|
THEOPHYLLINE ER 300MG CAP
|
Facility
|
OP
|
$6.83
|
|
| Hospital Charge Code |
41656622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$5.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.76
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.42
|
| Rate for Payer: Aetna Government |
$3.42
|
| Rate for Payer: Brighton Health Commercial |
$5.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.64
|
| Rate for Payer: Group Health Inc Commercial |
$3.42
|
| Rate for Payer: Group Health Inc Medicare |
$2.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.44
|
|
|
THEOPHYLLINE ER 300 MG PO CP24 [27421]
|
Facility
|
OP
|
$7.72
|
|
|
Service Code
|
NDC 52244030010
|
| Hospital Charge Code |
52244030010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$6.17 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.86
|
| Rate for Payer: Aetna Government |
$3.86
|
| Rate for Payer: Brighton Health Commercial |
$5.79
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.25
|
| Rate for Payer: Group Health Inc Commercial |
$3.86
|
| Rate for Payer: Group Health Inc Medicare |
$2.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.86
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.02
|
|
|
THEOPHYLLINE ER 300 MG PO TB12 [12098]
|
Facility
|
OP
|
$4.30
|
|
|
Service Code
|
NDC 62332002531
|
| Hospital Charge Code |
62332002531
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.36
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.15
|
| Rate for Payer: Aetna Government |
$2.15
|
| Rate for Payer: Brighton Health Commercial |
$3.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.92
|
| Rate for Payer: Group Health Inc Commercial |
$2.15
|
| Rate for Payer: Group Health Inc Medicare |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.79
|
|
|
THERABITE JAW MOTION REHAB SYSTEM
|
Facility
|
OP
|
$712.50
|
|
| Hospital Charge Code |
64904609
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$249.38 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$391.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$356.25
|
| Rate for Payer: Aetna Government |
$356.25
|
| Rate for Payer: Brighton Health Commercial |
$534.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$570.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$484.50
|
| Rate for Payer: Group Health Inc Commercial |
$356.25
|
| Rate for Payer: Group Health Inc Medicare |
$249.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$356.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$356.25
|
|
|
THERA M PLUS PO TABS [37053]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 00904549261
|
| Hospital Charge Code |
00904549261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.03
|
| Rate for Payer: Aetna Government |
$0.03
|
| Rate for Payer: Brighton Health Commercial |
$0.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.05
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.04
|
| Rate for Payer: Group Health Inc Commercial |
$0.03
|
| Rate for Payer: Group Health Inc Medicare |
$0.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.03
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.04
|
|
|
THERA,PAR DRUGS 2 OR >ADMIN
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
HCPCS D9612
|
| Hospital Charge Code |
42300754
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$14.47 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$110.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.47
|
| Rate for Payer: Aetna Government |
$14.47
|
| Rate for Payer: Brighton Health Commercial |
$150.00
|
| 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 |
$100.00
|
| Rate for Payer: Group Health Inc Medicare |
$70.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$100.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$100.00
|
|
|
THERAPEUTIC APHERESIS
|
Facility
|
OP
|
$4,008.93
|
|
|
Service Code
|
HCPCS 36511
|
| Hospital Charge Code |
40701199
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,412.00 |
| Max. Negotiated Rate |
$3,006.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,774.33
|
| Rate for Payer: Aetna Government |
$1,774.33
|
| Rate for Payer: Brighton Health Commercial |
$3,006.70
|
| Rate for Payer: Cash Price |
$1,774.33
|
| Rate for Payer: Cash Price |
$1,774.33
|
| Rate for Payer: Cash Price |
$1,774.33
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,774.33
|
| 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 |
$1,774.33
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,508.18
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,579.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,774.33
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,579.15
|
| Rate for Payer: Group Health Inc Commercial |
$1,774.33
|
| Rate for Payer: Group Health Inc Medicare |
$1,774.33
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,004.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,774.33
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,508.18
|
| Rate for Payer: Healthfirst QHP |
$1,774.33
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,774.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,774.33
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,419.46
|
| Rate for Payer: Wellcare Medicare |
$1,685.61
|
|
|
THERAPEUTIC APHERESIS
|
Facility
|
IP
|
$4,008.93
|
|
|
Service Code
|
HCPCS 36511
|
| Hospital Charge Code |
