|
UNNA BOOT
|
Facility
OP
|
$405.08
|
|
|
Service Code
|
HCPCS 29580
|
| Hospital Charge Code |
30305937
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$28.56 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$182.22
|
| Rate for Payer: Aetna Government |
$182.22
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$182.22
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$182.22
|
| 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 |
$182.22
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$28.56
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$154.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$162.18
|
| Rate for Payer: Fidelis Medicare Advantage |
$182.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$162.18
|
| 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 |
$202.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$182.22
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$182.22
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$182.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$182.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$182.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.78
|
| Rate for Payer: Wellcare Medicare |
$173.11
|
|
|
UNNA BOOT - BILATERAL
|
Facility
OP
|
$405.08
|
|
|
Service Code
|
HCPCS 29580 50
|
| Hospital Charge Code |
42500180
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$202.54 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$222.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$202.54
|
| Rate for Payer: Aetna Government |
$202.54
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| 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 |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$202.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$202.54
|
|
|
UNNA BOOT - LEFT
|
Facility
OP
|
$405.08
|
|
|
Service Code
|
HCPCS 29580 LT
|
| Hospital Charge Code |
42500154
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$202.54 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$222.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$202.54
|
| Rate for Payer: Aetna Government |
$202.54
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| 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 |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$202.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$202.54
|
|
|
UNNA BOOT/MULTILAYER COMPRESSION
|
Facility
OP
|
$405.08
|
|
|
Service Code
|
HCPCS 29580
|
| Hospital Charge Code |
41809433
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$31.73 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$182.22
|
| Rate for Payer: Aetna Government |
$182.22
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$182.22
|
| 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 |
$182.22
|
| Rate for Payer: EmblemHealth Commercial |
$182.22
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$182.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$154.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$162.18
|
| Rate for Payer: Fidelis Medicare Advantage |
$182.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$162.18
|
| Rate for Payer: Group Health Inc Commercial |
$182.22
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$202.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$182.22
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$31.73
|
| Rate for Payer: Healthfirst Medicare Advantage |
$154.89
|
| Rate for Payer: Healthfirst QHP |
$182.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$182.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$182.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.78
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
UNNA BOOT - RT
|
Facility
OP
|
$405.08
|
|
|
Service Code
|
HCPCS 29580 RT
|
| Hospital Charge Code |
42500230
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$202.54 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$222.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$202.54
|
| Rate for Payer: Aetna Government |
$202.54
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| 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 |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$202.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$202.54
|
|
|
UNSCHED DIALYSIS ESRD PT HOSP
|
Facility
OP
|
$1,938.50
|
|
|
Service Code
|
HCPCS G0257
|
| Hospital Charge Code |
30103060
|
|
Hospital Revenue Code
|
829
|
| Min. Negotiated Rate |
$435.00 |
| Max. Negotiated Rate |
$1,550.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,066.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$808.11
|
| Rate for Payer: Aetna Government |
$808.11
|
| Rate for Payer: Cash Price |
$808.11
|
| Rate for Payer: Cash Price |
$808.11
|
| Rate for Payer: Cash Price |
$808.11
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$808.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,550.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,318.18
|
| Rate for Payer: Elderplan Medicare Advantage |
$808.11
|
| Rate for Payer: EmblemHealth Commercial |
$445.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$686.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$719.22
|
| Rate for Payer: Fidelis Medicare Advantage |
$808.11
|
| Rate for Payer: Fidelis Qualified Health Plan |
$719.22
|
| Rate for Payer: Group Health Inc Commercial |
$650.00
|
| Rate for Payer: Group Health Inc Medicare |
$435.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$969.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$808.11
|
| Rate for Payer: Healthfirst Medicare Advantage |
$686.89
|
| Rate for Payer: Healthfirst QHP |
$808.11
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$808.11
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$808.11
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$646.49
|
| Rate for Payer: Wellcare Medicare |
$767.70
|
|
|
UNSCHED. DRSG CHNG (NOT BY TREATI
|
Facility
OP
|
$101.00
|
|
|
Service Code
|
HCPCS D4920
|
