|
TESTICULAR PROSTHESIS 2.7 X 4
|
Facility
|
OP
|
$4,775.00
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
64903962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,671.25 |
| Max. Negotiated Rate |
$5,013.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,626.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,775.00
|
| Rate for Payer: Aetna Government |
$3,775.00
|
| Rate for Payer: Brighton Health Commercial |
$2,865.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,387.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,745.62
|
| Rate for Payer: EmblemHealth Commercial |
$2,387.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$5,013.75
|
| Rate for Payer: Group Health Inc Commercial |
$2,387.50
|
| Rate for Payer: Group Health Inc Medicare |
$1,671.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,387.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,387.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,103.75
|
|
|
TESTICULAR PROSTHESIS 2.7 X 4
|
Facility
|
IP
|
$4,775.00
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
64903962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,387.50 |
| Max. Negotiated Rate |
$2,387.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,387.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,387.50
|
|
|
TESTOSTERINE, FREE+WEAKLY BOUND
|
Facility
|
IP
|
$63.68
|
|
|
Service Code
|
HCPCS 84402
|
| Hospital Charge Code |
40609118
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$25.47
|
|
|
TESTOSTERINE, FREE+WEAKLY BOUND
|
Facility
|
OP
|
$63.68
|
|
|
Service Code
|
HCPCS 84402
|
| Hospital Charge Code |
40609118
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$47.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$35.02
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$25.47
|
| Rate for Payer: Aetna Government |
$25.47
|
| Rate for Payer: Brighton Health Commercial |
$47.76
|
| Rate for Payer: Cash Price |
$25.47
|
| Rate for Payer: Cash Price |
$25.47
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$25.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$40.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$34.26
|
| Rate for Payer: Elderplan Medicare Advantage |
$25.47
|
| Rate for Payer: EmblemHealth Commercial |
$25.47
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$21.65
|
| Rate for Payer: Fidelis Essential Plan QHP |
$22.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$25.47
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22.67
|
| Rate for Payer: Group Health Inc Commercial |
$25.47
|
| Rate for Payer: Group Health Inc Medicare |
$25.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.84
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$25.47
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.47
|
| Rate for Payer: Healthfirst QHP |
$25.47
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$25.47
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$25.47
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20.38
|
| Rate for Payer: Wellcare Medicare |
$22.92
|
|
|
TESTOSTERONE 2.5 MG/24 HR PATCH
|
Facility
|
OP
|
$9.00
|
|
| Hospital Charge Code |
41655401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.50
|
| Rate for Payer: Aetna Government |
$4.50
|
| Rate for Payer: Brighton Health Commercial |
$6.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.12
|
| Rate for Payer: Group Health Inc Commercial |
$4.50
|
| Rate for Payer: Group Health Inc Medicare |
$3.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.85
|
|
|
TESTOSTERONE 2.5 MG/24 HR PATCH
|
Facility
|
OP
|
$9.00
|
|
| Hospital Charge Code |
41645401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.50
|
| Rate for Payer: Aetna Government |
$4.50
|
| Rate for Payer: Brighton Health Commercial |
$6.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.12
|
| Rate for Payer: Group Health Inc Commercial |
$4.50
|
| Rate for Payer: Group Health Inc Medicare |
$3.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.85
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN [126226]
|
Facility
|
OP
|
$25.96
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
00009041701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$20.77 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.03
|
| Rate for Payer: Aetna Government |
$0.03
|
| Rate for Payer: Brighton Health Commercial |
$19.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$20.77
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.65
|
| Rate for Payer: Group Health Inc Commercial |
$12.98
|
| Rate for Payer: Group Health Inc Medicare |
$9.09
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.98
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.01
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.01
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.01
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$16.87
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN [126226]
|
Facility
|
OP
|
$23.15
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
62756001540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$18.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.73
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.03
|
| Rate for Payer: Aetna Government |
$0.03
|
| Rate for Payer: Brighton Health Commercial |
$17.36
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.74
|
| Rate for Payer: Group Health Inc Commercial |
$11.58
|
| Rate for Payer: Group Health Inc Medicare |
$8.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.58
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.01
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.01
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.01
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.05
|
|
|
TESTOSTERONE, FREE+TOTAL LC/MS
|
Facility
|
IP
|
$63.68
|
|
|
Service Code
|
HCPCS 84402
|
| Hospital Charge Code |
40609119
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$25.47
|
|
|
TESTOSTERONE, FREE+TOTAL LC/MS
|
Facility
|
OP
|
$63.68
|
|
|
Service Code
|
HCPCS 84402
|
| Hospital Charge Code |
40609119
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$47.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$35.02
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$25.47
|
| Rate for Payer: Aetna Government |
$25.47
|
| Rate for Payer: Brighton Health Commercial |
$47.76
|
| Rate for Payer: Cash Price |
$25.47
|
| Rate for Payer: Cash Price |
$25.47
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$25.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$40.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$34.26
|
| Rate for Payer: Elderplan Medicare Advantage |
$25.47
