|
TOLVAPTAN 15 MG TAB
|
Facility
OP
|
$535.31
|
|
| Hospital Charge Code |
41645592
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$187.36 |
| Max. Negotiated Rate |
$428.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$294.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$267.66
|
| Rate for Payer: Aetna Government |
$267.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$428.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$364.01
|
| Rate for Payer: Group Health Inc Commercial |
$267.66
|
| Rate for Payer: Group Health Inc Medicare |
$187.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$347.95
|
|
|
TOLVAPTAN 30 MG TAB
|
Facility
OP
|
$535.31
|
|
| Hospital Charge Code |
41645593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$187.36 |
| Max. Negotiated Rate |
$428.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$294.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$267.66
|
| Rate for Payer: Aetna Government |
$267.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$428.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$364.01
|
| Rate for Payer: Group Health Inc Commercial |
$267.66
|
| Rate for Payer: Group Health Inc Medicare |
$187.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$347.95
|
|
|
TOLVAPTAN 30 MG TAB
|
Facility
OP
|
$535.31
|
|
| Hospital Charge Code |
41655593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$187.36 |
| Max. Negotiated Rate |
$428.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$294.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$267.66
|
| Rate for Payer: Aetna Government |
$267.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$428.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$364.01
|
| Rate for Payer: Group Health Inc Commercial |
$267.66
|
| Rate for Payer: Group Health Inc Medicare |
$187.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$347.95
|
|
|
TOMOGRAPHIC SURVEY
|
Facility
OP
|
$732.85
|
|
|
Service Code
|
HCPCS D0322
|
| Hospital Charge Code |
42300180
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$101.71 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$403.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| 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 |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$127.14
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$127.14
|
| Rate for Payer: Group Health Inc Medicare |
$127.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$366.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$108.07
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
TONE DECAY
|
Facility
OP
|
$101.25
|
|
|
Service Code
|
HCPCS 92563
|
| Hospital Charge Code |
42003100
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$36.93 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$55.69
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$46.38
|
| Rate for Payer: Aetna Government |
$46.38
|
| Rate for Payer: Cash Price |
$46.38
|
| Rate for Payer: Cash Price |
$46.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$46.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$81.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$68.85
|
| Rate for Payer: Elderplan Medicare Advantage |
$46.38
|
| Rate for Payer: EmblemHealth Commercial |
$46.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$36.93
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$41.28
|
| Rate for Payer: Fidelis Medicare Advantage |
$46.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.28
|
| Rate for Payer: Group Health Inc Commercial |
$46.38
|
| Rate for Payer: Group Health Inc Medicare |
$46.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$50.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$46.38
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$41.03
|
| Rate for Payer: Healthfirst Medicare Advantage |
$39.42
|
| Rate for Payer: Healthfirst QHP |
$46.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$46.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$46.38
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$37.10
|
| Rate for Payer: Wellcare Medicare |
$44.06
|
|
|
TONGUE BASE SUSPENSE, PERM SUTURE
|
Facility
OP
|
$14,691.05
|
|
|
Service Code
|
HCPCS 41512
|
| Hospital Charge Code |
30105544
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$7,345.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,772.21
|
| Rate for Payer: Aetna Government |
$6,772.21
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$6,772.21
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,772.21
|
| 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 |
$6,772.21
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$742.36
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,756.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6,027.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,772.21
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6,027.27
|
| 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 |
$7,345.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,772.21
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$6,772.21
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$6,772.21
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,772.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,772.21
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,417.77
|
| Rate for Payer: Wellcare Medicare |
$6,433.60
|
|
|
Tonsillectomy and adenoidectomy; age 12 or over
|
Facility
OP
|
$3,723.23
|
|
|
Service Code
|
CPT 42821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$339.96 |
| Max. Negotiated Rate |
$3,723.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,880.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,723.23
|
| Rate for Payer: Aetna Government |
$3,723.23
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,723.23
|
| 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 |
$3,723.23
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$339.96
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,164.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,313.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,723.23
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,313.67
|
| Rate for Payer: Group Health Inc Commercial |
$3,723.23
|
| Rate for Payer: Group Health Inc Medicare |
$3,723.23
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,723.23
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$377.73
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,164.75
|
| Rate for Payer: Healthfirst QHP |
$3,723.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,723.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,723.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,978.58
|
| Rate for Payer: Wellcare Medicare |
$3,537.07
|
|
|
Tonsillectomy and adenoidectomy; younger than age 12
