|
TX MAND/MAX ALVEOLAR RIDGE FX
|
Facility
OP
|
$7,933.18
|
|
|
Service Code
|
HCPCS 21440
|
| Hospital Charge Code |
30107821
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$3,966.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,723.23
|
| Rate for Payer: Aetna Government |
$3,723.23
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$3,723.23
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$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 |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$610.70
|
| 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 |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| 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 |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$3,723.23
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$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
|
|
|
TX MISSED ABORTION, 1ST TRIMESTER
|
Facility
OP
|
$7,566.13
|
|
|
Service Code
|
HCPCS 59820
|
| Hospital Charge Code |
30106629
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$3,783.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,880.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,615.39
|
| Rate for Payer: Aetna Government |
$3,615.39
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$3,615.39
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$3,615.39
|
| Rate for Payer: Cash Price |
$3,615.39
|
| Rate for Payer: Cash Price |
$3,615.39
|
| Rate for Payer: Cash Price |
$3,615.39
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,615.39
|
| 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 |
$3,615.39
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$456.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,073.08
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,217.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,615.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,217.70
|
| 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 |
$3,783.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,615.39
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$3,615.39
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$3,615.39
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,615.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,615.39
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,892.31
|
| Rate for Payer: Wellcare Medicare |
$3,434.62
|
|
|
TX OF BLADDER LESION
|
Facility
OP
|
$711.45
|
|
|
Service Code
|
HCPCS 51720
|
| Hospital Charge Code |
30305694
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$47.21 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$789.96
|
| Rate for Payer: Aetna Government |
$789.96
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$789.96
|
| Rate for Payer: Cash Price |
$789.96
|
| Rate for Payer: Cash Price |
$789.96
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$789.96
|
| 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 |
$789.96
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$47.21
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$671.47
|
| Rate for Payer: Fidelis Essential Plan QHP |
$703.06
|
| Rate for Payer: Fidelis Medicare Advantage |
$789.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$703.06
|
| 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 |
$355.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$789.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$52.46
|
| Rate for Payer: Healthfirst Medicare Advantage |
$671.47
|
| Rate for Payer: Healthfirst QHP |
$789.96
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$789.96
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$789.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$789.96
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$631.97
|
| Rate for Payer: Wellcare Medicare |
$750.46
|
|
|
TX OF COMPLICATIONS/POSTSURGICAL/
|
Facility
OP
|
$359.00
|
|
|
Service Code
|
HCPCS D9930
|
| Hospital Charge Code |
42302375
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$179.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.45
|
| 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 |
$179.50
|
| 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
|
|
|
TX OF FIBULA FRACTURE
|
Facility
OP
|
$653.13
|
|
|
Service Code
|
HCPCS 27780
|
| Hospital Charge Code |
30306666
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$218.17 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$272.71
|
| Rate for Payer: Aetna Government |
$272.71
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$272.71
|
| 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 |
$272.71
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$328.74
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$231.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$242.71
|
| Rate for Payer: Fidelis Medicare Advantage |
$272.71
|
| Rate for Payer: Fidelis Qualified Health Plan |
$242.71
|
| 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 |
$326.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$272.71
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$365.27
|
| Rate for Payer: Healthfirst Medicare Advantage |
$231.80
|
| Rate for Payer: Healthfirst QHP |
$272.71
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$272.71
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$272.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$272.71
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$218.17
|
| Rate for Payer: Wellcare Medicare |
$259.07
|
|
|
TX OF TIBIA FRACTURE
|
Facility
OP
|
$653.13
|
|
|
Service Code
|
HCPCS 27750
|
| Hospital Charge Code |
30305101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$272.71
|
| Rate for Payer: Aetna Government |
$272.71
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$272.71
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$272.71
|
| 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 |
$272.71
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$372.36
