|
COMPONENT MODULAR HEAD 28MM
|
Facility
OP
|
$1,222.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40209660
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$1,283.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$672.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$611.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$702.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,283.10
|
| Rate for Payer: Group Health Inc Commercial |
$611.00
|
| Rate for Payer: Group Health Inc Medicare |
$427.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$611.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$611.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$794.30
|
|
|
COMPONENT MODULAR HEAD 28MM2
|
Facility
IP
|
$1,830.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64901097
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$915.00 |
| Max. Negotiated Rate |
$915.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$915.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$915.00
|
|
|
COMPONENT MODULAR HEAD 28MM2
|
Facility
OP
|
$1,830.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64901097
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$1,921.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,006.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,052.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,921.50
|
| Rate for Payer: Group Health Inc Commercial |
$915.00
|
| Rate for Payer: Group Health Inc Medicare |
$640.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$915.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$915.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,189.50
|
|
|
COMPONENT STEMMED TIBIAL
|
Facility
IP
|
$5,391.13
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,695.56 |
| Max. Negotiated Rate |
$2,695.56 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,695.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,695.56
|
|
|
COMPONENT STEMMED TIBIAL
|
Facility
OP
|
$4,550.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40205057
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$4,778.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,503.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,275.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,616.77
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,778.44
|
| Rate for Payer: Group Health Inc Commercial |
$2,275.45
|
| Rate for Payer: Group Health Inc Medicare |
$1,592.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,275.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,275.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,958.08
|
|
|
COMPONENT STEMMED TIBIAL
|
Facility
IP
|
$4,550.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40205057
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,275.45 |
| Max. Negotiated Rate |
$2,275.45 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,275.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,275.45
|
|
|
COMPONENT STEMMED TIBIAL
|
Facility
OP
|
$5,391.13
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$5,660.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,965.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,695.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,099.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$5,660.69
|
| Rate for Payer: Group Health Inc Commercial |
$2,695.56
|
| Rate for Payer: Group Health Inc Medicare |
$1,886.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,695.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,695.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,504.23
|
|
|
COMPONENT TIBIAL COMPL KNEE
|
Facility
OP
|
$5,391.13
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64901974
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$5,660.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,965.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,695.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,099.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$5,660.69
|
| Rate for Payer: Group Health Inc Commercial |
$2,695.56
|
| Rate for Payer: Group Health Inc Medicare |
$1,886.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,695.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,695.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,504.23
|
|
|
COMPONENT TIBIAL COMPL KNEE
|
Facility
IP
|
$5,391.13
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64901974
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,695.56 |
| Max. Negotiated Rate |
$2,695.56 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,695.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,695.56
|
|
|
COMPONET FIXATIN PHALAG 9P15S180W
|
Facility
IP
|
$700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64906476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$350.00 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$350.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$350.00
|
|
|
COMPONET FIXATIN PHALAG 9P15S180W
|
Facility
OP
|
$700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64906476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$245.00 |
| Max. Negotiated Rate |
$735.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$385.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$350.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$402.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$735.00
|
| Rate for Payer: Group Health Inc Commercial |
$350.00
|
| Rate for Payer: Group Health Inc Medicare |
$245.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$350.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$350.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$455.00
|
|
|
COMPONET UNIV HEAD BPOLAR-UH15228
|
Facility
OP
|
$825.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64906467
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$288.75 |
| Max. Negotiated Rate |
$866.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$453.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$412.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$474.38
|
| Rate for Payer: Fidelis Medicare Advantage |
$866.25
|
| Rate for Payer: Group Health Inc Commercial |
$412.50
|
| Rate for Payer: Group Health Inc Medicare |
