|
SP VENOUS PRT RMV
|
Facility
|
IP
|
$1,909.65
|
|
|
Service Code
|
HCPCS 36590 TC
|
| Hospital Charge Code |
41549848
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,852.05
|
|
|
SP VENOUS PRT RMV
|
Facility
|
OP
|
$1,909.65
|
|
|
Service Code
|
HCPCS 36590 TC
|
| Hospital Charge Code |
41549848
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$954.82 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,852.05
|
| Rate for Payer: Aetna Government |
$1,852.05
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,296.44
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,296.44
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,296.44
|
| Rate for Payer: Brighton Health Commercial |
$1,432.24
|
| Rate for Payer: Cash Price |
$1,852.05
|
| Rate for Payer: Cash Price |
$1,852.05
|
| Rate for Payer: Cash Price |
$1,852.05
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,852.05
|
| 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 |
$1,852.05
|
| Rate for Payer: EmblemHealth Commercial |
$1,852.05
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,574.24
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,648.32
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,852.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,648.32
|
| Rate for Payer: Group Health Inc Commercial |
$1,852.05
|
| Rate for Payer: Group Health Inc Medicare |
$1,852.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$954.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,852.05
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,574.24
|
| Rate for Payer: Healthfirst QHP |
$1,852.05
|
| Rate for Payer: Humana Medicare |
$1,889.09
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,852.05
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,852.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,852.05
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,481.64
|
| Rate for Payer: Wellcare Medicare |
$1,759.45
|
|
|
SP VENOUS PUNCTURE >1ST
|
Facility
|
OP
|
$2,363.06
|
|
|
Service Code
|
HCPCS 36012 TC
|
| Hospital Charge Code |
41542688
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$780.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$930.33
|
| Rate for Payer: Aetna Government |
$930.33
|
| Rate for Payer: Brighton Health Commercial |
$1,772.30
|
| 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 |
$1,181.53
|
| Rate for Payer: Group Health Inc Medicare |
$827.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,181.53
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,181.53
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
|
|
SP VENOUS PUNCTURE 1ST
|
Facility
|
OP
|
$2,814.83
|
|
|
Service Code
|
HCPCS 36011 TC
|
| Hospital Charge Code |
41542687
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$780.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$901.46
|
| Rate for Payer: Aetna Government |
$901.46
|
| Rate for Payer: Brighton Health Commercial |
$2,111.12
|
| 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: Group Health Inc Commercial |
$1,407.42
|
| Rate for Payer: Group Health Inc Medicare |
$985.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,407.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,407.42
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
|
|
SP VEN PORT > 5 YRS OLD
|
Facility
|
IP
|
$8,393.53
|
|
|
Service Code
|
HCPCS 36571 TC
|
| Hospital Charge Code |
41549842
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$3,686.08
|
|
|
SP VEN PORT > 5 YRS OLD
|
Facility
|
OP
|
$8,393.53
|
|
|
Service Code
|
HCPCS 36571 TC
|
| Hospital Charge Code |
41549842
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,835.00 |
| Max. Negotiated Rate |
$6,295.15 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,686.08
|
| Rate for Payer: Aetna Government |
$3,686.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,580.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,580.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,580.26
|
| Rate for Payer: Brighton Health Commercial |
$6,295.15
|
| Rate for Payer: Cash Price |
$3,686.08
|
| Rate for Payer: Cash Price |
$3,686.08
|
| Rate for Payer: Cash Price |
$3,686.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,686.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$3,686.08
|
| Rate for Payer: EmblemHealth Commercial |
$3,686.08
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,133.17
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,280.61
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,686.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,280.61
|
| Rate for Payer: Group Health Inc Commercial |
$3,686.08
|
| Rate for Payer: Group Health Inc Medicare |
$3,686.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,196.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,686.08
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,133.17
|
| Rate for Payer: Healthfirst QHP |
$3,686.08
|
| Rate for Payer: Humana Medicare |
$3,759.80
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,686.08
|
| Rate for Payer: United Healthcare Commercial |
$1,835.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,686.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,686.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,948.86
|
| Rate for Payer: Wellcare Medicare |
$3,501.78
|
|
|
SP VERTEB AUG LUMBAR
|
Facility
|
OP
|
$18,618.83
|
|
|
Service Code
|
HCPCS 22514 TC
