|
XR LUMBAR SPINE AP/LATERAL
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 72110 TC
|
| Hospital Charge Code |
41102262
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.00 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$151.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$128.48
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$89.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$114.43
|
| Rate for Payer: Group Health Inc Medicare |
$114.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$127.14
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
XR LUMBAR SPINE W/OBLIQUES
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 72110 TC
|
| Hospital Charge Code |
41102446
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
XR LUMBAR SPINE W/OBLIQUES
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 72110 TC
|
| Hospital Charge Code |
41102446
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.00 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$151.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$128.48
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$89.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$114.43
|
| Rate for Payer: Group Health Inc Medicare |
$114.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$127.14
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
XR LUMB. SPINE W/BEND VIEWS
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 72114 TC
|
| Hospital Charge Code |
41102230
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.00 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$151.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$128.48
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$89.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$114.43
|
| Rate for Payer: Group Health Inc Medicare |
$114.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$127.14
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
XR LUMB. SPINE W/BEND VIEWS
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 72114 TC
|
| Hospital Charge Code |
41102230
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
XR LYMPHANG,EXTREMITY ONLY, BIL
|
Facility
|
OP
|
$4,940.28
|
|
|
Service Code
|
HCPCS 75803 TC
|
| Hospital Charge Code |
41107633
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$689.45 |
| Max. Negotiated Rate |
$2,717.15 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,717.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,852.05
|
| Rate for Payer: Aetna Government |
$1,852.05
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,296.44
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,296.44
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,296.44
|
| Rate for Payer: Brighton Health Commercial |
$1,852.05
|
| Rate for Payer: Cash Price |
$1,852.05
|
| Rate for Payer: Cash Price |
$1,852.05
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,852.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$814.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$689.45
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,852.05
|
| Rate for Payer: EmblemHealth Commercial |
$1,296.44
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,574.24
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,574.24
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,648.32
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,852.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,648.32
|
| Rate for Payer: Group Health Inc Commercial |
$1,666.84
|
| Rate for Payer: Group Health Inc Medicare |
$1,666.84
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,470.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,852.05
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,666.84
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,852.05
|
| Rate for Payer: Healthfirst QHP |
$1,852.05
|
| Rate for Payer: Humana Medicare |
$1,889.09
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,852.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,852.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,852.05
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,481.64
|
| Rate for Payer: Wellcare Medicare |
$1,759.45
|
|
|
XR LYMPHANG,EXTREMITY ONLY, BIL
|
Facility
|
IP
|
$4,940.28
|
|
|
Service Code
|
HCPCS 75803 TC
|
| Hospital Charge Code |
41107633
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$1,852.05
|
|
|
XR LYMPHANG,PELVIC/ABD, BIL
|
Facility
|
OP
|
$8,393.53
|
|
|
Service Code
|
HCPCS 75807 TC
|
| Hospital Charge Code |
41107637
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$689.45 |
| Max. Negotiated Rate |
$4,616.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,616.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,686.08
|
| Rate for Payer: Aetna Government |
$3,686.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,580.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,580.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,580.26
|
| Rate for Payer: Brighton Health Commercial |
$3,686.08
|
| Rate for Payer: Cash Price |
$3,686.08
|
| Rate for Payer: Cash Price |
$3,686.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,686.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$814.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$689.45
|
| Rate for Payer: Elderplan Medicare Advantage |
$3,686.08
|
| Rate for Payer: EmblemHealth Commercial |
$2,580.26
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3,133.17
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,133.17
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,280.61
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,686.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,280.61
|
| Rate for Payer: Group Health Inc Commercial |
$3,317.47
|
| Rate for Payer: Group Health Inc Medicare |
$3,317.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,196.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,686.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,317.47
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,686.08
|
| Rate for Payer: Healthfirst QHP |
$3,686.08
|
| Rate for Payer: Humana Medicare |
$3,759.80
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,686.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,686.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,686.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,948.86
|
| Rate for Payer: Wellcare Medicare |
$3,501.78
|
|
|
XR LYMPHANG,PELVIC/ABD, BIL
|
Facility
|
IP
|
$8,393.53
|
|
|
Service Code
|
HCPCS 75807 TC
|
| Hospital Charge Code |
41107637
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$3,686.08
|
|
|
XR MANDIBLE COMPLETE
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 70110 TC
|
| Hospital Charge Code |
41102166
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$76.27 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$89.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$114.43
|
| Rate for Payer: Group Health Inc Medicare |
$114.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$127.14
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
XR MANDIBLE COMPLETE
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 70110 TC
|
| Hospital Charge Code |
41102166
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
XR MANDIBLE LIMITED
|
Facility
|
IP
|
$241.73
|
|
|
Service Code
|
HCPCS 70100 TC
|
| Hospital Charge Code |
41102398
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$105.08
|
|
|
XR MANDIBLE LIMITED
|
Facility
|
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 70100 TC
|
| Hospital Charge Code |
41102398
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$73.56 |
| Max. Negotiated Rate |
$132.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$105.08
|
| Rate for Payer: Aetna Government |
$105.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$73.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$73.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$73.56
|
| Rate for Payer: Brighton Health Commercial |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$105.08
|
| Rate for Payer: EmblemHealth Commercial |
$73.56
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$89.32
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$89.32
|
| Rate for Payer: Fidelis Essential Plan QHP |
$93.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$105.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$93.52
|
| Rate for Payer: Group Health Inc Commercial |
$94.57
|
| Rate for Payer: Group Health Inc Medicare |