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$231.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$242.71
|
| Rate for Payer: Fidelis Medicare Advantage |
$272.71
|
| Rate for Payer: Fidelis Qualified Health Plan |
$242.71
|
| 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 |
$326.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$272.71
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$272.71
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$272.71
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$272.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$272.71
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$218.17
|
| Rate for Payer: Wellcare Medicare |
$259.07
|
|
|
TX OF TIBIA FRACTURE
|
Facility
OP
|
$653.13
|
|
|
Service Code
|
HCPCS 27750
|
| Hospital Charge Code |
30105101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$272.71
|
| Rate for Payer: Aetna Government |
$272.71
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$272.71
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$272.71
|
| 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 |
$272.71
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$372.36
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$231.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$242.71
|
| Rate for Payer: Fidelis Medicare Advantage |
$272.71
|
| Rate for Payer: Fidelis Qualified Health Plan |
$242.71
|
| 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 |
$326.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$272.71
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$272.71
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$272.71
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$272.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$272.71
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$218.17
|
| Rate for Payer: Wellcare Medicare |
$259.07
|
|
|
TX/PRO/DX INJ NEW DRUG ADD-ON
|
Facility
OP
|
$115.43
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
30305931
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$16.87 |
| Max. Negotiated Rate |
$92.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$63.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$54.93
|
| Rate for Payer: Aetna Government |
$54.93
|
| Rate for Payer: Cash Price |
$54.93
|
| Rate for Payer: Cash Price |
$54.93
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$54.93
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$92.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$78.49
|
| Rate for Payer: Elderplan Medicare Advantage |
$54.93
|
| Rate for Payer: EmblemHealth Commercial |
$54.93
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.87
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$46.69
|
| Rate for Payer: Fidelis Essential Plan QHP |
$48.89
|
| Rate for Payer: Fidelis Medicare Advantage |
$54.93
|
| Rate for Payer: Fidelis Qualified Health Plan |
$48.89
|
| Rate for Payer: Group Health Inc Commercial |
$54.93
|
| Rate for Payer: Group Health Inc Medicare |
$54.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$57.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$54.93
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18.74
|
| Rate for Payer: Healthfirst Medicare Advantage |
$46.69
|
| Rate for Payer: Healthfirst QHP |
$54.93
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$54.93
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$54.93
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$43.94
|
| Rate for Payer: Wellcare Medicare |
$52.18
|
|
|
TX/PRO/DX INJ NEW DRUG ADD-ON
|
Facility
OP
|
$115.43
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
30105931
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$16.87 |
| Max. Negotiated Rate |
$92.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$63.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$54.93
|
| Rate for Payer: Aetna Government |
$54.93
|
| Rate for Payer: Cash Price |
$54.93
|
| Rate for Payer: Cash Price |
$54.93
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$54.93
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$92.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$78.49
|
| Rate for Payer: Elderplan Medicare Advantage |
$54.93
|
| Rate for Payer: EmblemHealth Commercial |
$54.93
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.87
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$46.69
|
| Rate for Payer: Fidelis Essential Plan QHP |
$48.89
|
| Rate for Payer: Fidelis Medicare Advantage |
$54.93
|
| Rate for Payer: Fidelis Qualified Health Plan |
$48.89
|
| Rate for Payer: Group Health Inc Commercial |
$54.93
|
| Rate for Payer: Group Health Inc Medicare |
$54.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$57.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$54.93
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18.74
|
| Rate for Payer: Healthfirst Medicare Advantage |
$46.69
|
| Rate for Payer: Healthfirst QHP |
$54.93
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$54.93
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$54.93
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$43.94
|
| Rate for Payer: Wellcare Medicare |
$52.18
|
|
|
TX/PRO/DX INJ SAM DRUG ADD-ON
|
Facility
OP
|
$74.38
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
30105932
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$12.94 |
| Max. Negotiated Rate |
$59.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$40.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.94
|
| Rate for Payer: Aetna Government |
$12.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$59.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$50.58
|
| Rate for Payer: Group Health Inc Commercial |
$37.19
|
| Rate for Payer: Group Health Inc Medicare |
$26.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.19
|
|
|
TX/PRO/DX INJ SAME DRUG ADD-ON
|
Facility
OP
|
$74.38
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