| Hospital Charge Code |
42300950
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$50.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$55.55
|
| 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 |
$50.50
|
| 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
|
|
|
UNSPECIFIED
|
Facility
OP
|
$200.00
|
|
|
Service Code
|
HCPCS D8999
|
| Hospital Charge Code |
42300956
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$110.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$100.00
|
| Rate for Payer: Aetna Government |
$100.00
|
| 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 |
$100.00
|
| Rate for Payer: Group Health Inc Medicare |
$70.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$100.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$100.00
|
|
|
UNSPECIFIED ADJUNCTIVE PROCEDURE,
|
Facility
OP
|
$150.00
|
|
|
Service Code
|
HCPCS D9999
|
| Hospital Charge Code |
42302415
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$82.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$75.00
|
| Rate for Payer: Aetna Government |
$75.00
|
| 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 |
$75.00
|
| Rate for Payer: Group Health Inc Medicare |
$52.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$75.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$75.00
|
|
|
UNSPECIFIED DIAGNOSTIC OCEDURE, B
|
Facility
OP
|
$358.63
|
|
|
Service Code
|
HCPCS D0999
|
| Hospital Charge Code |
42300235
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$125.52 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$179.32
|
| Rate for Payer: Aetna Government |
$179.32
|
| 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 |
$179.32
|
| Rate for Payer: Group Health Inc Medicare |
$125.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$179.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.32
|
|
|
UNSPECIFIED ENDODONTIC PROCEDURE,
|
Facility
OP
|
$358.63
|
|
|
Service Code
|
HCPCS D3999
|
| Hospital Charge Code |
42300830
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$179.32 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.25
|
| 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 |
$179.32
|
| 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
|
|
|
UNSPECIFIED FIXED PROSTHODONTIC P
|
Facility
OP
|
$851.00
|
|
|
Service Code
|
HCPCS D6999
|
| Hospital Charge Code |
42301635
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$297.85 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$468.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$425.50
|
| Rate for Payer: Aetna Government |
$425.50
|
| 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 |
$425.50
|
| Rate for Payer: Group Health Inc Medicare |
$297.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$425.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$425.50
|
|
|
UNSPECIFIED IMPLANT PROCEDURE, BY
|
Facility
OP
|
$359.00
|
|
|
Service Code
|
HCPCS D6199
|
| Hospital Charge Code |
42301450
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$125.65 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$179.50
|
| Rate for Payer: Aetna Government |
$179.50
|
| 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 |
$179.50
|
| Rate for Payer: Group Health Inc Medicare |
$125.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$179.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.50
|
|
|
UNSPECIFIED ORAL SURGERY PROCEDUR
|
Facility
OP
|
$425.00
|
|
|
Service Code
|
HCPCS D7999
|
| Hospital Charge Code |
42302180
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$148.75 |
| Max. Negotiated Rate |
$2,915.00 |
| 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 |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| 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
|
|
|
UNSPECIFIED ORTHODONTIC PROCEDURE
|
Facility
OP
|
$200.00
|
|
|
Service Code
|
HCPCS D8999
|
| Hospital Charge Code |
42302275
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$110.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$100.00
|
| Rate for Payer: Aetna Government |
$100.00
|
| 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 |
$100.00
|
| Rate for Payer: Group Health Inc Medicare |
$70.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$100.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$100.00
|
|
|
UNSPECIFIED PERIODONTAL PROCEDURE
|
Facility
OP
|
$359.00
|
|
|
Service Code
|
HCPCS D4999
|
| Hospital Charge Code |
42300955
|
|
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 |
$282.47
|
| Rate for Payer: Aetna Government |
$282.47
|
| Rate for Payer: Cash Price |
$282.47
|
| Rate for Payer: Cash Price |
$282.47
|
| Rate for Payer: Cash Price |
$282.47
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$282.47
|
| 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 |
$282.47
|
| Rate for Payer: EmblemHealth Commercial |
$282.47
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$240.10
|
| Rate for Payer: Fidelis Essential Plan QHP |
$251.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$282.47
|
| Rate for Payer: Fidelis Qualified Health Plan |
$251.40
|
| Rate for Payer: Group Health Inc Commercial |
$282.47
|
| Rate for Payer: Group Health Inc Medicare |
$282.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$179.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$282.47
|
| Rate for Payer: Healthfirst Medicare Advantage |
$240.10
|
| Rate for Payer: Healthfirst QHP |
$282.47
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$282.47
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$282.47
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$225.98
|
| Rate for Payer: Wellcare Medicare |
$268.35
|
|
|
UNSPECIFIED REMOVE PROSTH, B/R
|
Facility
OP
|
$3,600.00
|
|
|
Service Code
|
HCPCS D5899
|
| Hospital Charge Code |
42300741
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,260.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,980.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,800.00
|
| Rate for Payer: Aetna Government |
