|
TMJ ARTHROCENTESIS
|
Facility
|
OP
|
$786.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
30302001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$233.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$342.51
|
| Rate for Payer: Aetna Government |
$342.51
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$342.51
|
| 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 |
$342.51
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$291.13
|
| Rate for Payer: Fidelis Essential Plan QHP |
$304.83
|
| Rate for Payer: Fidelis Medicare Advantage |
$342.51
|
| Rate for Payer: Fidelis Qualified Health Plan |
$304.83
|
| 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 |
$393.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$342.51
|
| Rate for Payer: Healthfirst Medicare Advantage |
$291.13
|
| Rate for Payer: Healthfirst QHP |
$342.51
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$342.51
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$342.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$342.51
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$274.01
|
| Rate for Payer: Wellcare Medicare |
$325.38
|
|
|
TMJ ARTHROCENTESIS
|
Facility
|
OP
|
$786.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
40029631
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$274.01 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$342.51
|
| Rate for Payer: Aetna Government |
$342.51
|
| Rate for Payer: Brighton Health Commercial |
$589.50
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$342.51
|
| 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 |
$342.51
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$291.13
|
| Rate for Payer: Fidelis Essential Plan QHP |
$304.83
|
| Rate for Payer: Fidelis Medicare Advantage |
$342.51
|
| Rate for Payer: Fidelis Qualified Health Plan |
$304.83
|
| Rate for Payer: Group Health Inc Commercial |
$342.51
|
| Rate for Payer: Group Health Inc Medicare |
$342.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$393.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$342.51
|
| Rate for Payer: Healthfirst Medicare Advantage |
$291.13
|
| Rate for Payer: Healthfirst QHP |
$342.51
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$342.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$342.51
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$274.01
|
| Rate for Payer: Wellcare Medicare |
$325.38
|
|
|
TMJ ARTHROCENTESIS
|
Facility
|
IP
|
$786.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
40029631
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$342.51
|
|
|
TMJ ARTHROCENTESIS
|
Facility
|
OP
|
$786.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
30103025
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$342.51
|
| Rate for Payer: Aetna Government |
$342.51
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$342.51
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$342.51
|
| 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 |
$342.51
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$291.13
|
| Rate for Payer: Fidelis Essential Plan QHP |
$304.83
|
| Rate for Payer: Fidelis Medicare Advantage |
$342.51
|
| Rate for Payer: Fidelis Qualified Health Plan |
$304.83
|
| 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 |
$393.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$342.51
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$342.51
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$342.51
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$342.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$342.51
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$274.01
|
| Rate for Payer: Wellcare Medicare |
$325.38
|
|
|
TMJ ARTHROCENTESIS
|
Facility
|
IP
|
$786.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
30302001
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$342.51
|
|
|
TMJ ARTHROCENTESIS
|
Facility
|
IP
|
$786.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
30103025
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$342.51
|
|
|
TMJ ARTHROGRAM, INCLUDING INJECTI
|
Facility
|
IP
|
$435.00
|
|
|
Service Code
|
HCPCS D0320
|
| Hospital Charge Code |
42300170
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$283.37
|
|
|
TMJ ARTHROGRAM, INCLUDING INJECTI
|
Facility
|
OP
|
$435.00
|
|
|
Service Code
|
HCPCS D0320
|
| Hospital Charge Code |
42300170
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$217.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$239.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$283.37
|
| Rate for Payer: Aetna Government |
$283.37
|
| Rate for Payer: Brighton Health Commercial |
$326.25
|
| Rate for Payer: Cash Price |
$283.37
|
| Rate for Payer: Cash Price |
$283.37
|
| Rate for Payer: Cash Price |
$283.37
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$283.37
|
| 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 |
$283.37
|
| Rate for Payer: EmblemHealth Commercial |
$283.37
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$240.86
|
| Rate for Payer: Fidelis Essential Plan QHP |
$252.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$283.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$252.20
|
| Rate for Payer: Group Health Inc Commercial |
$283.37
|
| Rate for Payer: Group Health Inc Medicare |