30305932
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$12.94 |
| Max. Negotiated Rate |
$59.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$40.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.94
|
| Rate for Payer: Aetna Government |
$12.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$59.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$50.58
|
| Rate for Payer: Group Health Inc Commercial |
$37.19
|
| Rate for Payer: Group Health Inc Medicare |
$26.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.19
|
|
|
TX/PROPH/DG ADD SEQ INN INF
|
Facility
OP
|
$74.38
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
30105933
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$12.94 |
| Max. Negotiated Rate |
$59.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$40.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.94
|
| Rate for Payer: Aetna Government |
$12.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$59.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$50.58
|
| Rate for Payer: Group Health Inc Commercial |
$37.19
|
| Rate for Payer: Group Health Inc Medicare |
$26.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.19
|
|
|
TX/PROPH DG ADD SEQ IV INF
|
Facility
OP
|
$74.38
|
|
|
Service Code
|
HCPCS 96367
|
| Hospital Charge Code |
30305933
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$31.22 |
| Max. Negotiated Rate |
$81.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$40.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$81.46
|
| Rate for Payer: Aetna Government |
$81.46
|
| Rate for Payer: Cash Price |
$81.46
|
| Rate for Payer: Cash Price |
$81.46
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$81.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$59.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$50.58
|
| Rate for Payer: Elderplan Medicare Advantage |
$81.46
|
| Rate for Payer: EmblemHealth Commercial |
$81.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$31.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$69.24
|
| Rate for Payer: Fidelis Essential Plan QHP |
$72.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$81.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$72.50
|
| Rate for Payer: Group Health Inc Commercial |
$81.46
|
| Rate for Payer: Group Health Inc Medicare |
$81.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$81.46
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$34.69
|
| Rate for Payer: Healthfirst Medicare Advantage |
$69.24
|
| Rate for Payer: Healthfirst QHP |
$81.46
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$81.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$81.46
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$65.17
|
| Rate for Payer: Wellcare Medicare |
$77.39
|
|
|
TYCO HEALTH HAND SWITCH ELECTRODE
|
Facility
OP
|
$454.72
|
|
| Hospital Charge Code |
40205552
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$159.15 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$250.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$227.36
|
| Rate for Payer: Aetna Government |
$227.36
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$363.78
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$309.21
|
| Rate for Payer: Group Health Inc Commercial |
$227.36
|
| Rate for Payer: Group Health Inc Medicare |
$159.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$227.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$227.36
|
|
|
TYMPANIC MEMBRANE REPAIR
|
Facility
OP
|
$4,086.83
|
|
|
Service Code
|
HCPCS 69610
|
| Hospital Charge Code |
40109207
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$319.44 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,763.60
|
| Rate for Payer: Aetna Government |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,763.60
|
| 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 |
$1,763.60
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$319.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,499.06
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,569.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,763.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,569.60
|
| Rate for Payer: Group Health Inc Commercial |
$1,763.60
|
| Rate for Payer: Group Health Inc Medicare |
$1,763.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,043.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,763.60
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$354.93
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,499.06
|
| Rate for Payer: Healthfirst QHP |
$1,763.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,763.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,763.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,410.88
|
| Rate for Payer: Wellcare Medicare |
$1,675.42
|
|
|
TYMPANOMETRY
|
Facility
OP
|
$101.25
|
|
|
Service Code
|
HCPCS 92567
|
| Hospital Charge Code |
42004505
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$11.21 |
| 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 |
$11.21
|
| 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 |
$12.46
|
| 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
|
|
|
TYMPANOMETRY & REFLEX THRESHOLD
|
Facility
OP
|
$419.03
|
|
|
Service Code
|
HCPCS 92550
|
| Hospital Charge Code |
30304750
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$23.07 |
| Max. Negotiated Rate |
$335.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$230.47
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$180.64
|
| Rate for Payer: Aetna Government |
$180.64
|
| Rate for Payer: Cash Price |
$180.64
|
| Rate for Payer: Cash Price |
$180.64
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$180.64
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$335.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$284.94
|
| Rate for Payer: Elderplan Medicare Advantage |
$180.64
|
| Rate for Payer: EmblemHealth Commercial |
