RESIN-BASED COMP. 4 + PERM POST
|
Facility
|
IP
|
$245.00
|
|
Service Code
|
HCPCS D2394
|
Hospital Charge Code |
42303282
|
Hospital Revenue Code
|
361
|
Rate for Payer: Cash Price |
$1,018.19
|
|
RESIN-BASED COMP. CROWN
|
Facility
|
OP
|
$245.00
|
|
Service Code
|
HCPCS D2390
|
Hospital Charge Code |
42303281
|
Hospital Revenue Code
|
361
|
Min. Negotiated Rate |
$122.50 |
Max. Negotiated Rate |
$2,915.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$134.75
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
Rate for Payer: Aetna Government |
$1,018.19
|
Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
Rate for Payer: Brighton Health Commercial |
$183.75
|
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 |
$122.50
|
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: Humana Medicare |
$1,038.55
|
Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
Rate for Payer: United Healthcare 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
|
|
RESIN-BASED COMP. CROWN
|
Facility
|
IP
|
$245.00
|
|
Service Code
|
HCPCS D2390
|
Hospital Charge Code |
42303281
|
Hospital Revenue Code
|
361
|
Rate for Payer: Cash Price |
$1,018.19
|
|
RESIN-FOUR+ SURF OR INVL INCISAL
|
Facility
|
OP
|
$245.00
|
|
Service Code
|
HCPCS D2335
|
Hospital Charge Code |
42300390
|
Hospital Revenue Code
|
361
|
Min. Negotiated Rate |
$122.50 |
Max. Negotiated Rate |
$2,915.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$134.75
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
Rate for Payer: Aetna Government |
$1,018.19
|
Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
Rate for Payer: Brighton Health Commercial |
$183.75
|
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 |
$122.50
|
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: Humana Medicare |
$1,038.55
|
Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
Rate for Payer: United Healthcare 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
|
|
RESIN-FOUR+ SURF OR INVL INCISAL
|
Facility
|
IP
|
$245.00
|
|
Service Code
|
HCPCS D2335
|
Hospital Charge Code |
42300390
|
Hospital Revenue Code
|
361
|
Rate for Payer: Cash Price |
$1,018.19
|
|
RESIN-ONE SURFACE, ANTERIOR
|
Facility
|
OP
|
$125.00
|
|
Service Code
|
HCPCS D2330
|
Hospital Charge Code |
42300375
|
Hospital Revenue Code
|
361
|
Min. Negotiated Rate |
$62.50 |
Max. Negotiated Rate |
$2,915.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$68.75
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
Rate for Payer: Aetna Government |
$1,018.19
|
Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
Rate for Payer: Brighton Health Commercial |
$93.75
|
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 |
$62.50
|
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: Humana Medicare |
$1,038.55
|
Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
Rate for Payer: United Healthcare 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
|
|
RESIN-ONE SURFACE, ANTERIOR
|
Facility
|
IP
|
$125.00
|
|
Service Code
|
HCPCS D2330
|
Hospital Charge Code |
42300375
|
Hospital Revenue Code
|
361
|
Rate for Payer: Cash Price |
$1,018.19
|
|
RESIN-ONE SURFACE, POSTERIOR
|
Facility
|
IP
|
$125.00
|
|
Service Code
|
HCPCS D2391
|
Hospital Charge Code |
42300415
|
Hospital Revenue Code
|
361
|
Rate for Payer: Cash Price |
$1,018.19
|
|
RESIN-ONE SURFACE, POSTERIOR
|
Facility
|
OP
|
$125.00
|
|
Service Code
|
HCPCS D2391
|
Hospital Charge Code |
42300415
|
Hospital Revenue Code
|
361
|
Min. Negotiated Rate |
$62.50 |
Max. Negotiated Rate |
$2,915.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$68.75
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
Rate for Payer: Aetna Government |
$1,018.19
|
Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
Rate for Payer: Brighton Health Commercial |
$93.75
|
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 |
$62.50
|
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: Humana Medicare |
$1,038.55
|
Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
Rate for Payer: United Healthcare 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