$288.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$412.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$412.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$536.25
|
|
|
COMPONET UNIV HEAD BPOLAR-UH15228
|
Facility
IP
|
$825.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64906467
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$412.50 |
| Max. Negotiated Rate |
$412.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$412.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$412.50
|
|
|
COMP ORTHO ADOLESCENT DENT
|
Facility
OP
|
$2,465.00
|
|
|
Service Code
|
HCPCS D8080
|
| Hospital Charge Code |
42303366
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$862.75 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,355.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$872.16
|
| Rate for Payer: Aetna Government |
$872.16
|
| 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 |
$1,232.50
|
| Rate for Payer: Group Health Inc Medicare |
$862.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,232.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,232.50
|
|
|
COMP ORTHO ADULT DENT
|
Facility
OP
|
$2,465.00
|
|
|
Service Code
|
HCPCS D8090
|
| Hospital Charge Code |
42303367
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$862.75 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,355.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$869.25
|
| Rate for Payer: Aetna Government |
$869.25
|
| 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 |
$1,232.50
|
| Rate for Payer: Group Health Inc Medicare |
$862.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,232.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,232.50
|
|
|
COMP ORTHO TRANSITIONAL DENTITION
|
Facility
OP
|
$2,465.00
|
|
|
Service Code
|
HCPCS D8070
|
| Hospital Charge Code |
42303365
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$642.64 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,355.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$642.64
|
| Rate for Payer: Aetna Government |
$642.64
|
| 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 |
$1,232.50
|
| Rate for Payer: Group Health Inc Medicare |
$862.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,232.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,232.50
|
|
|
COMPOSITE MESH
|
Facility
IP
|
$742.64
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
40209571
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$371.32 |
| Max. Negotiated Rate |
$371.32 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$371.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$371.32
|
|
|
COMPOSITE MESH
|
Facility
OP
|
$742.64
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
40209571
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$69.35 |
| Max. Negotiated Rate |
$779.77 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$408.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$69.35
|
| Rate for Payer: Aetna Government |
$69.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$371.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$427.02
|
| Rate for Payer: Fidelis Medicare Advantage |
$779.77
|
| Rate for Payer: Group Health Inc Commercial |
$371.32
|
| Rate for Payer: Group Health Inc Medicare |
$259.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$371.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$371.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$482.72
|
|
|
COMP. PERIO EVALUATION
|
Facility
OP
|
$90.00
|
|
|
Service Code
|
HCPCS D0180
|
| Hospital Charge Code |
42303410
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$49.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$152.87
|
| Rate for Payer: Aetna Government |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$152.87
|
| 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 |
$152.87
|
| Rate for Payer: EmblemHealth Commercial |
$152.87
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$129.94
|
| Rate for Payer: Fidelis Essential Plan QHP |
$136.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$152.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$136.05
|
| Rate for Payer: Group Health Inc Commercial |
$152.87
|
| Rate for Payer: Group Health Inc Medicare |
$152.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$45.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$152.87
|
| Rate for Payer: Healthfirst Medicare Advantage |
$129.94
|
| Rate for Payer: Healthfirst QHP |
$152.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$152.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$152.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$122.30
|
| Rate for Payer: Wellcare Medicare |
$145.23
|
|
|
COMPREHENSIVE ESTABLISH
|
Facility
OP
|
$351.13
|
|
|
Service Code
|
HCPCS 92014
|
| Hospital Charge Code |
42101100
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$77.38 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$193.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$152.87
|
| Rate for Payer: Aetna Government |
$152.87
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$152.87
|
| 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 |
$152.87
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$77.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$129.94
|
| Rate for Payer: Fidelis Essential Plan QHP |
$136.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$152.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$136.05
|
| 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 |
$175.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$152.87
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$85.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$129.94
|
| Rate for Payer: Healthfirst QHP |
$152.87
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$152.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$152.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$152.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$122.30
|
| Rate for Payer: Wellcare Medicare |
$145.23
|
|
|
COMPREHENSIVE EST PT 1/MORE VISIT
|
Facility
OP
|
$358.63
|
|
|
Service Code
|
HCPCS 92014
|
| Hospital Charge Code |
30300114
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$77.38 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$152.87
|
| Rate for Payer: Aetna Government |
$152.87