$180.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$23.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$153.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$160.77
|
| Rate for Payer: Fidelis Medicare Advantage |
$180.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$160.77
|
| Rate for Payer: Group Health Inc Commercial |
$180.64
|
| Rate for Payer: Group Health Inc Medicare |
$180.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$209.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$180.64
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$25.63
|
| Rate for Payer: Healthfirst Medicare Advantage |
$153.54
|
| Rate for Payer: Healthfirst QHP |
$180.64
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$180.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$180.64
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$144.51
|
| Rate for Payer: Wellcare Medicare |
$171.61
|
|
|
Tympanostomy (requiring insertion of ventilating tube), general anesthesia
|
Facility
OP
|
$2,915.00
|
|
|
Service Code
|
CPT 69436
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$176.89 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,763.60
|
| Rate for Payer: Aetna Government |
$1,763.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,763.60
|
| 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 |
$1,763.60
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$176.89
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,499.06
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,569.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,763.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,569.60
|
| Rate for Payer: Group Health Inc Commercial |
$1,763.60
|
| Rate for Payer: Group Health Inc Medicare |
$1,763.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,763.60
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$196.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,499.06
|
| Rate for Payer: Healthfirst QHP |
$1,763.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,763.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,763.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,410.88
|
| Rate for Payer: Wellcare Medicare |
$1,675.42
|
|
|
TYPHOID VACCINE CAP POLYSAC 25MCG
|
Facility
OP
|
$125.00
|
|
|
Service Code
|
HCPCS 90691
|
| Hospital Charge Code |
41655891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$81.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$68.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$77.85
|
| Rate for Payer: Aetna Government |
$77.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$62.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$71.88
|
| 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
|
|
|
TYPHOID VACCINE CAP POLYSAC 25MCG
|
Facility
IP
|
$125.00
|
|
|
Service Code
|
HCPCS 90691
|
| Hospital Charge Code |
41655891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.50 |
| Max. Negotiated Rate |
$62.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$62.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$62.50
|
|
|
TYPHOID VACCINE CAP POLYSAC 25MCG
|
Facility
OP
|
$125.00
|
|
|
Service Code
|
HCPCS 90691
|
| Hospital Charge Code |
41645891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$81.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$68.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$77.85
|
| Rate for Payer: Aetna Government |
$77.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$62.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$71.88
|
| 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
|
|
|
TYPHOID VACCINE CAP POLYSAC 25MCG
|
Facility
IP
|
$125.00
|
|
|
Service Code
|
HCPCS 90691
|
| Hospital Charge Code |
41645891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.50 |
| Max. Negotiated Rate |
$62.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$62.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$62.50
|
|
|
TYVEK ROLL
|
Facility
OP
|
$146.00
|
|
| Hospital Charge Code |
64905293
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$51.10 |
| Max. Negotiated Rate |
$116.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$80.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$73.00
|
| Rate for Payer: Aetna Government |
$73.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$116.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$99.28
|
| Rate for Payer: Group Health Inc Commercial |
$73.00
|
| Rate for Payer: Group Health Inc Medicare |
$51.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$73.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$73.00
|
|
|
TYVEK STERILIZATION ROLLS
|
Facility
OP
|
$484.30
|
|
| Hospital Charge Code |
64905297
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$169.50 |
| Max. Negotiated Rate |
$387.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$266.36
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$242.15
|
| Rate for Payer: Aetna Government |
$242.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$387.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$329.32
|
| Rate for Payer: Group Health Inc Commercial |
$242.15
|
| Rate for Payer: Group Health Inc Medicare |
$169.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$242.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$242.15
|
|
|
TYVEL ROLL STERILZATION ROLLS
|
Facility
OP
|
$151.25
|
|
| Hospital Charge Code |
64905303
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$52.94 |
| Max. Negotiated Rate |
$121.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$83.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$75.62
|
| Rate for Payer: Aetna Government |
$75.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$121.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$102.85
|
| Rate for Payer: Group Health Inc Commercial |
$75.62
|
| Rate for Payer: Group Health Inc Medicare |
$52.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$75.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$75.62
|
|
