|
BRA SURGICAL SMALL BREAST SUPPORT
|
Facility
OP
|
$37.35
|
|
| Hospital Charge Code |
64904186
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.07 |
| Max. Negotiated Rate |
$29.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.68
|
| Rate for Payer: Aetna Government |
$18.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$29.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$25.40
|
| Rate for Payer: Group Health Inc Commercial |
$18.68
|
| Rate for Payer: Group Health Inc Medicare |
$13.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.68
|
|
|
BRA SURGICAL X-LRG BREAST SUPPORT
|
Facility
OP
|
$36.60
|
|
| Hospital Charge Code |
64903994
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.81 |
| Max. Negotiated Rate |
$29.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.30
|
| Rate for Payer: Aetna Government |
$18.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$29.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.89
|
| Rate for Payer: Group Health Inc Commercial |
$18.30
|
| Rate for Payer: Group Health Inc Medicare |
$12.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.30
|
|
|
BRA SURGICAL XXLRG BREAST SUPPORT
|
Facility
OP
|
$39.83
|
|
| Hospital Charge Code |
64903996
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.94 |
| Max. Negotiated Rate |
$31.86 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$21.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.92
|
| Rate for Payer: Aetna Government |
$19.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$31.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$27.08
|
| Rate for Payer: Group Health Inc Commercial |
$19.92
|
| Rate for Payer: Group Health Inc Medicare |
$13.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.92
|
|
|
BRCA1&2 GENE FULL SEQ ALYS
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 81163
|
| Hospital Charge Code |
40608840
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$468.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$468.00
|
| Rate for Payer: Aetna Government |
$468.00
|
| Rate for Payer: Brighton Health Commercial |
$468.00
|
| Rate for Payer: Cash Price |
$468.00
|
| Rate for Payer: Cash Price |
$468.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$468.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Elderplan Medicare Advantage |
$468.00
|
| Rate for Payer: EmblemHealth Commercial |
$468.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$421.20
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$397.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$416.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$468.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$416.52
|
| Rate for Payer: Group Health Inc Commercial |
$468.00
|
| Rate for Payer: Group Health Inc Medicare |
$468.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$468.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$468.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$468.00
|
| Rate for Payer: Healthfirst QHP |
$468.00
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$468.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$468.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$374.40
|
| Rate for Payer: Wellcare Medicare |
$421.20
|
|
|
BRCA1&2 GEN FUL DUP/DEL ALYS
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 81164
|
| Hospital Charge Code |
40608839
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$584.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$584.23
|
| Rate for Payer: Aetna Government |
$584.23
|
| Rate for Payer: Brighton Health Commercial |
$584.23
|
| Rate for Payer: Cash Price |
$584.23
|
| Rate for Payer: Cash Price |
$584.23
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$584.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Elderplan Medicare Advantage |
$584.23
|
| Rate for Payer: EmblemHealth Commercial |
$584.23
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$525.81
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$496.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$519.96
|
| Rate for Payer: Fidelis Medicare Advantage |
$584.23
|
| Rate for Payer: Fidelis Qualified Health Plan |
$519.96
|
| Rate for Payer: Group Health Inc Commercial |
$584.23
|
| Rate for Payer: Group Health Inc Medicare |
$584.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$584.23
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$584.23
|
| Rate for Payer: Healthfirst Medicare Advantage |
$584.23
|
| Rate for Payer: Healthfirst QHP |
$584.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$584.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$584.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$467.38
|
| Rate for Payer: Wellcare Medicare |
$525.81
|
|
|
BRCA1&2 GEN FULL SEQ DUP/DEL
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 81162
|
| Hospital Charge Code |
40608841
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$1,824.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,824.88
|
| Rate for Payer: Aetna Government |
$1,824.88
|
| Rate for Payer: Brighton Health Commercial |
$1,824.88
|
| Rate for Payer: Cash Price |
$1,824.88
|
| Rate for Payer: Cash Price |
$1,824.88
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,824.88
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,824.88
|
| Rate for Payer: EmblemHealth Commercial |
$1,824.88
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,642.39
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,551.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,624.14
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,824.88
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,624.14
|
| Rate for Payer: Group Health Inc Commercial |
$1,824.88
|
| Rate for Payer: Group Health Inc Medicare |
$1,824.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,824.88
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,824.88
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,824.88
|
| Rate for Payer: Healthfirst QHP |
$1,824.88
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,824.88
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,824.88
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,459.90
|
| Rate for Payer: Wellcare Medicare |
