|
SECOND LEVEL ADD-ON
|
Facility
|
OP
|
$1,229.75
|
|
|
Service Code
|
HCPCS 64494
|
| Hospital Charge Code |
30305723
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$59.29 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$59.29
|
| Rate for Payer: Aetna Government |
$59.29
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| 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 |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$614.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$614.88
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
SECTION GUIDE SCREW
|
Facility
|
IP
|
$411.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64907312
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$205.62 |
| Max. Negotiated Rate |
$205.62 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$205.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$205.62
|
|
|
SECTION GUIDE SCREW
|
Facility
|
OP
|
$411.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64907312
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$431.81 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$226.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$246.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$205.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$236.47
|
| Rate for Payer: EmblemHealth Commercial |
$205.62
|
| Rate for Payer: Fidelis Medicare Advantage |
$431.81
|
| Rate for Payer: Group Health Inc Commercial |
$205.62
|
| Rate for Payer: Group Health Inc Medicare |
$143.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$205.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$205.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$267.31
|
|
|
SECUR-FIT MAX NECK ANGLE HIP STEM
|
Facility
|
IP
|
$8,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40201320
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,300.00 |
| Max. Negotiated Rate |
$4,300.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,300.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,300.00
|
|
|
SECUR-FIT MAX NECK ANGLE HIP STEM
|
Facility
|
OP
|
$8,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40201320
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$9,030.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,730.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$5,160.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,300.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4,945.00
|
| Rate for Payer: EmblemHealth Commercial |
$4,300.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$9,030.00
|
| Rate for Payer: Group Health Inc Commercial |
$4,300.00
|
| Rate for Payer: Group Health Inc Medicare |
$3,010.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,300.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,300.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5,590.00
|
|
|
SEDATIVE FILLING
|
Facility
|
IP
|
$110.57
|
|
|
Service Code
|
HCPCS D2940
|
| Hospital Charge Code |
42300635
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
SEDATIVE FILLING
|
Facility
|
OP
|
$110.57
|
|
|
Service Code
|
HCPCS D2940
|
| Hospital Charge Code |
42300635
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$55.28 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$60.81
|
| 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 |
$82.93
|
| 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 |
$55.28
|
| 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
|
|
|
SEDIMENTATION RATE WINTROBETYP
|
Facility
|
OP
|
$10.68
|
|
|
Service Code
|
HCPCS 85651
|
| Hospital Charge Code |
40621545
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$8.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.87
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.27
|
| Rate for Payer: Aetna Government |
$4.27
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2.99
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2.99
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2.99
|
| Rate for Payer: Brighton Health Commercial |
$8.01
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4.27
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.77
|
| Rate for Payer: Elderplan Medicare Advantage |
$4.27
|
| Rate for Payer: EmblemHealth Commercial |
$4.27
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3.63
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3.80
|
| Rate for Payer: Fidelis Medicare Advantage |
$4.27
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3.80
|
| Rate for Payer: Group Health Inc Commercial |
$4.27
|
| Rate for Payer: Group Health Inc Medicare |
$4.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.27
|
| Rate for Payer: Healthfirst Medicare Advantage |
$4.27
|
| Rate for Payer: Healthfirst QHP |
$4.27
|
| Rate for Payer: Humana Medicare |
$4.36
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4.27
|
| Rate for Payer: United Healthcare Commercial |
$4.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.27
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3.42
|
| Rate for Payer: Wellcare Medicare |
$3.84
|
|
|
SEDIMENTATION RATE WINTROBETYP
|
Facility
|
IP
|
$10.68
|
|
|
Service Code
|
HCPCS 85651
|
| Hospital Charge Code |
40621545
|
|
Hospital Revenue Code
|
305
|
| Rate for Payer: Cash Price |
$4.27
|
|
|
SEED EAR CLEAR MAGRAIN GOLD
|
Facility
|
OP
|
$38.75
|
|
| Hospital Charge Code |
64903040
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.56 |
| Max. Negotiated Rate |
$31.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$21.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.38
|
| Rate for Payer: Aetna Government |
$19.38
|
| Rate for Payer: Brighton Health Commercial |
$29.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$31.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$26.35
|
| Rate for Payer: Group Health Inc Commercial |
$19.38
|
| Rate for Payer: Group Health Inc Medicare |
$13.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.38
|
|
|
SEGMENT REV W/ML-FML 30MM-5004603
|
Facility
|
OP
|
$5,248.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64906414
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$5,510.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,886.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$3,148.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,624.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,017.60
