|
BONE CEMENT 3
|
Facility
OP
|
$816.60
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40201187
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$857.43 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$449.13
|
| 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 |
$408.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$469.54
|
| Rate for Payer: Fidelis Medicare Advantage |
$857.43
|
| Rate for Payer: Group Health Inc Commercial |
$408.30
|
| Rate for Payer: Group Health Inc Medicare |
$285.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$408.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$408.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$530.79
|
|
|
BONE CEMENT RADIOPAQUE
|
Facility
IP
|
$460.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202094
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$230.00 |
| Max. Negotiated Rate |
$230.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$230.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$230.00
|
|
|
BONE CEMENT RADIOPAQUE
|
Facility
OP
|
$460.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202094
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$483.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$253.00
|
| 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 |
$230.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$264.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$483.00
|
| Rate for Payer: Group Health Inc Commercial |
$230.00
|
| Rate for Payer: Group Health Inc Medicare |
$161.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$230.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$230.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$299.00
|
|
|
BONE CUBE CANCELLOUS 5CC
|
Facility
OP
|
$270.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202361
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$283.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$148.50
|
| 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 |
$135.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$155.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$283.50
|
| Rate for Payer: Group Health Inc Commercial |
$135.00
|
| Rate for Payer: Group Health Inc Medicare |
$94.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$135.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$135.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$175.50
|
|
|
BONE CUBE CANCELLOUS 5CC
|
Facility
IP
|
$380.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901829
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$190.00 |
| Max. Negotiated Rate |
$190.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$190.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$190.00
|
|
|
BONE CUBE CANCELLOUS 5CC
|
Facility
IP
|
$270.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202361
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$135.00 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$135.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$135.00
|
|
|
BONE CUBE CANCELLOUS 5CC
|
Facility
OP
|
$380.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901829
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$133.00 |
| Max. Negotiated Rate |
$399.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$209.00
|
| 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 |
$190.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$218.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$399.00
|
| Rate for Payer: Group Health Inc Commercial |
$190.00
|
| Rate for Payer: Group Health Inc Medicare |
$133.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$190.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$190.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$247.00
|
|
|
BONE CURETTE SET
|
Facility
OP
|
$18.78
|
|
| Hospital Charge Code |
40200640
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.57 |
| Max. Negotiated Rate |
$15.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.33
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.39
|
| Rate for Payer: Aetna Government |
$9.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.77
|
| Rate for Payer: Group Health Inc Commercial |
$9.39
|
| Rate for Payer: Group Health Inc Medicare |
$6.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.39
|
|
|
BONE DISEASES AND ARTHROPATHIES WITH MCC
|
Facility
IP
|
$26,590.99
|
|
|
Service Code
|
MS-DRG 553
|
| Min. Negotiated Rate |
$11,589.10 |
| Max. Negotiated Rate |
$26,590.99 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19,927.87
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26,069.60
|
| Rate for Payer: Aetna Government |
$26,069.60
|
| Rate for Payer: Brighton Health Commercial |
$19,596.75
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$26,590.99
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23,339.05
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19,260.39
|
| Rate for Payer: Elderplan Medicare Advantage |
$24,766.12
|
| Rate for Payer: EmblemHealth Commercial |
$11,589.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$26,069.60
|
| Rate for Payer: Group Health Inc Commercial |
$26,069.60
|
| Rate for Payer: Group Health Inc Medicare |
$26,069.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26,069.60
|
| Rate for Payer: Healthfirst Medicare Advantage |
$12,122.36
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26,069.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$26,069.60
|
| Rate for Payer: Wellcare Medicare |
$24,766.12
|
|
|
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC
|
Facility
IP
|
$19,098.54
|
|
|
Service Code
|
MS-DRG 554
|
| Min. Negotiated Rate |
$7,046.94 |
| Max. Negotiated Rate |
$19,098.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12,117.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18,724.06
|
| Rate for Payer: Aetna Government |
$18,724.06
|
| Rate for Payer: Brighton Health Commercial |
$11,916.10
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$19,098.54
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14,191.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11,711.57
|
| Rate for Payer: Elderplan Medicare Advantage |
$17,787.86
|
| Rate for Payer: EmblemHealth Commercial |
$7,046.94
|
| Rate for Payer: Fidelis Medicare Advantage |
$18,724.06
|
| Rate for Payer: Group Health Inc Commercial |
$18,724.06
|
| Rate for Payer: Group Health Inc Medicare |
$18,724.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18,724.06
|
| Rate for Payer: Healthfirst Medicare Advantage |
$8,706.69
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$18,724.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18,724.06
|
| Rate for Payer: Wellcare Medicare |
$17,787.86
|
|
|
BONE GRAFT
|
Facility
IP
|
$4,240.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40203019
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,120.00 |
| Max. Negotiated Rate |
$2,120.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,120.00
|
|
|
BONE GRAFT
|
Facility
OP
|
$4,240.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40203019
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$4,452.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,332.00
|
| 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 |
$2,120.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,438.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,452.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,120.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,484.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,120.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,756.00
|
|
|
Bone graft, any donor area; minor or small (eg, dowel or button)
|
Facility
OP
|
$8,273.12
|
|
|
Service Code
|
CPT 20900
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$202.36 |
| Max. Negotiated Rate |
$8,273.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8,273.12
|
| Rate for Payer: Aetna Government |
$8,273.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$8,273.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$8,273.12
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$202.36
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$7,032.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7,363.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$8,273.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7,363.08
