|
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC
|
Facility
|
IP
|
$25,745.58
|
|
|
Service Code
|
MSDRG 554
|
| Min. Negotiated Rate |
$7,046.94 |
| Max. Negotiated Rate |
$25,745.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12,117.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18,724.06
|
| Rate for Payer: Aetna Government |
$18,724.06
|
| Rate for Payer: Brighton Health Commercial |
$11,916.10
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$19,098.54
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14,191.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11,711.57
|
| Rate for Payer: Elderplan Medicare Advantage |
$17,787.86
|
| Rate for Payer: EmblemHealth Commercial |
$7,046.94
|
| Rate for Payer: Fidelis Medicare Advantage |
$18,724.06
|
| Rate for Payer: Group Health Inc Commercial |
$18,724.06
|
| Rate for Payer: Group Health Inc Medicare |
$18,724.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18,724.06
|
| Rate for Payer: Healthfirst Medicare Advantage |
$8,706.69
|
| Rate for Payer: Humana Medicare |
$25,745.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$18,724.06
|
| Rate for Payer: United Healthcare Commercial |
$16,343.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18,724.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18,724.06
|
| Rate for Payer: Wellcare Medicare |
$17,787.86
|
|
|
BONE GRAFT
|
Facility
|
OP
|
$4,240.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40203019
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$4,452.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,332.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$2,544.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,120.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,438.00
|
| Rate for Payer: EmblemHealth Commercial |
$2,120.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,452.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,120.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,484.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,120.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,756.00
|
|
|
BONE GRAFT
|
Facility
|
IP
|
$4,240.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40203019
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,120.00 |
| Max. Negotiated Rate |
$2,120.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,120.00
|
|
|
Bone graft, any donor area; minor or small (eg, dowel or button)
|
Facility
|
OP
|
$8,438.58
|
|
|
Service Code
|
CPT 20900
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$8,438.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8,273.12
|
| Rate for Payer: Aetna Government |
$8,273.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5,791.18
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5,791.18
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5,791.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$8,273.12
|
| 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: Elderplan Medicare Advantage |
$8,273.12
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$7,032.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7,363.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$8,273.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7,363.08
|
| Rate for Payer: Group Health Inc Commercial |
$8,273.12
|
| Rate for Payer: Group Health Inc Medicare |
$8,273.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,273.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7,032.15
|
| Rate for Payer: Healthfirst QHP |
$8,273.12
|
| Rate for Payer: Humana Medicare |
$8,438.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$8,273.12
|
| Rate for Payer: United Healthcare Commercial |
$1,835.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,273.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,273.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6,618.50
|
| Rate for Payer: Wellcare Medicare |
$7,859.46
|
|
|
BONE GRAFT ANY DONOR - LARGE
|
Facility
|
IP
|
$18,117.83
|
|
|
Service Code
|
HCPCS 20902
|
| Hospital Charge Code |
40089405
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$8,273.12
|
|
|
BONE GRAFT ANY DONOR - LARGE
|
Facility
|
OP
|
$18,117.83
|
|
|
Service Code
|
HCPCS 20902
|
| Hospital Charge Code |
40089405
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$13,588.37 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,485.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8,273.12
|
| Rate for Payer: Aetna Government |
$8,273.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5,791.18
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5,791.18
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5,791.18
|
| Rate for Payer: Brighton Health Commercial |
$13,588.37
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$8,273.12
|
| 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: Elderplan Medicare Advantage |
$8,273.12
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$7,032.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7,363.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$8,273.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7,363.08
|
| Rate for Payer: Group Health Inc Commercial |
$8,273.12
|
| Rate for Payer: Group Health Inc Medicare |
$8,273.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9,058.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,273.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7,032.15
|
| Rate for Payer: Healthfirst QHP |
$8,273.12
|
| Rate for Payer: Humana Medicare |
$8,438.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$8,273.12
|
| Rate for Payer: United Healthcare Commercial |
$1,835.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,273.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,273.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6,618.50
|
| Rate for Payer: Wellcare Medicare |
$7,859.46
|
|
|
BONE GRAFT ANY DONOR - SMALL
|
Facility
|
IP
|
$18,117.83
|
|
|
Service Code
|
HCPCS 20900
|
| Hospital Charge Code |
40082790
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$8,273.12
|
|
|
BONE GRAFT ANY DONOR - SMALL
|
Facility
|
OP
|
$18,117.83
|
|
|
Service Code
|
HCPCS 20900
|
| Hospital Charge Code |
40082790
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$13,588.37 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8,273.12
|
| Rate for Payer: Aetna Government |
