,908.94
|
| 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: Elderplan Medicare Advantage |
$7,908.94
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$406,911.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4,069.11
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4,069.11
|
| Rate for Payer: Fidelis Medicare Advantage |
$7,908.94
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4,272.57
|
| Rate for Payer: Group Health Inc Commercial |
$7,908.94
|
| Rate for Payer: Group Health Inc Medicare |
$7,908.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,069.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7,908.94
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$4,069.11
|
| Rate for Payer: Healthfirst Essential Plan |
$9,155.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$6,722.60
|
| Rate for Payer: Healthfirst QHP |
$4,069.11
|
| Rate for Payer: Humana Medicare |
$8,067.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$7,908.94
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$4,069.11
|
| Rate for Payer: SOMOS Essential |
$9,155.50
|
| Rate for Payer: United Healthcare Commercial |
$2,546.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$9,155.50
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$4,476.02
|
| Rate for Payer: United Healthcare Medicaid |
$4,069.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,908.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7,908.94
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6,327.15
|
| Rate for Payer: Wellcare Medicare |
$7,513.49
|
|
|
REPLCE SPINAL CRD STIMULATOR
|
Facility
|
IP
|
$18,739.28
|
|
|
Service Code
|
HCPCS 63650
|
| Hospital Charge Code |
40000460
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$7,908.94
|
|
|
REPLCMNT OF LOST/BROKEN RET-MANDI
|
Facility
|
OP
|
$181.25
|
|
|
Service Code
|
HCPCS D8704
|
| Hospital Charge Code |
42300728
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$63.44 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$99.69
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$85.88
|
| Rate for Payer: Aetna Government |
$85.88
|
| Rate for Payer: Brighton Health Commercial |
$135.94
|
| 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 |
$90.62
|
| Rate for Payer: Group Health Inc Medicare |
$63.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$90.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$90.62
|
|
|
REPL SEMI/PRECISION ATTACH
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
HCPCS D6091
|
| Hospital Charge Code |
42303423
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$152.48 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$330.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$152.48
|
| Rate for Payer: Aetna Government |
$152.48
|
| Rate for Payer: Brighton Health Commercial |
$450.00
|
| 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 |
$300.00
|
| Rate for Payer: Group Health Inc Medicare |
$210.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$300.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$300.00
|
|
|
REP NU/MU METATARSAL
|
Facility
|
IP
|
$18,117.83
|
|
|
Service Code
|
HCPCS 28322
|
| Hospital Charge Code |
40029960
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$8,273.12
|
|
|
REP NU/MU METATARSAL
|
Facility
|
OP
|
$18,117.83
|
|
|
Service Code
|
HCPCS 28322
|
| Hospital Charge Code |
40029960
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,468.00 |
| Max. Negotiated Rate |
$13,588.37 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,485.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8,273.12
|
| Rate for Payer: Aetna Government |
$8,273.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5,791.18
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5,791.18
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5,791.18
|
| Rate for Payer: Brighton Health Commercial |
$13,588.37
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$8,273.12
|
| 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: Elderplan Medicare Advantage |
$8,273.12
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$7,032.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7,363.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$8,273.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7,363.08
|
| Rate for Payer: Group Health Inc Commercial |
$8,273.12
|
| Rate for Payer: Group Health Inc Medicare |
$8,273.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9,058.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,273.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7,032.15
|
| Rate for Payer: Healthfirst QHP |
$8,273.12
|
| Rate for Payer: Humana Medicare |
$8,438.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$8,273.12
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,273.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,273.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6,618.50
|
| Rate for Payer: Wellcare Medicare |
$7,859.46
|
|
|
REPORT ON TRANSMITTED ECG
|
Facility
|
OP
|
$614.15
|
|
|
Service Code
|
HCPCS 93268
|
| Hospital Charge Code |
40801003
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$101.00 |
| Max. Negotiated Rate |
$491.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$337.78
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$183.03
|
| Rate for Payer: Aetna Government |
$183.03
|
| Rate for Payer: Brighton Health Commercial |
$460.61
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$491.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$417.62
|
| Rate for Payer: Group Health Inc Commercial |
$307.08
|
| Rate for Payer: Group Health Inc Medicare |
$214.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$307.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$307.08
|
| Rate for Payer: United Healthcare Commercial |
$101.00
|
|