|
Facility
OP
|
$6,772.21
|
|
|
Service Code
|
CPT 42820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$323.43 |
| Max. Negotiated Rate |
$6,772.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,772.21
|
| Rate for Payer: Aetna Government |
$6,772.21
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,772.21
|
| 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 |
$6,772.21
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$323.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,756.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6,027.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,772.21
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6,027.27
|
| Rate for Payer: Group Health Inc Commercial |
$6,772.21
|
| Rate for Payer: Group Health Inc Medicare |
$6,772.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,772.21
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$359.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5,756.38
|
| Rate for Payer: Healthfirst QHP |
$6,772.21
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,772.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,772.21
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,417.77
|
| Rate for Payer: Wellcare Medicare |
$6,433.60
|
|
|
TONSILLECTOMY OVER AGE 12
|
Facility
OP
|
$7,933.18
|
|
|
Service Code
|
HCPCS 42826
|
| Hospital Charge Code |
40109212
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$285.27 |
| Max. Negotiated Rate |
$3,966.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,485.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,723.23
|
| Rate for Payer: Aetna Government |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,723.23
|
| 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 |
$3,723.23
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$285.27
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,164.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,313.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,723.23
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,313.67
|
| Rate for Payer: Group Health Inc Commercial |
$3,723.23
|
| Rate for Payer: Group Health Inc Medicare |
$3,723.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,966.59
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,723.23
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$316.97
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,164.75
|
| Rate for Payer: Healthfirst QHP |
$3,723.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,723.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,723.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,978.58
|
| Rate for Payer: Wellcare Medicare |
$3,537.07
|
|
|
Tonsillectomy, primary or secondary; age 12 or over
|
Facility
OP
|
$3,723.23
|
|
|
Service Code
|
CPT 42826
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$285.27 |
| Max. Negotiated Rate |
$3,723.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,485.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,723.23
|
| Rate for Payer: Aetna Government |
$3,723.23
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,723.23
|
| 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 |
$3,723.23
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$285.27
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,164.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,313.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,723.23
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,313.67
|
| Rate for Payer: Group Health Inc Commercial |
$3,723.23
|
| Rate for Payer: Group Health Inc Medicare |
$3,723.23
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,723.23
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$316.97
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,164.75
|
| Rate for Payer: Healthfirst QHP |
$3,723.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,723.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,723.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,978.58
|
| Rate for Payer: Wellcare Medicare |
$3,537.07
|
|
|
TONSILLECTOMY UNDER AGE 12
|
Facility
OP
|
$14,691.05
|
|
|
Service Code
|
HCPCS 42825
|
| Hospital Charge Code |
40108940
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$299.41 |
| Max. Negotiated Rate |
$7,345.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,485.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,772.21
|
| Rate for Payer: Aetna Government |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,772.21
|
| 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 |
$6,772.21
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$299.41
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,756.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6,027.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,772.21
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6,027.27
|
| Rate for Payer: Group Health Inc Commercial |
$6,772.21
|
| Rate for Payer: Group Health Inc Medicare |
$6,772.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7,345.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,772.21
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$332.68
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5,756.38
|
| Rate for Payer: Healthfirst QHP |
$6,772.21
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,772.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,772.21
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,417.77
|
| Rate for Payer: Wellcare Medicare |
$6,433.60
|
|
|
TONSIL TRAY (RU)
|
Facility
OP
|
$57.76
|
|
| Hospital Charge Code |
40207811
|
|
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
|
|
|
TOOL BALL FLUTED LEGEND 6MM 9CM
|
Facility
OP
|
$465.00
|
|
| Hospital Charge Code |
64904326
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$162.75 |
| Max. Negotiated Rate |
$372.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$255.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$232.50
|
| Rate for Payer: Aetna Government |
$232.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$372.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$316.20
|
| Rate for Payer: Group Health Inc Commercial |
$232.50
|
| Rate for Payer: Group Health Inc Medicare |
$162.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$232.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$232.50
|
|
|
TOOL DISSEC MATCH LEGND 3MM 9CM
|
Facility
OP
|
$452.50
|
|
| Hospital Charge Code |
64904324
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$158.38 |
| Max. Negotiated Rate |
$362.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$248.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$226.25
|
| Rate for Payer: Aetna Government |
$226.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$362.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$307.70