|
| Rate for Payer: Group Health Inc Commercial |
$8,273.12
|
| Rate for Payer: Group Health Inc Medicare |
$8,273.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,273.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$224.85
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7,032.15
|
| Rate for Payer: Healthfirst QHP |
$8,273.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$8,273.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,273.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6,618.50
|
| Rate for Payer: Wellcare Medicare |
$7,859.46
|
|
|
BONE GRAFT ANY DONOR - LARGE
|
Facility
OP
|
$18,117.83
|
|
|
Service Code
|
HCPCS 20902
|
| Hospital Charge Code |
40089405
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$309.03 |
| Max. Negotiated Rate |
$9,058.92 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,485.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8,273.12
|
| Rate for Payer: Aetna Government |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$8,273.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$8,273.12
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$309.03
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$7,032.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7,363.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$8,273.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7,363.08
|
| Rate for Payer: Group Health Inc Commercial |
$8,273.12
|
| Rate for Payer: Group Health Inc Medicare |
$8,273.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9,058.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,273.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$343.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7,032.15
|
| Rate for Payer: Healthfirst QHP |
$8,273.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$8,273.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,273.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6,618.50
|
| Rate for Payer: Wellcare Medicare |
$7,859.46
|
|
|
BONE GRAFT ANY DONOR - SMALL
|
Facility
OP
|
$18,117.83
|
|
|
Service Code
|
HCPCS 20900
|
| Hospital Charge Code |
40082790
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$202.36 |
| Max. Negotiated Rate |
$9,058.92 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8,273.12
|
| Rate for Payer: Aetna Government |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$8,273.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$8,273.12
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$202.36
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$7,032.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7,363.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$8,273.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7,363.08
|
| Rate for Payer: Group Health Inc Commercial |
$8,273.12
|
| Rate for Payer: Group Health Inc Medicare |
$8,273.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9,058.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,273.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$224.85
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7,032.15
|
| Rate for Payer: Healthfirst QHP |
$8,273.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$8,273.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,273.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6,618.50
|
| Rate for Payer: Wellcare Medicare |
$7,859.46
|
|
|
BONE GRAFT FEMUR
|
Facility
OP
|
$4,144.04
|
|
|
Service Code
|
HCPCS 27170
|
| Hospital Charge Code |
40023261
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,214.68 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,279.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,214.68
|
| Rate for Payer: Aetna Government |
$1,214.68
|
| 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: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,332.11
|
| Rate for Payer: Group Health Inc Commercial |
$2,072.02
|
| Rate for Payer: Group Health Inc Medicare |
$1,450.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,072.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,072.02
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,480.12
|
|
|
BONE GRAFT FOR RIDGE PRESERVATION
|
Facility
OP
|
$625.00
|
|
|
Service Code
|
HCPCS D7953
|
| Hospital Charge Code |
42300751
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$62.53 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$343.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$62.53
|
| Rate for Payer: Aetna Government |
$62.53
|
| 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 |
$312.50
|
| Rate for Payer: Group Health Inc Medicare |
$218.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$312.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$312.50
|
|
|
BONE GRAFT INJ 2CC
|
Facility
OP
|
$2,375.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901192
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$2,493.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,306.25
|
| 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 |
$1,187.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,365.62
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,493.75
|
| Rate for Payer: Group Health Inc Commercial |
$1,187.50
|
| Rate for Payer: Group Health Inc Medicare |
$831.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,187.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,187.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,543.75
|
|
|
BONE GRAFT INJ 2CC
|
Facility
IP
|
$2,375.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901192
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,187.50 |
| Max. Negotiated Rate |
$1,187.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,187.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,187.50
|
|
|
BONE GRAFT INJ 5CC
|
Facility
OP
|
$3,987.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$4,186.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,193.12
|
| 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 |
$1,993.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,292.81
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,186.88
|
| Rate for Payer: Group Health Inc Commercial |
$1,993.75
|
| Rate for Payer: Group Health Inc Medicare |
$1,395.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,993.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,993.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,591.88
|
|
|
BONE GRAFT INJ 5CC
|
Facility
IP
|
$3,987.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,993.75 |
| Max. Negotiated Rate |
$1,993.75 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,993.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,993.75
|
|
|
BONE GRAFT MANDIBLE
|
Facility
OP
|
$14,691.05
|
|
|
Service Code
|
HCPCS 21215
|
| Hospital Charge Code |
40013263
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$845.85 |
| Max. Negotiated Rate |
$7,345.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,065.00
|
| 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 |
$845.85
|
| 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 |
$939.83
|
| 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
|
|
|
BONE GRAFT REPAIR PERIMPLANT
|
Facility
OP
|
$500.00
|
|
|
Service Code
|
HCPCS D6103
|
| Hospital Charge Code |
42300997
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$275.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$272.65
|
| Rate for Payer: Aetna Government |
$272.65
|
| 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 |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$250.00
|
|
|
BONE GRAFT STRIP 19X26X7
|
Facility
OP
|
$5,500.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$5,775.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3,025.00
|
| 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 |
$2,750.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,162.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$5,775.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,750.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,925.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,750.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,575.00
|
|
|
BONE GRAFT STRIP 19X26X7
|
Facility
IP
|
$5,500.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,750.00 |
| Max. Negotiated Rate |
$2,750.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,750.00
|
|