40701199
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$1,774.33
|
|
|
THERAPEUTIC APHERESIS FOR PLASMA
|
Facility
|
OP
|
$4,008.93
|
|
|
Service Code
|
HCPCS 36514
|
| Hospital Charge Code |
30301510
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$233.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,774.33
|
| Rate for Payer: Aetna Government |
$1,774.33
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$1,774.33
|
| Rate for Payer: Cash Price |
$1,774.33
|
| Rate for Payer: Cash Price |
$1,774.33
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,774.33
|
| 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 |
$1,774.33
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,508.18
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,579.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,774.33
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,579.15
|
| 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 |
$2,004.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,774.33
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,508.18
|
| Rate for Payer: Healthfirst QHP |
$1,774.33
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,774.33
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,774.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,774.33
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,419.46
|
| Rate for Payer: Wellcare Medicare |
$1,685.61
|
|
|
THERAPEUTIC APHERESIS FOR PLASMA
|
Facility
|
IP
|
$4,008.93
|
|
|
Service Code
|
HCPCS 36514
|
| Hospital Charge Code |
30301510
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$1,774.33
|
|
|
THERAPEUTIC BEHAVIORAL SERVICES
|
Facility
|
OP
|
$250.63
|
|
|
Service Code
|
HCPCS H2020
|
| Hospital Charge Code |
30302057
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$31.36 |
| Max. Negotiated Rate |
$200.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$137.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$31.36
|
| Rate for Payer: Aetna Government |
$31.36
|
| Rate for Payer: Brighton Health Commercial |
$187.97
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$200.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$170.43
|
| Rate for Payer: Group Health Inc Commercial |
$125.32
|
| Rate for Payer: Group Health Inc Medicare |
$87.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$125.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$125.32
|
|
|
THERAPEUTIC DRUG INJECTION, BY RE
|
Facility
|
OP
|
$37.50
|
|
|
Service Code
|
HCPCS D9610
|
| Hospital Charge Code |
42302355
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$13.12 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.47
|
| Rate for Payer: Aetna Government |
$14.47
|
| Rate for Payer: Brighton Health Commercial |
$28.12
|
| 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 |
$18.75
|
| Rate for Payer: Group Health Inc Medicare |
$13.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.75
|
|
|
THERAPEUTIC EXERCISE-GROUP
|
Facility
|
OP
|
$52.88
|
|
|
Service Code
|
HCPCS 97150
|
| Hospital Charge Code |
41701004
|
|
Hospital Revenue Code
|
429
|
| Min. Negotiated Rate |
$10.34 |
| Max. Negotiated Rate |
$182.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$29.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.34
|
| Rate for Payer: Aetna Government |
$10.34
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Group Health Inc Commercial |
$26.44
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.44
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
THERAPEUTIC IM
|
Facility
|
IP
|
$183.15
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
30103280
|
|
Hospital Revenue Code
|
260
|
| Rate for Payer: Cash Price |
$81.46
|
|
|
THERAPEUTIC IM
|
Facility
|
OP
|
$183.15
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
30103280
|
|
Hospital Revenue Code
|
260
|
| 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: 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: 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: 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: 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
|
|
|
THERAPEUTIC INFUSION
|
Facility
|
OP
|
$556.50
|
|
|
Service Code
|
HCPCS 96360
|
| Hospital Charge Code |
40509874
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$198.30 |
| Max. Negotiated Rate |
$445.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$306.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$247.87
|
| Rate for Payer: Aetna Government |
$247.87
|
| Rate for Payer: Brighton Health Commercial |
$417.38
|
| Rate for Payer: Cash Price |
$247.87
|
| Rate for Payer: Cash Price |
$247.87
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$247.87
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$445.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$378.42
|
| Rate for Payer: Elderplan Medicare Advantage |
$247.87
|
| Rate for Payer: EmblemHealth Commercial |
$247.87
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$210.69
|
| Rate for Payer: Fidelis Essential Plan QHP |
$220.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$247.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$220.60
|
| Rate for Payer: Group Health Inc Commercial |
$247.87
|
| Rate for Payer: Group Health Inc Medicare |
$247.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$278.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$247.87