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$152.87
|
| 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 |
$152.87
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$77.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$129.94
|
| Rate for Payer: Fidelis Essential Plan QHP |
$136.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$152.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$136.05
|
| 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 |
$179.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$152.87
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$85.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$129.94
|
| Rate for Payer: Healthfirst QHP |
$152.87
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$152.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$152.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$152.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$122.30
|
| Rate for Payer: Wellcare Medicare |
$145.23
|
|
|
COMPREHENSIVE METABOLIC PANEL
|
Facility
OP
|
$26.40
|
|
|
Service Code
|
HCPCS 80053
|
| Hospital Charge Code |
40602501
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$16.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.52
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.56
|
| Rate for Payer: Aetna Government |
$10.56
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$10.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$14.21
|
| Rate for Payer: Elderplan Medicare Advantage |
$10.56
|
| Rate for Payer: EmblemHealth Commercial |
$10.56
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$9.50
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$8.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$9.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$10.56
|
| Rate for Payer: Fidelis Qualified Health Plan |
$9.40
|
| Rate for Payer: Group Health Inc Commercial |
$10.56
|
| Rate for Payer: Group Health Inc Medicare |
$10.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.56
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$10.56
|
| Rate for Payer: Healthfirst Medicare Advantage |
$10.56
|
| Rate for Payer: Healthfirst QHP |
$10.56
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$10.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.56
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$8.45
|
| Rate for Payer: Wellcare Medicare |
$9.50
|
|
|
COMPREHENSIVE NEW
|
Facility
OP
|
$351.13
|
|
|
Service Code
|
HCPCS 92004
|
| Hospital Charge Code |
42101000
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$280.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$193.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$152.87
|
| Rate for Payer: Aetna Government |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$152.87
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.77
|
| Rate for Payer: Elderplan Medicare Advantage |
$152.87
|
| Rate for Payer: EmblemHealth Commercial |
$152.87
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$95.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$129.94
|
| Rate for Payer: Fidelis Essential Plan QHP |
$136.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$152.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$136.05
|
| Rate for Payer: Group Health Inc Commercial |
$152.87
|
| Rate for Payer: Group Health Inc Medicare |
$152.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$152.87
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$105.63
|
| Rate for Payer: Healthfirst Medicare Advantage |
$129.94
|
| Rate for Payer: Healthfirst QHP |
$152.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$152.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$152.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$122.30
|
| Rate for Payer: Wellcare Medicare |
$145.23
|
|
|
COMPREHENSIVE ORAL EVALUATION
|
Facility
OP
|
$75.00
|
|
|
Service Code
|
HCPCS D0150
|
| Hospital Charge Code |
42303272
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$37.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$41.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$152.87
|
| Rate for Payer: Aetna Government |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Cash Price |
$152.87
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$152.87
|
| 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 |
$152.87
|
| Rate for Payer: EmblemHealth Commercial |
$152.87
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$129.94
|
| Rate for Payer: Fidelis Essential Plan QHP |
$136.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$152.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$136.05
|
| Rate for Payer: Group Health Inc Commercial |
$152.87
|
| Rate for Payer: Group Health Inc Medicare |
$152.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$152.87
|
| Rate for Payer: Healthfirst Medicare Advantage |
$129.94
|
| Rate for Payer: Healthfirst QHP |
$152.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$152.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$152.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$122.30
|
| Rate for Payer: Wellcare Medicare |
$145.23
|
|
|
COMP REPAIR 2.6CM-7.5CM
|
Facility
OP
|
$1,505.35
|
|
|
Service Code
|
HCPCS 13132
|
| Hospital Charge Code |
30105927
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$726.29
|
| Rate for Payer: Aetna Government |
$726.29
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$726.29
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$726.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$726.29
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$327.20
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$617.35
|
| Rate for Payer: Fidelis Essential Plan QHP |
$646.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$726.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$646.40
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$752.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$726.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$726.29
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$726.29
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$726.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$726.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$581.03
|
| Rate for Payer: Wellcare Medicare |
$689.98
|
|