|
| Hospital Charge Code |
41543554
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,477.75 |
| Max. Negotiated Rate |
$13,964.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,593.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8,273.12
|
| Rate for Payer: Aetna Government |
$8,273.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5,791.18
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5,791.18
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5,791.18
|
| Rate for Payer: Brighton Health Commercial |
$13,964.12
|
| 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 |
$8,273.12
|
| 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 |
$9,309.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,273.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7,032.15
|
| Rate for Payer: Healthfirst QHP |
$8,273.12
|
| Rate for Payer: Humana Medicare |
$8,438.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$8,273.12
|
| Rate for Payer: United Healthcare Commercial |
$2,546.00
|
| Rate for Payer: United Healthcare 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
|
|
|
SP VERTEB AUG LUMBAR
|
Facility
|
IP
|
$18,618.83
|
|
|
Service Code
|
HCPCS 22514 TC
|
| Hospital Charge Code |
41543554
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$8,273.12
|
|
|
SP VERTEB AUGMENT EACH ADDL
|
Facility
|
OP
|
$13,964.12
|
|
|
Service Code
|
HCPCS 22515 TC
|
| Hospital Charge Code |
41543555
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,113.00 |
| Max. Negotiated Rate |
$1,628,818.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,593.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,518.40
|
| Rate for Payer: Aetna Government |
$4,518.40
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$36,648.40
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$36,648.40
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$16,288.18
|
| Rate for Payer: Amida Care Medicaid |
$16,288.18
|
| Rate for Payer: Brighton Health Commercial |
$10,473.09
|
| 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 |
$1,628,818.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$16,288.18
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16,288.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$17,102.59
|
| Rate for Payer: Group Health Inc Commercial |
$6,982.06
|
| Rate for Payer: Group Health Inc Medicare |
$4,887.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16,288.18
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,982.06
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$16,288.18
|
| Rate for Payer: Healthfirst Essential Plan |
$36,648.40
|
| Rate for Payer: Healthfirst QHP |
$16,288.18
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$16,288.18
|
| Rate for Payer: SOMOS Essential |
$36,648.40
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$36,648.40
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$17,917.00
|
| Rate for Payer: United Healthcare Medicaid |
$16,288.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$16,288.18
|
|
|
SP VERTEB AUG THORACIC
|
Facility
|
IP
|
$18,618.83
|
|
|
Service Code
|
HCPCS 22513 TC
|
| Hospital Charge Code |
41543553
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$8,273.12
|
|
|
SP VERTEB AUG THORACIC
|
Facility
|
OP
|
$18,618.83
|
|
|
Service Code
|
HCPCS 22513 TC
|
| Hospital Charge Code |
41543553
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,477.75 |
| Max. Negotiated Rate |
$13,964.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,593.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8,273.12
|
| Rate for Payer: Aetna Government |
$8,273.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5,791.18
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5,791.18
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5,791.18
|
| Rate for Payer: Brighton Health Commercial |
$13,964.12
|
| 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 |
$8,273.12
|
| 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 |
$9,309.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,273.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7,032.15
|
| Rate for Payer: Healthfirst QHP |
$8,273.12
|
| Rate for Payer: Humana Medicare |
$8,438.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$8,273.12
|
| Rate for Payer: United Healthcare Commercial |
$2,546.00
|
| Rate for Payer: United Healthcare 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
|
|
|
SP VERTEB LUMBOSACRAL INJ
|
Facility
|
OP
|
$8,291.05
|
|
|
Service Code
|
HCPCS 22511 TC
|
| Hospital Charge Code |
41543551
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,835.00 |
| Max. Negotiated Rate |
$6,218.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,593.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,743.15
|
| Rate for Payer: Aetna Government |
$3,743.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,620.20
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,620.20
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,620.20
|
| Rate for Payer: Brighton Health Commercial |
$6,218.29
|
| Rate for Payer: Cash Price |
$3,743.15
|
| Rate for Payer: Cash Price |
$3,743.15
|
| Rate for Payer: Cash Price |
$3,743.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,743.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$3,743.15
|
| Rate for Payer: EmblemHealth Commercial |
$3,743.15
