|
TOWEL, O.R., STANDARD
|
Facility
|
OP
|
$1.12
|
|
| Hospital Charge Code |
64901266
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.56
|
| Rate for Payer: Aetna Government |
$0.56
|
| Rate for Payer: Brighton Health Commercial |
$0.84
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.76
|
| Rate for Payer: Group Health Inc Commercial |
$0.56
|
| Rate for Payer: Group Health Inc Medicare |
$0.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.56
|
|
|
TOXOPLASMA AB IGG, CSF
|
Facility
|
OP
|
$35.98
|
|
|
Service Code
|
HCPCS 86777
|
| Hospital Charge Code |
40619181
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$26.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.39
|
| Rate for Payer: Aetna Government |
$14.39
|
| Rate for Payer: Brighton Health Commercial |
$26.98
|
| Rate for Payer: Cash Price |
$14.39
|
| Rate for Payer: Cash Price |
$14.39
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$14.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$22.87
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.35
|
| Rate for Payer: Elderplan Medicare Advantage |
$14.39
|
| Rate for Payer: EmblemHealth Commercial |
$14.39
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.23
|
| Rate for Payer: Fidelis Essential Plan QHP |
$12.81
|
| Rate for Payer: Fidelis Medicare Advantage |
$14.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$12.81
|
| Rate for Payer: Group Health Inc Commercial |
$14.39
|
| Rate for Payer: Group Health Inc Medicare |
$14.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.39
|
| Rate for Payer: Healthfirst Medicare Advantage |
$14.39
|
| Rate for Payer: Healthfirst QHP |
$14.39
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$14.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.39
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$11.51
|
| Rate for Payer: Wellcare Medicare |
$12.95
|
|
|
TOXOPLASMA AB IGG, CSF
|
Facility
|
IP
|
$35.98
|
|
|
Service Code
|
HCPCS 86777
|
| Hospital Charge Code |
40619181
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$14.39
|
|
|
TOXOPLASMA AB IGG, W/IGM
|
Facility
|
IP
|
$35.98
|
|
|
Service Code
|
HCPCS 86777
|
| Hospital Charge Code |
40608069
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$14.39
|
|
|
TOXOPLASMA AB IGG, W/IGM
|
Facility
|
OP
|
$35.98
|
|
|
Service Code
|
HCPCS 86777
|
| Hospital Charge Code |
40608069
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$26.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.39
|
| Rate for Payer: Aetna Government |
$14.39
|
| Rate for Payer: Brighton Health Commercial |
$26.98
|
| Rate for Payer: Cash Price |
$14.39
|
| Rate for Payer: Cash Price |
$14.39
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$14.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$22.87
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.35
|
| Rate for Payer: Elderplan Medicare Advantage |
$14.39
|
| Rate for Payer: EmblemHealth Commercial |
$14.39
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.23
|
| Rate for Payer: Fidelis Essential Plan QHP |
$12.81
|
| Rate for Payer: Fidelis Medicare Advantage |
$14.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$12.81
|
| Rate for Payer: Group Health Inc Commercial |
$14.39
|
| Rate for Payer: Group Health Inc Medicare |
$14.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.39
|
| Rate for Payer: Healthfirst Medicare Advantage |
$14.39
|
| Rate for Payer: Healthfirst QHP |
$14.39
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$14.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.39
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$11.51
|
| Rate for Payer: Wellcare Medicare |
$12.95
|
|
|
TOXOPLASMA GONDII AB,IGM,QN
|
Facility
|
OP
|
$36.03
|
|
|
Service Code
|
HCPCS 86778
|
| Hospital Charge Code |
40619183
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$27.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.82
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.41
|
| Rate for Payer: Aetna Government |
$14.41
|
| Rate for Payer: Brighton Health Commercial |
$27.02
|
| Rate for Payer: Cash Price |
$14.41
|
| Rate for Payer: Cash Price |
$14.41
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$14.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$22.91
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.38
|
| Rate for Payer: Elderplan Medicare Advantage |
$14.41
|
| Rate for Payer: EmblemHealth Commercial |
$14.41
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.25
|
| Rate for Payer: Fidelis Essential Plan QHP |
$12.82
|
| Rate for Payer: Fidelis Medicare Advantage |
$14.41
|
| Rate for Payer: Fidelis Qualified Health Plan |
$12.82
|
| Rate for Payer: Group Health Inc Commercial |
$14.41
|
| Rate for Payer: Group Health Inc Medicare |
$14.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.41
|
| Rate for Payer: Healthfirst Medicare Advantage |
$14.41
|
| Rate for Payer: Healthfirst QHP |
$14.41
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$14.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.41
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$11.53
|
| Rate for Payer: Wellcare Medicare |
$12.97
|
|
|
TOXOPLASMA GONDII AB,IGM,QN
|
Facility
|
IP
|
$36.03
|
|
|
Service Code
|
HCPCS 86778
|
| Hospital Charge Code |
40619183
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$14.41
|
|
|
TOXOPLASMA IGG,REFLEX IGM
|
Facility
|
IP
|
$35.98
|
|
|
Service Code
|
HCPCS 86777
|
| Hospital Charge Code |
40619180
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$14.39
|
|
|
TOXOPLASMA IGG,REFLEX IGM
|
Facility
|
OP
|
$35.98
|
|
|
Service Code
|
HCPCS 86777
|
| Hospital Charge Code |
40619180
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$26.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.39
|
| Rate for Payer: Aetna Government |
$14.39
|
| Rate for Payer: Brighton Health Commercial |
$26.98
|
| Rate for Payer: Cash Price |
$14.39
|