|
|
RESINS ONE SURFACE
|
Facility
|
IP
|
$125.00
|
|
Service Code
|
HCPCS D2330
|
Hospital Charge Code |
42300400
|
Hospital Revenue Code
|
361
|
Rate for Payer: Cash Price |
$1,018.19
|
|
RESINS ONE SURFACE
|
Facility
|
OP
|
$125.00
|
|
Service Code
|
HCPCS D2330
|
Hospital Charge Code |
42300400
|
Hospital Revenue Code
|
361
|
Min. Negotiated Rate |
$62.50 |
Max. Negotiated Rate |
$2,915.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$68.75
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
Rate for Payer: Aetna Government |
$1,018.19
|
Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
Rate for Payer: Brighton Health Commercial |
$93.75
|
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 |
$62.50
|
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: Humana Medicare |
$1,038.55
|
Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
Rate for Payer: United Healthcare 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
|
|
RESINS THREE SURFACE
|
Facility
|
IP
|
$217.50
|
|
Service Code
|
HCPCS D2332
|
Hospital Charge Code |
42300410
|
Hospital Revenue Code
|
361
|
Rate for Payer: Cash Price |
$1,018.19
|
|
RESINS THREE SURFACE
|
Facility
|
OP
|
$217.50
|
|
Service Code
|
HCPCS D2332
|
Hospital Charge Code |
42300410
|
Hospital Revenue Code
|
361
|
Min. Negotiated Rate |
$108.75 |
Max. Negotiated Rate |
$2,915.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$119.62
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
Rate for Payer: Aetna Government |
$1,018.19
|
Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
Rate for Payer: Brighton Health Commercial |
$163.12
|
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 |
$108.75
|
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: Humana Medicare |
$1,038.55
|
Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
Rate for Payer: United Healthcare 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
|
|
RESINS TWO SURFACE
|
Facility
|
OP
|
$182.50
|
|
Service Code
|
HCPCS D2331
|
Hospital Charge Code |
42300405
|
Hospital Revenue Code
|
361
|
Min. Negotiated Rate |
$91.25 |
Max. Negotiated Rate |
$2,915.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$100.38
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
Rate for Payer: Aetna Government |
$1,018.19
|
Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
Rate for Payer: Brighton Health Commercial |
$136.88
|
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 |
$91.25
|
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: Humana Medicare |
$1,038.55
|
Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
Rate for Payer: United Healthcare 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
|
|
RESINS TWO SURFACE
|
Facility
|
IP
|
$182.50
|
|
Service Code
|
HCPCS D2331
|
Hospital Charge Code |
42300405
|
Hospital Revenue Code
|
361
|
Rate for Payer: Cash Price |
$1,018.19
|
|
RESIN-THREE OR MORE SURFACES, POS
|
Facility
|
OP
|
$205.00
|
|
Service Code
|
HCPCS D2393
|
Hospital Charge Code |
42300425
|
Hospital Revenue Code
|
361
|
Min. Negotiated Rate |
$102.50 |
Max. Negotiated Rate |
$2,915.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$112.75
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
Rate for Payer: Aetna Government |
$1,018.19
|
Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
Rate for Payer: Brighton Health Commercial |
$153.75
|
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 |
$102.50
|
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: Humana Medicare |
$1,038.55
|
Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
Rate for Payer: United Healthcare 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
|
|
RESIN-THREE OR MORE SURFACES, POS
|
Facility
|
IP
|
$205.00
|
|
Service Code
|
HCPCS D2393
|
Hospital Charge Code |
42300425
|
Hospital Revenue Code
|
361
|
Rate for Payer: Cash Price |
$1,018.19
|
|
RESIN-THREE SURFACES, ANTERIOR
|
Facility
|
OP
|
$217.50
|
|
Service Code
|
HCPCS D2332
|
Hospital Charge Code |
42300385
|
Hospital Revenue Code
|
361
|
Min. Negotiated Rate |