|
| Rate for Payer: EmblemHealth Commercial |
$25.47
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$21.65
|
| Rate for Payer: Fidelis Essential Plan QHP |
$22.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$25.47
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22.67
|
| Rate for Payer: Group Health Inc Commercial |
$25.47
|
| Rate for Payer: Group Health Inc Medicare |
$25.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.84
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$25.47
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.47
|
| Rate for Payer: Healthfirst QHP |
$25.47
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$25.47
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$25.47
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20.38
|
| Rate for Payer: Wellcare Medicare |
$22.92
|
|
|
TESTOSTERONE, TOTAL, LC/MS
|
Facility
|
IP
|
$64.53
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
40609120
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$25.81
|
|
|
TESTOSTERONE, TOTAL, LC/MS
|
Facility
|
OP
|
$64.53
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
40609120
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.65 |
| Max. Negotiated Rate |
$48.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$35.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$25.81
|
| Rate for Payer: Aetna Government |
$25.81
|
| Rate for Payer: Brighton Health Commercial |
$48.40
|
| Rate for Payer: Cash Price |
$25.81
|
| Rate for Payer: Cash Price |
$25.81
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$25.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$41.03
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$34.72
|
| Rate for Payer: Elderplan Medicare Advantage |
$25.81
|
| Rate for Payer: EmblemHealth Commercial |
$25.81
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$21.94
|
| Rate for Payer: Fidelis Essential Plan QHP |
$22.97
|
| Rate for Payer: Fidelis Medicare Advantage |
$25.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22.97
|
| Rate for Payer: Group Health Inc Commercial |
$25.81
|
| Rate for Payer: Group Health Inc Medicare |
$25.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$25.81
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.81
|
| Rate for Payer: Healthfirst QHP |
$25.81
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$25.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$25.81
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20.65
|
| Rate for Payer: Wellcare Medicare |
$23.23
|
|
|
TESTOSTERONE, TOT, LC/MS/MS
|
Facility
|
IP
|
$64.53
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
40608436
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$25.81
|
|
|
TESTOSTERONE, TOT, LC/MS/MS
|
Facility
|
OP
|
$64.53
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
40608436
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.65 |
| Max. Negotiated Rate |
$48.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$35.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$25.81
|
| Rate for Payer: Aetna Government |
$25.81
|
| Rate for Payer: Brighton Health Commercial |
$48.40
|
| Rate for Payer: Cash Price |
$25.81
|
| Rate for Payer: Cash Price |
$25.81
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$25.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$41.03
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$34.72
|
| Rate for Payer: Elderplan Medicare Advantage |
$25.81
|
| Rate for Payer: EmblemHealth Commercial |
$25.81
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$21.94
|
| Rate for Payer: Fidelis Essential Plan QHP |
$22.97
|
| Rate for Payer: Fidelis Medicare Advantage |
$25.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22.97
|
| Rate for Payer: Group Health Inc Commercial |
$25.81
|
| Rate for Payer: Group Health Inc Medicare |
$25.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$25.81
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.81
|
| Rate for Payer: Healthfirst QHP |
$25.81
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$25.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$25.81
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20.65
|
| Rate for Payer: Wellcare Medicare |
$23.23
|
|
|
TEST PREGNANCY ICON 25 COMBO HCG
|
Facility
|
OP
|
$2.12
|
|
| Hospital Charge Code |
64901074
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.06
|
| Rate for Payer: Aetna Government |
$1.06
|
| Rate for Payer: Brighton Health Commercial |
$1.59
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.44
|
| Rate for Payer: Group Health Inc Commercial |
$1.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.06
|
|
|
TEST TO ANALYZE CORNEA SHAPE
|
Facility
|
OP
|
$172.39
|
|
|
Service Code
|
HCPCS 92025
|
| Hospital Charge Code |
30302055
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$56.59 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$94.81
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$70.74
|
| Rate for Payer: Aetna Government |
$70.74
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| 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 |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$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 |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$86.20
|
| 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: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$70.74
|
| Rate for Payer: Senior Whole Health 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
|
|
|
TEST TO ANALYZE CORNEA SHAPE
|
Facility
|
IP
|
$172.39
|
|
|
Service Code
|
HCPCS 92025
|
| Hospital Charge Code |
30302055
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$70.74
|
|
|
TETANUS ANTITOXOID IGG AB
|
Facility
|
IP
|
$37.48
|
|
|
Service Code
|
HCPCS 86317
|
| Hospital Charge Code |
40729339
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$14.99
|
|
|
TETANUS ANTITOXOID IGG AB
|
Facility
|
OP
|
$37.48
|
|
|
Service Code
|
HCPCS 86317
|
| Hospital Charge Code |
40729339
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.99 |
| Max. Negotiated Rate |
$28.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.99
|
| Rate for Payer: Aetna Government |
$14.99
|
| Rate for Payer: Brighton Health Commercial |
$28.11
|
| Rate for Payer: Cash Price |
$14.99
|
| Rate for Payer: Cash Price |
$14.99
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$14.99
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$20.17
|
| Rate for Payer: Elderplan Medicare Advantage |
$14.99
|
| Rate for Payer: EmblemHealth Commercial |
$14.99
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.74
|
| Rate for Payer: Fidelis Essential Plan QHP |
$13.34