$8,273.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5,791.18
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5,791.18
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5,791.18
|
| Rate for Payer: Brighton Health Commercial |
$13,588.37
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$8,273.12
|
| 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: Elderplan Medicare Advantage |
$8,273.12
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$7,032.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7,363.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$8,273.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7,363.08
|
| Rate for Payer: Group Health Inc Commercial |
$8,273.12
|
| Rate for Payer: Group Health Inc Medicare |
$8,273.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9,058.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,273.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7,032.15
|
| Rate for Payer: Healthfirst QHP |
$8,273.12
|
| Rate for Payer: Humana Medicare |
$8,438.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$8,273.12
|
| Rate for Payer: United Healthcare Commercial |
$1,835.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,273.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,273.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6,618.50
|
| Rate for Payer: Wellcare Medicare |
$7,859.46
|
|
|
BONE GRAFT FEMUR
|
Facility
|
OP
|
$4,144.04
|
|
|
Service Code
|
HCPCS 27170
|
| Hospital Charge Code |
40023261
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,214.68 |
| Max. Negotiated Rate |
$3,108.03 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,279.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,214.68
|
| Rate for Payer: Aetna Government |
$1,214.68
|
| Rate for Payer: Brighton Health Commercial |
$3,108.03
|
| 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: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,072.02
|
| Rate for Payer: Group Health Inc Medicare |
$1,450.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,072.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,072.02
|
| Rate for Payer: United Healthcare Commercial |
$2,546.00
|
|
|
BONE GRAFT FOR RIDGE PRESERVATION
|
Facility
|
OP
|
$625.00
|
|
|
Service Code
|
HCPCS D7953
|
| Hospital Charge Code |
42300751
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$62.53 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$343.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$62.53
|
| Rate for Payer: Aetna Government |
$62.53
|
| Rate for Payer: Brighton Health Commercial |
$468.75
|
| 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 |
$312.50
|
| Rate for Payer: Group Health Inc Medicare |
$218.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$312.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$312.50
|
|
|
BONE GRAFT INJ 2CC
|
Facility
|
IP
|
$2,375.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901192
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,187.50 |
| Max. Negotiated Rate |
$1,187.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,187.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,187.50
|
|
|
BONE GRAFT INJ 2CC
|
Facility
|
OP
|
$2,375.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901192
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$2,493.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,306.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$1,425.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,187.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,365.62
|
| Rate for Payer: EmblemHealth Commercial |
$1,187.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,493.75
|
| Rate for Payer: Group Health Inc Commercial |
$1,187.50
|
| Rate for Payer: Group Health Inc Medicare |
$831.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,187.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,187.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,543.75
|
|
|
BONE GRAFT INJ 5CC
|
Facility
|
OP
|
$3,987.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$4,186.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,193.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$2,392.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,993.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,292.81
|
| Rate for Payer: EmblemHealth Commercial |
$1,993.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,186.88
|
| Rate for Payer: Group Health Inc Commercial |
$1,993.75
|
| Rate for Payer: Group Health Inc Medicare |
$1,395.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,993.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,993.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,591.88
|
|
|
BONE GRAFT INJ 5CC
|
Facility
|
IP
|
$3,987.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,993.75 |
| Max. Negotiated Rate |
$1,993.75 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,993.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,993.75
|
|
|
BONE GRAFT MANDIBLE
|
Facility
|
IP
|
$14,691.05
|
|
|
Service Code
|
HCPCS 21215
|
| Hospital Charge Code |
40013263
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$6,772.21
|
|
|
BONE GRAFT MANDIBLE
|
Facility
|
OP
|
$14,691.05
|
|
|
Service Code
|
HCPCS 21215
|
| Hospital Charge Code |
40013263
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$11,018.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,065.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,772.21
|
| Rate for Payer: Aetna Government |
$6,772.21
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$4,740.55
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$4,740.55
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$4,740.55
|
| Rate for Payer: Brighton Health Commercial |
$11,018.29
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,772.21
|
| 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 |
$6,772.21
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,756.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6,027.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,772.21
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6,027.27
|
| Rate for Payer: Group Health Inc Commercial |
$6,772.21
|
| Rate for Payer: Group Health Inc Medicare |
$6,772.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7,345.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,772.21