|
| Rate for Payer: Group Health Inc Commercial |
$226.25
|
| Rate for Payer: Group Health Inc Medicare |
$158.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$226.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$226.25
|
|
|
TOOL DISSECTING M33
|
Facility
OP
|
$465.00
|
|
| Hospital Charge Code |
64904134
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$162.75 |
| Max. Negotiated Rate |
$372.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$255.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$232.50
|
| Rate for Payer: Aetna Government |
$232.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$372.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$316.20
|
| Rate for Payer: Group Health Inc Commercial |
$232.50
|
| Rate for Payer: Group Health Inc Medicare |
$162.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$232.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$232.50
|
|
|
TOOL DISSECTING M-35 MEDTRONIC
|
Facility
OP
|
$425.00
|
|
| Hospital Charge Code |
64904810
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$148.75 |
| Max. Negotiated Rate |
$340.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$233.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$212.50
|
| Rate for Payer: Aetna Government |
$212.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$340.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$289.00
|
| 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
|
|
|
TOOL DISSECTING MIDAS REX
|
Facility
OP
|
$375.00
|
|
| Hospital Charge Code |
64904125
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$131.25 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$206.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$187.50
|
| Rate for Payer: Aetna Government |
$187.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$300.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$255.00
|
| Rate for Payer: Group Health Inc Commercial |
$187.50
|
| Rate for Payer: Group Health Inc Medicare |
$131.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$187.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$187.50
|
|
|
TOOL LEGEND 7.6CM 1.6MM CARBIDE
|
Facility
OP
|
$497.50
|
|
| Hospital Charge Code |
64904748
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$174.12 |
| Max. Negotiated Rate |
$398.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$273.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$248.75
|
| Rate for Payer: Aetna Government |
$248.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$398.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$338.30
|
| Rate for Payer: Group Health Inc Commercial |
$248.75
|
| Rate for Payer: Group Health Inc Medicare |
$174.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$248.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$248.75
|
|
|
TOOL LEGEND 7.6CM 25.4MM DI WHEEL
|
Facility
OP
|
$457.50
|
|
| Hospital Charge Code |
64904750
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$160.12 |
| Max. Negotiated Rate |
$366.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$251.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$228.75
|
| Rate for Payer: Aetna Government |
$228.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$366.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$311.10
|
| Rate for Payer: Group Health Inc Commercial |
$228.75
|
| Rate for Payer: Group Health Inc Medicare |
$160.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$228.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$228.75
|
|
|
TOOL MATCH LEGEND 3MM 14CM
|
Facility
OP
|
$455.00
|
|
| Hospital Charge Code |
64904330
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$159.25 |
| Max. Negotiated Rate |
$364.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$250.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$227.50
|
| Rate for Payer: Aetna Government |
$227.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$364.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$309.40
|
| Rate for Payer: Group Health Inc Commercial |
$227.50
|
| Rate for Payer: Group Health Inc Medicare |
$159.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$227.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$227.50
|
|
|
TOOL TAPERED LEGEND 1.1MM 8CM
|
Facility
OP
|
$322.50
|
|
| Hospital Charge Code |
64904332
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$112.88 |
| Max. Negotiated Rate |
$258.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$177.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$161.25
|
| Rate for Payer: Aetna Government |
$161.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$258.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$219.30
|
| Rate for Payer: Group Health Inc Commercial |
$161.25
|
| Rate for Payer: Group Health Inc Medicare |
$112.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$161.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$161.25
|
|
|
TOOL TAPERED LEGEND 1.5MM 8CM
|
Facility
OP
|
$330.00
|
|
| Hospital Charge Code |
64904328
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$115.50 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$181.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$165.00
|
| Rate for Payer: Aetna Government |
$165.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$264.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$224.40
|
| Rate for Payer: Group Health Inc Commercial |
$165.00
|
| Rate for Payer: Group Health Inc Medicare |
$115.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$165.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$165.00
|
|
|
TOOTHBRUSH 39 TUFT TRANS PURPLE
|
Facility
OP
|
$0.10
|
|
| Hospital Charge Code |
64901979
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.05
|
| Rate for Payer: Aetna Government |
$0.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.05
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.05
|
|
|
TOOTHBRUSH MICROTIP FULL HEAD
|
Facility
OP
|
$0.62
|
|
| Hospital Charge Code |
64901707
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.34
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.31
|
| Rate for Payer: Aetna Government |
$0.31
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.42
|
| Rate for Payer: Group Health Inc Commercial |
$0.31
|
| Rate for Payer: Group Health Inc Medicare |
$0.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.31
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.31
|
|
|
TOOTH TRANSPLANTATION
|
Facility
OP
|
$375.00
|
|
|
Service Code
|
HCPCS D7272
|
| Hospital Charge Code |
42301700
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$187.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$206.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$187.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