$1,642.39
|
|
|
BRCASSURE COMPREHENSIVE TEST
|
Facility
OP
|
$4,824.00
|
|
|
Service Code
|
HCPCS 81211
|
| Hospital Charge Code |
40609026
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,688.40 |
| Max. Negotiated Rate |
$3,859.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,653.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,412.00
|
| Rate for Payer: Aetna Government |
$2,412.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,859.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,280.32
|
| Rate for Payer: Group Health Inc Commercial |
$2,412.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,688.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,412.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,412.00
|
|
|
BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC
|
Facility
IP
|
$35,178.27
|
|
|
Service Code
|
MS-DRG 584
|
| Min. Negotiated Rate |
$16,037.15 |
| Max. Negotiated Rate |
$35,178.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$28,879.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$34,488.50
|
| Rate for Payer: Aetna Government |
$34,488.50
|
| Rate for Payer: Brighton Health Commercial |
$28,399.70
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$35,178.27
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$33,823.06
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$27,912.24
|
| Rate for Payer: Elderplan Medicare Advantage |
$32,764.08
|
| Rate for Payer: EmblemHealth Commercial |
$16,795.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$34,488.50
|
| Rate for Payer: Group Health Inc Commercial |
$34,488.50
|
| Rate for Payer: Group Health Inc Medicare |
$34,488.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$34,488.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$16,037.15
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$34,488.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34,488.50
|
| Rate for Payer: Wellcare Medicare |
$32,764.08
|
|
|
BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC
|
Facility
IP
|
$31,294.12
|
|
|
Service Code
|
MS-DRG 585
|
| Min. Negotiated Rate |
$14,266.44 |
| Max. Negotiated Rate |
$31,294.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$24,830.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30,680.51
|
| Rate for Payer: Aetna Government |
$30,680.51
|
| Rate for Payer: Brighton Health Commercial |
$24,418.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$31,294.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$29,081.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$23,998.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$29,146.48
|
| Rate for Payer: EmblemHealth Commercial |
$14,440.30
|
| Rate for Payer: Fidelis Medicare Advantage |
$30,680.51
|
| Rate for Payer: Group Health Inc Commercial |
$30,680.51
|
| Rate for Payer: Group Health Inc Medicare |
$30,680.51
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30,680.51
|
| Rate for Payer: Healthfirst Medicare Advantage |
$14,266.44
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30,680.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$30,680.51
|
| Rate for Payer: Wellcare Medicare |
$29,146.48
|
|
|
BREAST EXPANDER A
|
Facility
OP
|
$3,662.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
64902951
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$402.32 |
| Max. Negotiated Rate |
$3,845.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,014.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$402.32
|
| Rate for Payer: Aetna Government |
$402.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,831.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,105.94
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,845.62
|
| Rate for Payer: Group Health Inc Commercial |
$1,831.25
|
| Rate for Payer: Group Health Inc Medicare |
$1,281.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,831.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,831.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,380.62
|
|
|
BREAST EXPANDER A
|
Facility
IP
|
$3,662.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
64902951
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,831.25 |
| Max. Negotiated Rate |
$1,831.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,831.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,831.25
|
|
|
BREAST EXPANDER B
|
Facility
IP
|
$3,662.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
64902953
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,831.25 |
| Max. Negotiated Rate |
$1,831.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,831.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,831.25
|
|
|
BREAST EXPANDER B
|
Facility
OP
|
$3,662.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
64902953
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$402.32 |
| Max. Negotiated Rate |
$3,845.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,014.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$402.32
|
| Rate for Payer: Aetna Government |
$402.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,831.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,105.94
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,845.62
|
| Rate for Payer: Group Health Inc Commercial |
$1,831.25
|
| Rate for Payer: Group Health Inc Medicare |
$1,281.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,831.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,831.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,380.62
|
|
|
BREAST EXPANDER C
|
Facility
IP
|
$3,662.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
64902955
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,831.25 |
| Max. Negotiated Rate |
$1,831.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,831.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,831.25
|
|
|
BREAST EXPANDER C
|
Facility
OP
|
$3,662.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
64902955
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$402.32 |
| Max. Negotiated Rate |
$3,845.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,014.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$402.32
|
| Rate for Payer: Aetna Government |