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5,756.38
|
| Rate for Payer: Healthfirst QHP |
$6,772.21
|
| Rate for Payer: Humana Medicare |
$6,907.65
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,772.21
|
| Rate for Payer: United Healthcare Commercial |
$2,683.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,772.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,772.21
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,417.77
|
| Rate for Payer: Wellcare Medicare |
$6,433.60
|
|
|
BONE GRAFT REPAIR PERIMPLANT
|
Facility
|
OP
|
$500.00
|
|
|
Service Code
|
HCPCS D6103
|
| Hospital Charge Code |
42300997
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$275.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$272.65
|
| Rate for Payer: Aetna Government |
$272.65
|
| Rate for Payer: Brighton Health Commercial |
$375.00
|
| 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 |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$250.00
|
|
|
BONE GRAFT STRIP 19X26X7
|
Facility
|
IP
|
$5,500.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,750.00 |
| Max. Negotiated Rate |
$2,750.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,750.00
|
|
|
BONE GRAFT STRIP 19X26X7
|
Facility
|
OP
|
$5,500.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$5,775.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3,025.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$3,300.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,750.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,162.50
|
| Rate for Payer: EmblemHealth Commercial |
$2,750.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$5,775.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,750.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,925.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,750.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,575.00
|
|
|
BONE GRAFT TIME OF IMPL PLACEMT
|
Facility
|
OP
|
$625.00
|
|
|
Service Code
|
HCPCS D6104
|
| Hospital Charge Code |
42300743
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$218.75 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$343.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$219.91
|
| Rate for Payer: Aetna Government |
$219.91
|
| Rate for Payer: Brighton Health Commercial |
$468.75
|
| 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 |
$312.50
|
| Rate for Payer: Group Health Inc Medicare |
$218.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$312.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$312.50
|
|
|
BONE GRAFT TX ORBIT
|
Facility
|
OP
|
$14,691.05
|
|
|
Service Code
|
HCPCS 21408
|
| Hospital Charge Code |
40013262
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$11,018.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3,387.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,772.21
|
| Rate for Payer: Aetna Government |
$6,772.21
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$4,740.55
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$4,740.55
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$4,740.55
|
| Rate for Payer: Brighton Health Commercial |
$11,018.29
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,772.21
|
| 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 |
$6,772.21
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,756.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6,027.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,772.21
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6,027.27
|
| Rate for Payer: Group Health Inc Commercial |
$6,772.21
|
| Rate for Payer: Group Health Inc Medicare |
$6,772.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7,345.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,772.21
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5,756.38
|
| Rate for Payer: Healthfirst QHP |
$6,772.21
|
| Rate for Payer: Humana Medicare |
$6,907.65
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,772.21
|
| Rate for Payer: United Healthcare Commercial |
$2,683.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,772.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,772.21
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,417.77
|
| Rate for Payer: Wellcare Medicare |
$6,433.60
|
|
|
BONE GRAFT TX ORBIT
|
Facility
|
IP
|
$14,691.05
|
|
|
Service Code
|
HCPCS 21408
|
| Hospital Charge Code |
40013262
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$6,772.21
|
|
|
BONE GROWTH STIMULATOR
|
Facility
|
IP
|
$23,285.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64904357
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,642.50 |
| Max. Negotiated Rate |
$11,642.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11,642.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11,642.50
|
|
|
BONE GROWTH STIMULATOR
|
Facility
|
OP
|
$23,285.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64904357
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$24,449.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12,806.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$13,971.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11,642.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13,388.88
|
| Rate for Payer: EmblemHealth Commercial |
$11,642.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$24,449.25
|
| Rate for Payer: Group Health Inc Commercial |
$11,642.50
|
| Rate for Payer: Group Health Inc Medicare |
$8,149.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11,642.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11,642.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15,135.25
|
|
|
BONE HOOK
|
Facility
|
OP
|
$416.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40006114
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$436.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$228.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$249.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$208.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$239.20
|
| Rate for Payer: EmblemHealth Commercial |
$208.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$436.80
|
| Rate for Payer: Group Health Inc Commercial |
$208.00
|
| Rate for Payer: Group Health Inc Medicare |
$145.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$208.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$208.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$270.40
|
|