$283.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$217.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$283.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$240.86
|
| Rate for Payer: Healthfirst QHP |
$283.37
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$283.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$283.37
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$226.70
|
| Rate for Payer: Wellcare Medicare |
$269.20
|
|
|
TMJ ARTHROSC LAT RELEASE
|
Facility
|
OP
|
$8,291.05
|
|
|
Service Code
|
HCPCS 29804
|
| Hospital Charge Code |
40029630
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$6,218.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,743.15
|
| Rate for Payer: Aetna Government |
$3,743.15
|
| 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 |
$1,505.00
|
| 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: Senior Whole Health 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
|
|
|
TMJ ARTHROSC LAT RELEASE
|
Facility
|
IP
|
$8,291.05
|
|
|
Service Code
|
HCPCS 29804
|
| Hospital Charge Code |
40029630
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$3,743.15
|
|
|
TOBACCO CESS >10 MIN
|
Facility
|
IP
|
$82.75
|
|
|
Service Code
|
HCPCS 99407
|
| Hospital Charge Code |
30400125
|
|
Hospital Revenue Code
|
942
|
| Rate for Payer: Cash Price |
$33.18
|
|
|
TOBACCO CESS >10 MIN
|
Facility
|
OP
|
$82.75
|
|
|
Service Code
|
HCPCS 99407
|
| Hospital Charge Code |
30400125
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$26.54 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$45.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$33.18
|
| Rate for Payer: Aetna Government |
$33.18
|
| Rate for Payer: Brighton Health Commercial |
$62.06
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$33.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$66.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$56.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$28.20
|
| Rate for Payer: Fidelis Essential Plan QHP |
$29.53
|
| Rate for Payer: Fidelis Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$29.53
|
| 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 |
$41.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$33.18
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.20
|
| Rate for Payer: Healthfirst QHP |
$33.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$33.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$33.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.54
|
| Rate for Payer: Wellcare Medicare |
$31.52
|
|
|
TOBACCO CESS,>10 MIN
|
Facility
|
OP
|
$82.75
|
|
|
Service Code
|
HCPCS 99407
|
| Hospital Charge Code |
30301260
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$26.54 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$45.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$33.18
|
| Rate for Payer: Aetna Government |
$33.18
|
| Rate for Payer: Brighton Health Commercial |
$62.06
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$33.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$66.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$56.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$28.20
|
| Rate for Payer: Fidelis Essential Plan QHP |
$29.53
|
| Rate for Payer: Fidelis Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$29.53
|
| 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 |
$41.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$33.18
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.20
|
| Rate for Payer: Healthfirst QHP |
$33.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$33.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$33.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.54
|
| Rate for Payer: Wellcare Medicare |
$31.52
|
|
|
TOBACCO CESS,>10 MIN
|
Facility
|
IP
|
$82.75
|
|
|
Service Code
|
HCPCS 99407
|
| Hospital Charge Code |
30301260
|
|
Hospital Revenue Code
|
942
|
| Rate for Payer: Cash Price |
$33.18
|
|
|
TOBACCO CESS>10 MIN
|
Facility
|
IP
|
$82.75
|
|
|
Service Code
|
HCPCS 99407
|
| Hospital Charge Code |
32401260
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$33.18
|
|
|
TOBACCO CESS>10 MIN
|
Facility
|
OP
|
$82.75
|
|
|
Service Code
|
HCPCS 99407
|
| Hospital Charge Code |
32401260
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.54 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$45.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$33.18
|
| Rate for Payer: Aetna Government |
$33.18
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$33.18
|
| 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 |
$33.18
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$28.20
|
| Rate for Payer: Fidelis Essential Plan QHP |
$29.53
|
| Rate for Payer: Fidelis Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$29.53
|
| 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 |
$41.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$33.18
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.20
|
| Rate for Payer: Healthfirst QHP |
$33.18
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$33.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$33.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$33.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.54
|
| Rate for Payer: Wellcare Medicare |
$31.52
|
|
|
TOBACCO COUN. & PREV. OF ORAL DIS
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS D1320