| Rate for Payer: Cash Price |
$14.39
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$14.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$22.87
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$19.35
|
| Rate for Payer: Elderplan Medicare Advantage |
$14.39
|
| Rate for Payer: EmblemHealth Commercial |
$14.39
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.23
|
| Rate for Payer: Fidelis Essential Plan QHP |
$12.81
|
| Rate for Payer: Fidelis Medicare Advantage |
$14.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$12.81
|
| Rate for Payer: Group Health Inc Commercial |
$14.39
|
| Rate for Payer: Group Health Inc Medicare |
$14.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.39
|
| Rate for Payer: Healthfirst Medicare Advantage |
$14.39
|
| Rate for Payer: Healthfirst QHP |
$14.39
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$14.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.39
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$11.51
|
| Rate for Payer: Wellcare Medicare |
$12.95
|
|
|
T PALLIDUM AB (FTA-AB)
|
Facility
|
OP
|
$33.10
|
|
|
Service Code
|
HCPCS 86780
|
| Hospital Charge Code |
40729381
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.59 |
| Max. Negotiated Rate |
$24.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$13.24
|
| Rate for Payer: Aetna Government |
$13.24
|
| Rate for Payer: Brighton Health Commercial |
$24.82
|
| Rate for Payer: Cash Price |
$13.24
|
| Rate for Payer: Cash Price |
$13.24
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$13.24
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$21.05
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.81
|
| Rate for Payer: Elderplan Medicare Advantage |
$13.24
|
| Rate for Payer: EmblemHealth Commercial |
$13.24
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$11.25
|
| Rate for Payer: Fidelis Essential Plan QHP |
$11.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$13.24
|
| Rate for Payer: Fidelis Qualified Health Plan |
$11.78
|
| Rate for Payer: Group Health Inc Commercial |
$13.24
|
| Rate for Payer: Group Health Inc Medicare |
$13.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.24
|
| Rate for Payer: Healthfirst Medicare Advantage |
$13.24
|
| Rate for Payer: Healthfirst QHP |
$13.24
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$13.24
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.24
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$10.59
|
| Rate for Payer: Wellcare Medicare |
$11.92
|
|
|
T PALLIDUM AB (FTA-AB)
|
Facility
|
IP
|
$33.10
|
|
|
Service Code
|
HCPCS 86780
|
| Hospital Charge Code |
40729381
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$13.24
|
|
|
TPN CVP DRESSING SET
|
Facility
|
OP
|
$6.73
|
|
| Hospital Charge Code |
40207593
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$5.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.36
|
| Rate for Payer: Aetna Government |
$3.36
|
| Rate for Payer: Brighton Health Commercial |
$5.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.58
|
| Rate for Payer: Group Health Inc Commercial |
$3.36
|
| Rate for Payer: Group Health Inc Medicare |
$2.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.36
|
|
|
TPN INFUSION
|
Facility
|
OP
|
$181.00
|
|
| Hospital Charge Code |
41651551
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$144.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$99.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$90.50
|
| Rate for Payer: Aetna Government |
$90.50
|
| Rate for Payer: Brighton Health Commercial |
$135.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$144.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$123.08
|
| Rate for Payer: Group Health Inc Commercial |
$90.50
|
| Rate for Payer: Group Health Inc Medicare |
$63.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$90.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$90.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$117.65
|
|
|
TPN INFUSION
|
Facility
|
OP
|
$181.00
|
|
| Hospital Charge Code |
41641551
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$144.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$99.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$90.50
|
| Rate for Payer: Aetna Government |
$90.50
|
| Rate for Payer: Brighton Health Commercial |
$135.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$144.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$123.08
|
| Rate for Payer: Group Health Inc Commercial |
$90.50
|
| Rate for Payer: Group Health Inc Medicare |
$63.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$90.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$90.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$117.65
|
|
|
TPN INFUSION NEONATAL
|
Facility
|
OP
|
$386.00
|
|
| Hospital Charge Code |
41650007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$135.10 |
| Max. Negotiated Rate |
$308.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$212.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$193.00
|
| Rate for Payer: Aetna Government |
$193.00
|
| Rate for Payer: Brighton Health Commercial |
$289.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$308.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$262.48
|
| Rate for Payer: Group Health Inc Commercial |
$193.00
|
| Rate for Payer: Group Health Inc Medicare |
$135.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$193.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$193.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$250.90
|
|
|
TPN INFUSION NEONATAL
|
Facility
|
OP
|
$386.00
|
|
| Hospital Charge Code |
41640007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$135.10 |
| Max. Negotiated Rate |
$308.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$212.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$193.00
|
| Rate for Payer: Aetna Government |
$193.00
|
| Rate for Payer: Brighton Health Commercial |