|
| Rate for Payer: Healthfirst Medicare Advantage |
$210.69
|
| Rate for Payer: Healthfirst QHP |
$247.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$247.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$247.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$198.30
|
| Rate for Payer: Wellcare Medicare |
$235.48
|
|
|
THERAPEUTIC INFUSION
|
Facility
|
IP
|
$556.50
|
|
|
Service Code
|
HCPCS 96360
|
| Hospital Charge Code |
40509874
|
|
Hospital Revenue Code
|
260
|
| Rate for Payer: Cash Price |
$247.87
|
|
|
THERAPEUTIC INJECTION IM/SQ
|
Facility
|
OP
|
$183.15
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
40509863
|
|
Hospital Revenue Code
|
260
|
| 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: 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: 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: 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: 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
|
|
|
THERAPEUTIC INJECTION IM/SQ
|
Facility
|
IP
|
$183.15
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
40509863
|
|
Hospital Revenue Code
|
260
|
| Rate for Payer: Cash Price |
$81.46
|
|
|
THERAPEUTIC PULPOTOMY (EXCLUDING
|
Facility
|
OP
|
$217.50
|
|
|
Service Code
|
HCPCS D3220
|
| Hospital Charge Code |
42300705
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$108.75 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$119.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Brighton Health Commercial |
$163.12
|
| 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 |
$108.75
|
| 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: Senior Whole Health 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
|
|
|
THERAPEUTIC PULPOTOMY (EXCLUDING
|
Facility
|
IP
|
$217.50
|
|
|
Service Code
|
HCPCS D3220
|
| Hospital Charge Code |
42300705
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
THERA PULSE II BED
|
Facility
|
OP
|
$200.00
|
|
| Hospital Charge Code |
40209309
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$160.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$110.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$100.00
|
| Rate for Payer: Aetna Government |
$100.00
|
| Rate for Payer: Brighton Health Commercial |
$150.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$160.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$136.00
|
| Rate for Payer: Group Health Inc Commercial |
$100.00
|
| Rate for Payer: Group Health Inc Medicare |
$70.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$100.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$100.00
|
|
|
THERAPY FOR CONTOUR DEFECTS
|
Facility
|
OP
|
$1,505.35
|
|
|
Service Code
|
HCPCS 11952
|
| Hospital Charge Code |
42201111
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$342.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$726.29
|
| Rate for Payer: Aetna Government |
$726.29
|
| Rate for Payer: Brighton Health Commercial |
$1,129.01
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$726.29
|
| 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 |
$726.29
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$617.35
|
| Rate for Payer: Fidelis Essential Plan QHP |
$646.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$726.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$646.40
|
| Rate for Payer: Group Health Inc Commercial |
$726.29
|
| Rate for Payer: Group Health Inc Medicare |
$726.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$752.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$726.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$617.35
|
| Rate for Payer: Healthfirst QHP |
$726.29
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$726.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$726.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$581.03
|
| Rate for Payer: Wellcare Medicare |
$689.98
|
|
|
THERAPY FOR CONTOUR DEFECTS
|
Facility
|
IP
|
$1,505.35
|
|
|
Service Code
|
HCPCS 11952
|
| Hospital Charge Code |
42201111
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$726.29
|
|
|
THERAPY FOR CONTOUR DEFECTS >10CC
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 11954
|
| Hospital Charge Code |
42201700
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$342.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$726.29
|
| Rate for Payer: Aetna Government |
$726.29
|
| Rate for Payer: Brighton Health Commercial |
$725.80
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$726.29
|
| 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 |
$726.29
|
| Rate for Payer: EmblemHealth Commercial |
$726.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$617.35
|
| Rate for Payer: Fidelis Essential Plan QHP |
$646.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$726.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$646.40
|
| Rate for Payer: Group Health Inc Commercial |
$726.29
|
| Rate for Payer: Group Health Inc Medicare |
$726.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$726.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$617.35
|
| Rate for Payer: Healthfirst QHP |
$726.29
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$726.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$726.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$581.03
|
| Rate for Payer: Wellcare Medicare |
$689.98
|
|