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,181.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,331.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,743.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,331.40
|
| Rate for Payer: Group Health Inc Commercial |
$3,743.15
|
| Rate for Payer: Group Health Inc Medicare |
$3,743.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,145.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,743.15
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,181.68
|
| Rate for Payer: Healthfirst QHP |
$3,743.15
|
| Rate for Payer: Humana Medicare |
$3,818.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,743.15
|
| Rate for Payer: United Healthcare Commercial |
$1,835.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,743.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,743.15
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,994.52
|
| Rate for Payer: Wellcare Medicare |
$3,555.99
|
|
|
SP VERTEB LUMBOSACRAL INJ
|
Facility
|
IP
|
$8,291.05
|
|
|
Service Code
|
HCPCS 22511 TC
|
| Hospital Charge Code |
41543551
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$3,743.15
|
|
|
SP VERTEBROPLASTY ADDL INJ
|
Facility
|
OP
|
$1,957.50
|
|
|
Service Code
|
HCPCS 22512 TC
|
| Hospital Charge Code |
41543552
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$685.12 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$997.09
|
| Rate for Payer: Aetna Government |
$997.09
|
| Rate for Payer: Brighton Health Commercial |
$1,468.12
|
| 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: Group Health Inc Commercial |
$978.75
|
| Rate for Payer: Group Health Inc Medicare |
$685.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$978.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$978.75
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
|
|
SP VISC TRANSLUMBAR
|
Facility
|
OP
|
$5,248.77
|
|
|
Service Code
|
HCPCS 0235T
|
| Hospital Charge Code |
41542764
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,837.07 |
| Max. Negotiated Rate |
$3,936.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,886.82
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,162.54
|
| Rate for Payer: Aetna Government |
$2,162.54
|
| Rate for Payer: Brighton Health Commercial |
$3,936.58
|
| 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 |
$2,624.38
|
| Rate for Payer: Group Health Inc Medicare |
$1,837.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,624.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,624.38
|
|
|
SP WHITAKER TEST
|
Facility
|
OP
|
$1,685.60
|
|
|
Service Code
|
HCPCS 50396 TC
|
| Hospital Charge Code |
41547455
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$552.97 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$789.96
|
| Rate for Payer: Aetna Government |
$789.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$552.97
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$552.97
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$552.97
|
| Rate for Payer: Brighton Health Commercial |
$1,264.20
|
| Rate for Payer: Cash Price |
$789.96
|
| Rate for Payer: Cash Price |
$789.96
|
| Rate for Payer: Cash Price |
$789.96
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$789.96
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$789.96
|
| Rate for Payer: EmblemHealth Commercial |
$789.96
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$671.47
|
| Rate for Payer: Fidelis Essential Plan QHP |
$703.06
|
| Rate for Payer: Fidelis Medicare Advantage |
$789.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$703.06
|
| Rate for Payer: Group Health Inc Commercial |
$789.96
|
| Rate for Payer: Group Health Inc Medicare |
$789.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$842.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$789.96
|
| Rate for Payer: Healthfirst Medicare Advantage |
$671.47
|
| Rate for Payer: Healthfirst QHP |
$789.96
|
| Rate for Payer: Humana Medicare |
$805.76
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$789.96
|
| Rate for Payer: United Healthcare Commercial |
$1,188.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$789.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$789.96
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$631.97
|
| Rate for Payer: Wellcare Medicare |
$750.46
|
|
|
SP WHITAKER TEST
|
Facility
|
IP
|
$1,685.60
|
|
|
Service Code
|
HCPCS 50396 TC
|
| Hospital Charge Code |
41547455
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$789.96
|
|
|
SP WRIST ARTHOGRAM
|
Facility
|
OP
|
$525.71
|
|
|
Service Code
|
HCPCS 25246 TC
|
| Hospital Charge Code |
41561910
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$162.43 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$162.43
|
| Rate for Payer: Aetna Government |
$162.43
|
| Rate for Payer: Brighton Health Commercial |
$394.28
|
| 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 |
$262.86
|
| Rate for Payer: Group Health Inc Medicare |
$184.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$262.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$262.86
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
|
|
SQ/IM INJECTION
|
Facility
|
IP
|
$183.15
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
40509905
|
|
Hospital Revenue Code
|
269
|
| Rate for Payer: Cash Price |
$81.46
|
|
|
SQ/IM INJECTION
|
Facility
|
OP
|
$183.15
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
40509905
|
|