$289.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$308.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$262.48
|
| Rate for Payer: Group Health Inc Commercial |
$193.00
|
| Rate for Payer: Group Health Inc Medicare |
$135.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$193.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$193.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$250.90
|
|
|
TRABECULAR CENT CONE X-SM
|
Facility
|
OP
|
$12,812.50
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
64907526
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,484.38 |
| Max. Negotiated Rate |
$13,453.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7,046.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,406.25
|
| Rate for Payer: Aetna Government |
$6,406.25
|
| Rate for Payer: Brighton Health Commercial |
$7,687.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6,406.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7,367.19
|
| Rate for Payer: EmblemHealth Commercial |
$6,406.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$13,453.12
|
| Rate for Payer: Group Health Inc Commercial |
$6,406.25
|
| Rate for Payer: Group Health Inc Medicare |
$4,484.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6,406.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,406.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,328.12
|
|
|
TRABECULAR CENT CONE X-SM
|
Facility
|
IP
|
$12,812.50
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
64907526
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,406.25 |
| Max. Negotiated Rate |
$6,406.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6,406.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,406.25
|
|
|
TRABECULAR METAL MONOBLOCK TIBIAL
|
Facility
|
OP
|
$8,824.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40206096
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$9,265.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,853.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$5,294.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,412.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5,073.80
|
| Rate for Payer: EmblemHealth Commercial |
$4,412.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$9,265.20
|
| Rate for Payer: Group Health Inc Commercial |
$4,412.00
|
| Rate for Payer: Group Health Inc Medicare |
$3,088.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,412.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,412.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5,735.60
|
|
|
TRABECULAR METAL MONOBLOCK TIBIAL
|
Facility
|
IP
|
$8,824.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40206096
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,412.00 |
| Max. Negotiated Rate |
$4,412.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,412.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,412.00
|
|
|
TRABECULAR MTL MONOBLOCK PATELLA
|
Facility
|
IP
|
$3,171.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40209917
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,585.60 |
| Max. Negotiated Rate |
$1,585.60 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,585.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,585.60
|
|
|
TRABECULAR MTL MONOBLOCK PATELLA
|
Facility
|
OP
|
$3,171.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40209917
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$3,329.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,744.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$1,902.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,585.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,823.44
|
| Rate for Payer: EmblemHealth Commercial |
$1,585.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,329.76
|
| Rate for Payer: Group Health Inc Commercial |
$1,585.60
|
| Rate for Payer: Group Health Inc Medicare |
$1,109.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,585.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,585.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,061.28
|
|
|
TRAB METAL ST PR 7 10MM
|
Facility
|
OP
|
$9,710.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$10,195.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,340.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$5,826.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,855.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5,583.25
|
| Rate for Payer: EmblemHealth Commercial |
$4,855.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$10,195.50
|
| Rate for Payer: Group Health Inc Commercial |
$4,855.00
|
| Rate for Payer: Group Health Inc Medicare |
$3,398.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,855.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,855.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,311.50
|
|
|
TRAB METAL ST PR 7 10MM
|
Facility
|
IP
|
$9,710.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,855.00 |
| Max. Negotiated Rate |
$4,855.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,855.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,855.00
|
|
|
TRAB MTL MNBLCK TIB COMPONENT SZ4
|
Facility
|
OP
|
$7,768.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40200051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$8,156.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,272.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$4,660.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,884.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4,466.60
|
| Rate for Payer: EmblemHealth Commercial |
$3,884.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$8,156.40
|
| Rate for Payer: Group Health Inc Commercial |
$3,884.00
|
| Rate for Payer: Group Health Inc Medicare |
$2,718.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,884.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,884.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5,049.20
|
|