|
| Rate for Payer: EmblemHealth Commercial |
$2,624.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$5,510.40
|
| Rate for Payer: Group Health Inc Commercial |
$2,624.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,836.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,624.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,624.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,411.20
|
|
|
SEGMENT REV W/ML-FML 30MM-5004603
|
Facility
|
IP
|
$5,248.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64906414
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,624.00 |
| Max. Negotiated Rate |
$2,624.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,624.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,624.00
|
|
|
SEIZURES WITH MCC
|
Facility
|
IP
|
$47,877.42
|
|
|
Service Code
|
MSDRG 100
|
| Min. Negotiated Rate |
$16,191.27 |
| Max. Negotiated Rate |
$47,877.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$29,231.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$34,819.94
|
| Rate for Payer: Aetna Government |
$34,819.94
|
| Rate for Payer: Brighton Health Commercial |
$28,746.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$35,516.34
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$34,235.79
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$28,252.85
|
| Rate for Payer: Elderplan Medicare Advantage |
$33,078.94
|
| Rate for Payer: EmblemHealth Commercial |
$16,999.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$34,819.94
|
| Rate for Payer: Group Health Inc Commercial |
$34,819.94
|
| Rate for Payer: Group Health Inc Medicare |
$34,819.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$34,819.94
|
| Rate for Payer: Healthfirst Medicare Advantage |
$16,191.27
|
| Rate for Payer: Humana Medicare |
$47,877.42
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$34,819.94
|
| Rate for Payer: United Healthcare Commercial |
$39,425.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$34,819.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34,819.94
|
| Rate for Payer: Wellcare Medicare |
$33,078.94
|
|
|
SEIZURES WITHOUT MCC
|
Facility
|
IP
|
$27,419.74
|
|
|
Service Code
|
MSDRG 101
|
| Min. Negotiated Rate |
$7,799.82 |
| Max. Negotiated Rate |
$27,419.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13,412.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19,941.63
|
| Rate for Payer: Aetna Government |
$19,941.63
|
| Rate for Payer: Brighton Health Commercial |
$13,189.20
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$20,340.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15,707.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12,962.82
|
| Rate for Payer: Elderplan Medicare Advantage |
$18,944.55
|
| Rate for Payer: EmblemHealth Commercial |
$7,799.82
|
| Rate for Payer: Fidelis Medicare Advantage |
$19,941.63
|
| Rate for Payer: Group Health Inc Commercial |
$19,941.63
|
| Rate for Payer: Group Health Inc Medicare |
$19,941.63
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19,941.63
|
| Rate for Payer: Healthfirst Medicare Advantage |
$9,272.86
|
| Rate for Payer: Humana Medicare |
$27,419.74
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$19,941.63
|
| Rate for Payer: United Healthcare Commercial |
$18,089.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19,941.63
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19,941.63
|
| Rate for Payer: Wellcare Medicare |
$18,944.55
|
|
|
Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological supervision and interpretation (eg, middle cerebral artery, posterior inferior cerebellar artery) (List separately in addition to code for primary procedure)
|
Facility
|
OP
|
$4,065.00
|
|
|
Service Code
|
CPT 36228
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$260.78 |
| Max. Negotiated Rate |
$4,065.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,065.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$260.78
|
| Rate for Payer: Aetna Government |
$260.78
|
| 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: United Healthcare Commercial |
$1,113.00
|
|
|
Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure)
|
Facility
|
OP
|
$4,065.00
|
|
|
Service Code
|
CPT 36227
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$127.38 |
| Max. Negotiated Rate |
$4,065.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,065.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.38
|
| Rate for Payer: Aetna Government |
$127.38
|
| 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: United Healthcare Commercial |
$1,113.00
|
|
|
Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed
|
Facility
|
OP
|
$6,482.04
|
|
|
Service Code
|
CPT 36224
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,477.75 |
| Max. Negotiated Rate |
$6,482.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,065.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,354.94
|
| Rate for Payer: Aetna Government |
$6,354.94
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$4,448.46
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$4,448.46
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$4,448.46
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,354.94
|
| 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 |
$6,354.94
|
| Rate for Payer: EmblemHealth Commercial |
$6,354.94
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,401.70
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5,655.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,354.94
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5,655.90
|
| Rate for Payer: Group Health Inc Commercial |
$6,354.94
|
| Rate for Payer: Group Health Inc Medicare |
$6,354.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,354.94
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5,401.70
|
| Rate for Payer: Healthfirst QHP |
$6,354.94
|
| Rate for Payer: Humana Medicare |
$6,482.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,354.94
|
| Rate for Payer: United Healthcare Commercial |
$2,546.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,354.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,354.94
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,083.95
|
| Rate for Payer: Wellcare Medicare |
$6,037.19
|
|
|
Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed
|
Facility
|
OP
|
$6,482.04
|
|
|
Service Code
|
CPT 36226
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,477.75 |
| Max. Negotiated Rate |
$6,482.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,065.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,354.94
|
| Rate for Payer: Aetna Government |
$6,354.94
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$4,448.46
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$4,448.46
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$4,448.46
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,354.94
|
| 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 |
$6,354.94
|
| Rate for Payer: EmblemHealth Commercial |
$6,354.94
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,401.70
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5,655.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,354.94
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5,655.90
|
| Rate for Payer: Group Health Inc Commercial |
$6,354.94
|
| Rate for Payer: Group Health Inc Medicare |
$6,354.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,354.94
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5,401.70
|
| Rate for Payer: Healthfirst QHP |
$6,354.94
|
| Rate for Payer: Humana Medicare |
$6,482.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,354.94
|
| Rate for Payer: United Healthcare Commercial |
$2,546.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,354.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,354.94
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,083.95
|
| Rate for Payer: Wellcare Medicare |
$6,037.19
|
|
|
SELECT PICTURE AUDIOMETRY
|
Facility
|
OP
|
$101.25
|
|
|
Service Code
|
HCPCS 92583
|
| Hospital Charge Code |
42004514
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$49.52 |
| Max. Negotiated Rate |
$158.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$55.69
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$70.74
|
| Rate for Payer: Aetna Government |
$70.74
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$49.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$49.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$49.52
|
| Rate for Payer: Brighton Health Commercial |
$75.94
|
| Rate for Payer: Cash Price |
$70.74
|
| Rate for Payer: Cash Price |
$70.74
|
| Rate for Payer: Cash Price |
$70.74
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$70.74
|
| 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 |
$70.74
|
| Rate for Payer: EmblemHealth Commercial |
$70.74
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$60.13
|
| Rate for Payer: Fidelis Essential Plan QHP |
$62.96
|
| Rate for Payer: Fidelis Medicare Advantage |
$70.74
|
| Rate for Payer: Fidelis Qualified Health Plan |
$62.96
|
| Rate for Payer: Group Health Inc Commercial |
$70.74
|
| Rate for Payer: Group Health Inc Medicare |
$70.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$50.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$70.74
|
| Rate for Payer: Healthfirst Medicare Advantage |
$60.13
|
| Rate for Payer: Healthfirst QHP |
$70.74
|
| Rate for Payer: Humana Medicare |
$72.15
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$70.74
|
| Rate for Payer: United Healthcare Commercial |
$158.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$70.74
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$70.74
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$56.59
|
| Rate for Payer: Wellcare Medicare |
$67.20
|
|
|
SELECT PICTURE AUDIOMETRY
|
Facility
|
IP
|
$101.25
|
|
|
Service Code
|
HCPCS 92583
|
| Hospital Charge Code |
42004514
|
|
Hospital Revenue Code
|
471
|
| Rate for Payer: Cash Price |
$70.74
|
|
|
SELEGILENE 5MG TABLET
|
Facility
|
OP
|
$1.09
|
|
| Hospital Charge Code |
41646045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.55
|
| Rate for Payer: Aetna Government |
$0.55
|
| Rate for Payer: Brighton Health Commercial |
$0.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.87
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.74
|
| Rate for Payer: Group Health Inc Commercial |
$0.55
|
| Rate for Payer: Group Health Inc Medicare |
$0.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.55
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.71
|
|
|
SELEGILENE 5MG TABLET
|
Facility
|
OP
|
$1.09
|
|
| Hospital Charge Code |
41656045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.55
|
| Rate for Payer: Aetna Government |
$0.55
|
| Rate for Payer: Brighton Health Commercial |
$0.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.87
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.74
|
| Rate for Payer: Group Health Inc Commercial |
$0.55
|
| Rate for Payer: Group Health Inc Medicare |
$0.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.55
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.71
|
|
|
SELEGILINE HCL 5 MG PO TABS [11340]
|
Facility
|
OP
|
$2.10
|
|
|
Service Code
|
NDC 50090291800
|
| Hospital Charge Code |
50090291800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.05
|
| Rate for Payer: Aetna Government |
$1.05
|
| Rate for Payer: Brighton Health Commercial |
$1.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.43
|
| Rate for Payer: Group Health Inc Commercial |
$1.05
|
| Rate for Payer: Group Health Inc Medicare |
$0.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.37
|
|
|
SELENIUM 400MCG/10ML INJ
|
Facility
|
OP
|
$7.00
|
|
| Hospital Charge Code |
41659589
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.50
|
| Rate for Payer: Aetna Government |
$3.50
|
| Rate for Payer: Brighton Health Commercial |
$5.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.76
|
| Rate for Payer: Group Health Inc Commercial |
$3.50
|
| Rate for Payer: Group Health Inc Medicare |
$2.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.55
|
|
|
SELENIUM 400MCG/10ML INJ
|
Facility
|
OP
|
$7.00
|
|
| Hospital Charge Code |
41649589
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.50
|
| Rate for Payer: Aetna Government |
$3.50
|
| Rate for Payer: Brighton Health Commercial |
$5.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.76
|
| Rate for Payer: Group Health Inc Commercial |
$3.50
|
| Rate for Payer: Group Health Inc Medicare |
$2.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.55
|
|