Hospital Revenue Code
|
269
|
| Min. Negotiated Rate |
$13.36 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$100.73
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$81.46
|
| Rate for Payer: Aetna Government |
$81.46
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$30.06
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$30.06
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$13.36
|
| Rate for Payer: Amida Care Medicaid |
$13.36
|
| Rate for Payer: Brighton Health Commercial |
$137.36
|
| Rate for Payer: Cash Price |
$81.46
|
| Rate for Payer: Cash Price |
$81.46
|
| Rate for Payer: Cash Price |
$81.46
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$81.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$146.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.54
|
| Rate for Payer: Elderplan Medicare Advantage |
$81.46
|
| Rate for Payer: EmblemHealth Commercial |
$81.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,336.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$13.36
|
| Rate for Payer: Fidelis Essential Plan QHP |
$13.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$81.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$14.03
|
| Rate for Payer: Group Health Inc Commercial |
$81.46
|
| Rate for Payer: Group Health Inc Medicare |
$81.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$81.46
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$13.36
|
| Rate for Payer: Healthfirst Essential Plan |
$30.06
|
| Rate for Payer: Healthfirst Medicare Advantage |
$69.24
|
| Rate for Payer: Healthfirst QHP |
$13.36
|
| Rate for Payer: Humana Medicare |
$83.09
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$81.46
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$13.36
|
| Rate for Payer: SOMOS Essential |
$13.36
|
| Rate for Payer: United Healthcare Commercial |
$76.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$30.06
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$14.70
|
| Rate for Payer: United Healthcare Medicaid |
$13.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$81.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$81.46
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$65.17
|
| Rate for Payer: Wellcare Medicare |
$77.39
|
|
|
SQ LIVE YELLOW FEVER VACCINE
|
Facility
|
IP
|
$358.63
|
|
|
Service Code
|
HCPCS 90717
|
| Hospital Charge Code |
30101238
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$179.32 |
| Max. Negotiated Rate |
$179.32 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$179.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.32
|
|
|
SQ LIVE YELLOW FEVER VACCINE
|
Facility
|
OP
|
$358.63
|
|
|
Service Code
|
HCPCS 90717
|
| Hospital Charge Code |
30101238
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$125.52 |
| Max. Negotiated Rate |
$233.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$143.47
|
| Rate for Payer: Aetna Government |
$143.47
|
| Rate for Payer: Brighton Health Commercial |
$215.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$179.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$206.21
|
| 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
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$233.11
|
|
|
SREP S/N/A/G/TR/E, 20.1-30.0CM
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 12006
|
| Hospital Charge Code |
30103257
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
SREP S/N/A/G/TR/E, 20.1-30.0CM
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 12006
|
| Hospital Charge Code |
30103257
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$461.12
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$461.12
|
| 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 |
$461.12
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| 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 |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$461.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
SREP S/N/A/G/TR/E, OVER 30CM
|
Facility
|
OP
|
$529.23
|
|
|
Service Code
|
HCPCS 12007
|
| Hospital Charge Code |
30103258
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$162.06 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$231.52
|
| Rate for Payer: Aetna Government |
$231.52
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$162.06
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$162.06
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$162.06
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$231.52
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$231.52
|
| 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 |
$231.52
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$196.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$206.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$231.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$206.05
|
| 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 |
$264.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$231.52
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$231.52
|
| Rate for Payer: Humana Medicare |
$236.15
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$231.52
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$231.52
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$231.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$231.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$185.22
|
| Rate for Payer: Wellcare Medicare |
$219.94
|
|