$1,800.00
|
| 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 |
$1,800.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,260.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,800.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,800.00
|
|
|
UNSPECIFIED RESTORATIVE PROCEDURE
|
Facility
OP
|
$358.63
|
|
|
Service Code
|
HCPCS D2999
|
| Hospital Charge Code |
42300690
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$179.32 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.25
|
| 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 |
$179.32
|
| 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
|
|
|
UNSPECIFIED TMD THERAPY, BY REPOR
|
Facility
OP
|
$359.00
|
|
|
Service Code
|
HCPCS D7899
|
| Hospital Charge Code |
42302035
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$125.65 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$179.50
|
| Rate for Payer: Aetna Government |
$179.50
|
| 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 |
$179.50
|
| Rate for Payer: Group Health Inc Medicare |
$125.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$179.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.50
|
|
|
UNSPEC MAXILLOFACIAL PROSTH B/R
|
Facility
OP
|
$2,400.00
|
|
|
Service Code
|
HCPCS D5999
|
| Hospital Charge Code |
42301410
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,320.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,200.00
|
| Rate for Payer: Aetna Government |
$1,200.00
|
| 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 |
$1,200.00
|
| Rate for Payer: Group Health Inc Medicare |
$840.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,200.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,200.00
|
|
|
U PD-CST METL BASE W/RES SAD INC
|
Facility
OP
|
$1,400.00
|
|
|
Service Code
|
HCPCS D5213
|
| Hospital Charge Code |
42300990
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$285.71 |
| Max. Negotiated Rate |
$28,571.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$770.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$444.73
|
| Rate for Payer: Aetna Government |
$444.73
|
| Rate for Payer: Amida Care Medicaid |
$285.71
|
| 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: Fidelis CHP/HARP/Medicaid |
$28,571.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$285.71
|
| Rate for Payer: Fidelis Essential Plan QHP |
$285.71
|
| Rate for Payer: Fidelis Qualified Health Plan |
$300.00
|
| Rate for Payer: Group Health Inc Commercial |
$700.00
|
| Rate for Payer: Group Health Inc Medicare |
$490.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$285.71
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$700.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$285.71
|
| Rate for Payer: Healthfirst Essential Plan |
$642.85
|
| Rate for Payer: Healthfirst QHP |
$285.71
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$285.71
|
| Rate for Payer: SOMOS Essential |
$642.85
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$285.71
|
|
|
U PD-RESIN BASE INCL. CONVEN. CLA
|
Facility
OP
|
$875.00
|
|
|
Service Code
|
HCPCS D5211
|
| Hospital Charge Code |
42300980
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$306.25 |
| Max. Negotiated Rate |
$37,121.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$481.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.83
|
| Rate for Payer: Aetna Government |
$339.83
|
| Rate for Payer: Amida Care Medicaid |
$371.21
|
| 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: Fidelis CHP/HARP/Medicaid |
$37,121.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$371.21
|
| Rate for Payer: Fidelis Essential Plan QHP |
$371.21
|
| Rate for Payer: Fidelis Qualified Health Plan |
$389.77
|
| Rate for Payer: Group Health Inc Commercial |
$437.50
|
| Rate for Payer: Group Health Inc Medicare |
$306.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$371.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$437.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$371.21
|
| Rate for Payer: Healthfirst Essential Plan |
$835.22
|
| Rate for Payer: Healthfirst QHP |
$371.21
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$371.21
|
| Rate for Payer: SOMOS Essential |
$835.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$371.21
|
|
|
UPPERFACE/MIDFACE 3 PRONG BENDER
|
Facility
IP
|
$492.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40209872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$246.00 |
| Max. Negotiated Rate |
$246.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$246.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$246.00
|
|
|
UPPERFACE/MIDFACE 3 PRONG BENDER
|
Facility
OP
|
$492.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40209872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$516.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$270.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$246.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$282.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$516.60
|
| Rate for Payer: Group Health Inc Commercial |
$246.00
|
| Rate for Payer: Group Health Inc Medicare |
$172.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$246.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$246.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$319.80
|
|
|
UPPERFACE/MIDFACE IN-SITU PLATE
|
Facility
OP
|
$1,150.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40209873
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$1,207.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$632.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$575.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$661.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,207.50
|
| Rate for Payer: Group Health Inc Commercial |
$575.00
|
| Rate for Payer: Group Health Inc Medicare |
$402.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$575.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$575.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$747.50
|
|