|
| Rate for Payer: Fidelis Medicare Advantage |
$14.99
|
| Rate for Payer: Fidelis Qualified Health Plan |
$13.34
|
| Rate for Payer: Group Health Inc Commercial |
$14.99
|
| Rate for Payer: Group Health Inc Medicare |
$14.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.99
|
| Rate for Payer: Healthfirst Medicare Advantage |
$14.99
|
| Rate for Payer: Healthfirst QHP |
$14.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$14.99
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.99
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$11.99
|
| Rate for Payer: Wellcare Medicare |
$13.49
|
|
|
TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP [41628]
|
Facility
|
OP
|
$113.90
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
49281040020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.80 |
| Max. Negotiated Rate |
$91.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$62.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$35.80
|
| Rate for Payer: Aetna Government |
$35.80
|
| Rate for Payer: Brighton Health Commercial |
$85.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$91.12
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$77.45
|
| Rate for Payer: Group Health Inc Commercial |
$56.95
|
| Rate for Payer: Group Health Inc Medicare |
$39.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$56.95
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$39.09
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$41.43
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$41.43
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$41.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$74.03
|
|
|
TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP [41628]
|
Facility
|
OP
|
$113.89
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
49281040010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.80 |
| Max. Negotiated Rate |
$91.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$62.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$35.80
|
| Rate for Payer: Aetna Government |
$35.80
|
| Rate for Payer: Brighton Health Commercial |
$85.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$91.11
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$77.45
|
| Rate for Payer: Group Health Inc Commercial |
$56.95
|
| Rate for Payer: Group Health Inc Medicare |
$39.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$56.95
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$39.09
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$41.43
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$41.43
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$41.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$74.03
|
|
|
TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSP [41293]
|
Facility
|
OP
|
$112.84
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
58160084211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.80 |
| Max. Negotiated Rate |
$90.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$62.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$35.80
|
| Rate for Payer: Aetna Government |
$35.80
|
| Rate for Payer: Brighton Health Commercial |
$84.63
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.73
|
| Rate for Payer: Group Health Inc Commercial |
$56.42
|
| Rate for Payer: Group Health Inc Medicare |
$39.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$56.42
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$39.09
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$41.43
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$41.43
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$41.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$73.35
|
|
|
TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSP [41293]
|
Facility
|
OP
|
$112.84
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
58160084201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.80 |
| Max. Negotiated Rate |
$90.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$62.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$35.80
|
| Rate for Payer: Aetna Government |
$35.80
|
| Rate for Payer: Brighton Health Commercial |
$84.63
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.73
|
| Rate for Payer: Group Health Inc Commercial |
$56.42
|
| Rate for Payer: Group Health Inc Medicare |
$39.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$56.42
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$39.09
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$41.43
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$41.43
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$41.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$73.35
|
|
|
TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSY [180683]
|
Facility
|
OP
|
$112.84
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
58160084252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.80 |
| Max. Negotiated Rate |
$90.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$62.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$35.80
|
| Rate for Payer: Aetna Government |
$35.80
|
| Rate for Payer: Brighton Health Commercial |
$84.63
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.73
|
| Rate for Payer: Group Health Inc Commercial |
$56.42
|
| Rate for Payer: Group Health Inc Medicare |
$39.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$56.42
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$39.09
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$41.43
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$41.43
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$41.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$73.35
|
|
|
TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSY [180683]
|
Facility
|
OP
|
$112.84
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
58160084243
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.80 |
| Max. Negotiated Rate |
$90.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$62.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$35.80
|
| Rate for Payer: Aetna Government |
$35.80
|
| Rate for Payer: Brighton Health Commercial |
$84.63
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.73
|
| Rate for Payer: Group Health Inc Commercial |
$56.42
|
| Rate for Payer: Group Health Inc Medicare |
$39.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$56.42
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$39.09
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$41.43
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$41.43
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$41.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$73.35
|
|