$402.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,831.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,105.94
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,845.62
|
| Rate for Payer: Group Health Inc Commercial |
$1,831.25
|
| Rate for Payer: Group Health Inc Medicare |
$1,281.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,831.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,831.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,380.62
|
|
|
BREAST IMP HSC+ SMTH RD MOD + PRO
|
Facility
OP
|
$895.00
|
|
| Hospital Charge Code |
40006230
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$313.25 |
| Max. Negotiated Rate |
$716.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$492.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$447.50
|
| Rate for Payer: Aetna Government |
$447.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$716.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$608.60
|
| Rate for Payer: Group Health Inc Commercial |
$447.50
|
| Rate for Payer: Group Health Inc Medicare |
$313.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$447.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$447.50
|
|
|
BREAST IMP HSC+ S RND MOD + PROJE
|
Facility
OP
|
$895.00
|
|
| Hospital Charge Code |
40006231
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$313.25 |
| Max. Negotiated Rate |
$716.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$492.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$447.50
|
| Rate for Payer: Aetna Government |
$447.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$716.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$608.60
|
| Rate for Payer: Group Health Inc Commercial |
$447.50
|
| Rate for Payer: Group Health Inc Medicare |
$313.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$447.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$447.50
|
|
|
BREAST IMPLANT
|
Facility
IP
|
$1,900.00
|
|
|
Service Code
|
HCPCS L8600
|
| Hospital Charge Code |
40203021
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$950.00 |
| Max. Negotiated Rate |
$950.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$950.00
|
|
|
BREAST IMPLANT
|
Facility
OP
|
$1,900.00
|
|
|
Service Code
|
HCPCS L8600
|
| Hospital Charge Code |
40203021
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$326.16 |
| Max. Negotiated Rate |
$1,995.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,045.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$326.16
|
| Rate for Payer: Aetna Government |
$326.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$950.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,092.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,995.00
|
| Rate for Payer: Group Health Inc Commercial |
$950.00
|
| Rate for Payer: Group Health Inc Medicare |
$665.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$950.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,235.00
|
|
|
BREAST IMPLANT 250CC
|
Facility
OP
|
$1,300.00
|
|
|
Service Code
|
HCPCS L8600
|
| Hospital Charge Code |
40203152
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$326.16 |
| Max. Negotiated Rate |
$1,365.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$715.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$326.16
|
| Rate for Payer: Aetna Government |
$326.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$650.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$747.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,365.00
|
| Rate for Payer: Group Health Inc Commercial |
$650.00
|
| Rate for Payer: Group Health Inc Medicare |
$455.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$650.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$650.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$845.00
|
|
|
BREAST IMPLANT 250CC
|
Facility
IP
|
$1,300.00
|
|
|
Service Code
|
HCPCS L8600
|
| Hospital Charge Code |
40203152
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$650.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$650.00
|
|
|
BREAST IMPLANT 350CC
|
Facility
IP
|
$1,900.00
|
|
|
Service Code
|
HCPCS L8600
|
| Hospital Charge Code |
40203153
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$950.00 |
| Max. Negotiated Rate |
$950.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$950.00
|
|
|
BREAST IMPLANT 350CC
|
Facility
OP
|
$1,900.00
|
|
|
Service Code
|
HCPCS L8600
|
| Hospital Charge Code |
40203153
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$326.16 |
| Max. Negotiated Rate |
$1,995.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,045.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$326.16
|
| Rate for Payer: Aetna Government |
$326.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$950.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,092.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,995.00
|
| Rate for Payer: Group Health Inc Commercial |
$950.00
|
| Rate for Payer: Group Health Inc Medicare |
$665.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$950.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,235.00
|
|
|
BREAST IMPLANT,INSPIRA 275CC
|
Facility
IP
|
$1,987.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
64905681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$993.75 |
| Max. Negotiated Rate |
$993.75 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$993.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$993.75
|
|
|
BREAST IMPLANT,INSPIRA 275CC
|
Facility
OP
|
$1,987.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
64905681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$402.32 |
| Max. Negotiated Rate |
$2,086.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,093.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$402.32
|
| Rate for Payer: Aetna Government |
$402.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$993.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,142.81
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,086.88
|
| Rate for Payer: Group Health Inc Commercial |
$993.75
|
| Rate for Payer: Group Health Inc Medicare |
$695.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$993.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$993.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,291.88
|
|