$108.75 |
Max. Negotiated Rate |
$2,915.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$119.62
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
Rate for Payer: Aetna Government |
$1,018.19
|
Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
Rate for Payer: Brighton Health Commercial |
$163.12
|
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 |
$108.75
|
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: Humana Medicare |
$1,038.55
|
Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
Rate for Payer: United Healthcare 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
|
|
RESIN-THREE SURFACES, ANTERIOR
|
Facility
|
IP
|
$217.50
|
|
Service Code
|
HCPCS D2332
|
Hospital Charge Code |
42300385
|
Hospital Revenue Code
|
361
|
Rate for Payer: Cash Price |
$1,018.19
|
|
RESIN-TWO SURFACES, ANTERIOR
|
Facility
|
OP
|
$182.50
|
|
Service Code
|
HCPCS D2331
|
Hospital Charge Code |
42300380
|
Hospital Revenue Code
|
361
|
Min. Negotiated Rate |
$91.25 |
Max. Negotiated Rate |
$2,915.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$100.38
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
Rate for Payer: Aetna Government |
$1,018.19
|
Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
Rate for Payer: Brighton Health Commercial |
$136.88
|
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 |
$91.25
|
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: Humana Medicare |
$1,038.55
|
Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
Rate for Payer: United Healthcare 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
|
|
RESIN-TWO SURFACES, ANTERIOR
|
Facility
|
IP
|
$182.50
|
|
Service Code
|
HCPCS D2331
|
Hospital Charge Code |
42300380
|
Hospital Revenue Code
|
361
|
Rate for Payer: Cash Price |
$1,018.19
|
|
RESIN-TWO SURFACES, POSTERIOR-PRI
|
Facility
|
IP
|
$167.50
|
|
Service Code
|
HCPCS D2392
|
Hospital Charge Code |
42300420
|
Hospital Revenue Code
|
361
|
Rate for Payer: Cash Price |
$1,018.19
|
|
RESIN-TWO SURFACES, POSTERIOR-PRI
|
Facility
|
OP
|
$167.50
|
|
Service Code
|
HCPCS D2392
|
Hospital Charge Code |
42300420
|
Hospital Revenue Code
|
361
|
Min. Negotiated Rate |
$83.75 |
Max. Negotiated Rate |
$2,915.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$92.12
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
Rate for Payer: Aetna Government |
$1,018.19
|
Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
Rate for Payer: Brighton Health Commercial |
$125.62
|
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 |
$83.75
|
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: Humana Medicare |
$1,038.55
|
Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
Rate for Payer: United Healthcare 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
|
|
RESOLUTE ONXY 3.00X22
|
Facility
|
IP
|
$3,000.00
|
|
Service Code
|
HCPCS C1874
|
Hospital Charge Code |
66521638
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,500.00 |
Max. Negotiated Rate |
$1,500.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,500.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,500.00
|
|
RESOLUTE ONXY 3.00X22
|
Facility
|
OP
|
$3,000.00
|
|
Service Code
|
HCPCS C1874
|
Hospital Charge Code |
66521638
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$265.52 |
Max. Negotiated Rate |
$3,150.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,650.00
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$265.52
|
Rate for Payer: Aetna Government |
$265.52
|
Rate for Payer: Brighton Health Commercial |
$1,800.00
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,500.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,725.00
|
Rate for Payer: EmblemHealth Commercial |
$1,500.00
|
Rate for Payer: Fidelis Medicare Advantage |
$3,150.00
|
Rate for Payer: Group Health Inc Commercial |
$1,500.00
|
Rate for Payer: Group Health Inc Medicare |
$1,050.00
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,500.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,500.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,950.00
|
|