$94.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$105.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$94.57
|
| Rate for Payer: Healthfirst Medicare Advantage |
$105.08
|
| Rate for Payer: Healthfirst QHP |
$105.08
|
| Rate for Payer: Humana Medicare |
$107.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$105.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$105.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$105.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$84.06
|
| Rate for Payer: Wellcare Medicare |
$99.83
|
|
|
XR MASTOIDS COMPLETE
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 70130 TC
|
| Hospital Charge Code |
41102168
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$76.27 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$89.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$114.43
|
| Rate for Payer: Group Health Inc Medicare |
$114.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$127.14
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
XR MASTOIDS COMPLETE
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 70130 TC
|
| Hospital Charge Code |
41102168
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
XR MASTOIDS LIMITED
|
Facility
|
IP
|
$339.45
|
|
|
Service Code
|
HCPCS 70120 TC
|
| Hospital Charge Code |
41102400
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
XR MASTOIDS LIMITED
|
Facility
|
OP
|
$339.45
|
|
|
Service Code
|
HCPCS 70120 TC
|
| Hospital Charge Code |
41102400
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$76.27 |
| Max. Negotiated Rate |
$186.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$186.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$89.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$114.43
|
| Rate for Payer: Group Health Inc Medicare |
$114.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$169.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$127.14
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
XR NASAL BONES
|
Facility
|
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 70160 TC
|
| Hospital Charge Code |
41102172
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$73.56 |
| Max. Negotiated Rate |
$132.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$105.08
|
| Rate for Payer: Aetna Government |
$105.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$73.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$73.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$73.56
|
| Rate for Payer: Brighton Health Commercial |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$105.08
|
| Rate for Payer: EmblemHealth Commercial |
$73.56
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$89.32
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$89.32
|
| Rate for Payer: Fidelis Essential Plan QHP |
$93.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$105.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$93.52
|
| Rate for Payer: Group Health Inc Commercial |
$94.57
|
| Rate for Payer: Group Health Inc Medicare |
$94.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$105.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$94.57
|
| Rate for Payer: Healthfirst Medicare Advantage |
$105.08
|
| Rate for Payer: Healthfirst QHP |
$105.08
|
| Rate for Payer: Humana Medicare |
$107.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$105.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$105.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$105.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$84.06
|
| Rate for Payer: Wellcare Medicare |
$99.83
|
|
|
XR NASAL BONES
|
Facility
|
IP
|
$241.73
|
|
|
Service Code
|
HCPCS 70160 TC
|
| Hospital Charge Code |
41102172
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$105.08
|
|
|
XR OPTIC FERAMINA
|
Facility
|
IP
|
$241.73
|
|
|
Service Code
|
HCPCS 70190 TC
|
| Hospital Charge Code |
41102176
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$105.08
|
|
|
XR OPTIC FERAMINA
|
Facility
|
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 70190 TC
|
| Hospital Charge Code |
41102176
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$73.56 |
| Max. Negotiated Rate |
$132.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$105.08
|
| Rate for Payer: Aetna Government |
$105.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$73.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$73.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$73.56
|
| Rate for Payer: Brighton Health Commercial |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$105.08
|
| Rate for Payer: EmblemHealth Commercial |
$73.56
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$89.32
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$89.32
|
| Rate for Payer: Fidelis Essential Plan QHP |
$93.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$105.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$93.52
|
| Rate for Payer: Group Health Inc Commercial |
$94.57
|
| Rate for Payer: Group Health Inc Medicare |
$94.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$105.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$94.57
|
| Rate for Payer: Healthfirst Medicare Advantage |
$105.08
|
| Rate for Payer: Healthfirst QHP |
$105.08
|
| Rate for Payer: Humana Medicare |
$107.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$105.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$105.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$105.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$84.06
|
| Rate for Payer: Wellcare Medicare |
$99.83
|
|
|
XR ORBITS
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 70200 TC
|
| Hospital Charge Code |
41102174
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$76.27 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$89.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$89.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$89.00
|
| Rate for Payer: Brighton Health Commercial |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$89.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.15
|
| Rate for Payer: Group Health Inc Commercial |
$114.43
|
| Rate for Payer: Group Health Inc Medicare |
$114.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$114.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$127.14
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Humana Medicare |
$129.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.71
|
| Rate for Payer: Wellcare Medicare |
$120.78
|
|
|
XR ORBITS
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 70200 TC
|
| Hospital Charge Code |
41102174
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$127.14
|
|
|
XR OS CALCIS
|
Facility
|
IP
|
$241.73
|
|
|
Service Code
|
HCPCS 73650 TC
|
| Hospital Charge Code |
41102084
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$105.08
|
|
|
XR OS CALCIS
|
Facility
|
OP
|
$241.73
|
|
|
Service Code
|
HCPCS 73650 TC
|
| Hospital Charge Code |
41102084
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$73.56 |
| Max. Negotiated Rate |
$132.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$105.08
|
| Rate for Payer: Aetna Government |
$105.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$73.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$73.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$73.56
|
| Rate for Payer: Brighton Health Commercial |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$105.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.14
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$105.08
|
| Rate for Payer: EmblemHealth Commercial |
$73.56
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$89.32
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$89.32
|
| Rate for Payer: Fidelis Essential Plan QHP |
$93.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$105.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$93.52
|
| Rate for Payer: Group Health Inc Commercial |
$94.57
|
| Rate for Payer: Group Health Inc Medicare |
$94.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$105.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$94.57
|
| Rate for Payer: Healthfirst Medicare Advantage |
$105.08
|
| Rate for Payer: Healthfirst QHP |
$105.08
|
| Rate for Payer: Humana Medicare |
$107.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$105.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$105.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$105.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$84.06
|
| Rate for Payer: Wellcare Medicare |
$99.83
|
|