|
| Hospital Charge Code |
42303280
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$13.72
|
| Rate for Payer: Aetna Government |
$13.72
|
| Rate for Payer: Brighton Health Commercial |
$18.75
|
| 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 |
$12.50
|
| Rate for Payer: Group Health Inc Medicare |
$8.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.50
|
|
|
TOBACCO NON-USER
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 1036F
|
| Hospital Charge Code |
30307887
|
|
Hospital Revenue Code
|
969
|
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$0.01
|
| 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 |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
TOBRAMYCIN 0.3% OPHTHALMIC OINT 3.5 GRAM
|
Facility
|
OP
|
$125.00
|
|
| Hospital Charge Code |
41640610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$68.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$62.50
|
| Rate for Payer: Aetna Government |
$62.50
|
| Rate for Payer: Brighton Health Commercial |
$93.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$100.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$85.00
|
| Rate for Payer: Group Health Inc Commercial |
$62.50
|
| Rate for Payer: Group Health Inc Medicare |
$43.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$62.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$62.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$81.25
|
|
|
TOBRAMYCIN 0.3% OPHTHALMIC OINT 3.5 GRAM
|
Facility
|
OP
|
$125.00
|
|
| Hospital Charge Code |
41650610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$68.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$62.50
|
| Rate for Payer: Aetna Government |
$62.50
|
| Rate for Payer: Brighton Health Commercial |
$93.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$100.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$85.00
|
| Rate for Payer: Group Health Inc Commercial |
$62.50
|
| Rate for Payer: Group Health Inc Medicare |
$43.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$62.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$62.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$81.25
|
|
|
TOBRAMYCIN 0.3% OPHTHALMIC SOLN
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
41640461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.00
|
| Rate for Payer: Aetna Government |
$1.00
|
| Rate for Payer: Brighton Health Commercial |
$1.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.36
|
| Rate for Payer: Group Health Inc Commercial |
$1.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.30
|
|
|
TOBRAMYCIN 0.3% OPHTHALMIC SOLN
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
41650461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.00
|
| Rate for Payer: Aetna Government |
$1.00
|
| Rate for Payer: Brighton Health Commercial |
$1.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.36
|
| Rate for Payer: Group Health Inc Commercial |
$1.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.30
|
|
|
TOBRAMYCIN 0.3 % OP OINT [125508]
|
Facility
|
OP
|
$73.49
|
|
|
Service Code
|
NDC 00065064435
|
| Hospital Charge Code |
00065064435
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.72 |
| Max. Negotiated Rate |
$58.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$40.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$36.75
|
| Rate for Payer: Aetna Government |
$36.75
|
| Rate for Payer: Brighton Health Commercial |
$55.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$58.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$49.98
|
| Rate for Payer: Group Health Inc Commercial |
$36.75
|
| Rate for Payer: Group Health Inc Medicare |
$25.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$36.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$36.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$47.77
|
|
|
TOBRAMYCIN 0.3 % OP OINT [125508]
|
Facility
|
OP
|
$87.35
|
|
|
Service Code
|
NDC 00078081301
|
| Hospital Charge Code |
00078081301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.57 |
| Max. Negotiated Rate |
$69.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$48.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$43.68
|
| Rate for Payer: Aetna Government |
$43.68
|
| Rate for Payer: Brighton Health Commercial |
$65.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$69.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$59.40
|
| Rate for Payer: Group Health Inc Commercial |
$43.68
|
| Rate for Payer: Group Health Inc Medicare |
$30.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$43.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$43.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$56.78
|
|
|
TOBRAMYCIN 0.3 % OP SOLN [124422]
|
Facility
|
OP
|
$1.25
|
|
|
Service Code
|
NDC 70069013101
|
| Hospital Charge Code |
70069013101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.69
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.63
|
| Rate for Payer: Aetna Government |
$0.63
|
| Rate for Payer: Brighton Health Commercial |
$0.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.85
|
| Rate for Payer: Group Health Inc Commercial |
$0.63
|
| Rate for Payer: Group Health Inc Medicare |
$0.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.63
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.63
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.81
|
|
