|
CONE ASYM TRI AUG
|
Facility
OP
|
$16,132.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64907220
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$16,939.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8,872.88
|
| 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 |
$8,066.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9,276.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$16,939.12
|
| Rate for Payer: Group Health Inc Commercial |
$8,066.25
|
| Rate for Payer: Group Health Inc Medicare |
$5,646.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8,066.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,066.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10,486.12
|
|
|
CONE ASYM TRI AUG
|
Facility
IP
|
$16,132.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64907220
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,066.25 |
| Max. Negotiated Rate |
$8,066.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8,066.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,066.25
|
|
|
CONE BEAM CT CAP & INTE LTD VIEWS
|
Facility
OP
|
$697.50
|
|
|
Service Code
|
HCPCS D0364
|
| Hospital Charge Code |
42300703
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$101.71 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$383.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Cash Price |
$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 |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$127.14
|
| 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 |
$127.14
|
| Rate for Payer: Group Health Inc Medicare |
$127.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$348.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$108.07
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Senior Whole Health 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
|
|
|
CONE BEAM CT CAP&INTR JAW W/CRANI
|
Facility
OP
|
$697.50
|
|
|
Service Code
|
HCPCS D0367
|
| Hospital Charge Code |
42300702
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$101.71 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$383.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Cash Price |
$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 |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$127.14
|
| 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 |
$127.14
|
| Rate for Payer: Group Health Inc Medicare |
$127.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$348.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$108.07
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Senior Whole Health 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
|
|
|
CONE BEAM CT CAPTURE & INTRP FULL
|
Facility
OP
|
$697.50
|
|
|
Service Code
|
HCPCS D0365
|
| Hospital Charge Code |
42300709
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$101.71 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$383.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Cash Price |
$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 |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$127.14
|
| 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 |
$127.14
|
| Rate for Payer: Group Health Inc Medicare |
$127.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$348.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$108.07
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Senior Whole Health 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
|
|
|
CONE BEAM CT IMAGE LTD VIEW
|
Facility
OP
|
$150.00
|
|
|
Service Code
|
HCPCS D0380
|
| Hospital Charge Code |
42300701
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$82.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Cash Price |
$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 |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$127.14
|
| 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 |
$127.14
|
| Rate for Payer: Group Health Inc Medicare |
$127.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$75.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$108.07
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Senior Whole Health 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
|
|
|
CONE BEAM CT MAXILLA AND CRANIUM
|
Facility
OP
|
$697.50
|
|
|
Service Code
|
HCPCS D0366
|
| Hospital Charge Code |
42300711
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$101.71 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$383.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Cash Price |
$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 |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$127.14
|
| 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 |
$127.14
|
| Rate for Payer: Group Health Inc Medicare |
$127.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$348.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$108.07
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Senior Whole Health 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
|
|
|
CONE BEAM CT TMJ SERIES ICLD 2+
|
Facility
OP
|
$697.50
|
|
|
Service Code
|
HCPCS D0368
|
| Hospital Charge Code |
42300712
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$101.71 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$383.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$127.14
|
| Rate for Payer: Aetna Government |
$127.14
|
| Rate for Payer: Cash Price |
$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 |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$127.14
|
| Rate for Payer: EmblemHealth Commercial |
$127.14
|
| 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 |
$127.14
|
| Rate for Payer: Group Health Inc Medicare |
$127.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$348.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$108.07
|
| Rate for Payer: Healthfirst QHP |
$127.14
|
| Rate for Payer: Senior Whole Health 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
|
|
|
CONE FEM TRI AUG
|
Facility
OP
|
$17,178.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64907221
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$18,037.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9,448.31
|
| 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 |
$8,589.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9,877.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$18,037.69
|
| Rate for Payer: Group Health Inc Commercial |
$8,589.38
|
| Rate for Payer: Group Health Inc Medicare |
$6,012.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8,589.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,589.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11,166.19
|
|
|
CONE FEM TRI AUG
|
Facility
IP
|
$17,178.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64907221
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,589.38 |
| Max. Negotiated Rate |
$8,589.38 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8,589.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,589.38
|
|
|
CONE PROX ARCOS OFFSET REV
|
Facility
OP
|
$19,312.00
|
|
| Hospital Charge Code |
64906709
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$6,759.20 |
| Max. Negotiated Rate |
$15,449.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10,621.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9,656.00
|
| Rate for Payer: Aetna Government |
$9,656.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15,449.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13,132.16
|
| Rate for Payer: Group Health Inc Commercial |
$9,656.00
|
| Rate for Payer: Group Health Inc Medicare |
$6,759.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9,656.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9,656.00
|
|
|
CONE PROX STD ARCOS REV
|
Facility
OP
|
$19,312.00
|
|
| Hospital Charge Code |
64906708
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$6,759.20 |
| Max. Negotiated Rate |
$15,449.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10,621.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9,656.00
|
| Rate for Payer: Aetna Government |
$9,656.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15,449.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13,132.16
|
| Rate for Payer: Group Health Inc Commercial |
$9,656.00
|
| Rate for Payer: Group Health Inc Medicare |
$6,759.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9,656.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9,656.00
|
|
|
CONE SYM TRI AUG
|
Facility
IP
|
$15,084.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64907219
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,542.19 |
| Max. Negotiated Rate |
$7,542.19 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7,542.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7,542.19
|
|
|
CONE SYM TRI AUG
|
Facility
OP
|
$15,084.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64907219
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$15,838.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8,296.41
|
| 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 |
$7,542.19
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8,673.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$15,838.60
|
| Rate for Payer: Group Health Inc Commercial |
$7,542.19
|
| Rate for Payer: Group Health Inc Medicare |
$5,279.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7,542.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7,542.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9,804.85
|
|
|
CON FOAM PAD (EGG CRATE)
|
Facility
OP
|
$39.33
|
|
| Hospital Charge Code |
40207638
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.77 |
| Max. Negotiated Rate |
$31.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$21.63
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.66
|
| Rate for Payer: Aetna Government |
$19.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$31.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$26.74
|
| Rate for Payer: Group Health Inc Commercial |
$19.66
|
| Rate for Payer: Group Health Inc Medicare |
$13.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.66
|
|
|
CONICAL EXTRACTOR
|
Facility
OP
|
$368.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40006156
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$128.80 |
| Max. Negotiated Rate |
$386.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$202.40
|
| 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 |
$184.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$211.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$386.40
|
| Rate for Payer: Group Health Inc Commercial |
$184.00
|
| Rate for Payer: Group Health Inc Medicare |
$128.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$184.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$184.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$239.20
|
|
|
CONICAL EXTRACTOR
|
Facility
IP
|
$368.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40006156
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$184.00 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$184.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$184.00
|
|
|
CONIZATION OF CERVIX
|
Facility
OP
|
$7,566.13
|
|
|
Service Code
|
HCPCS 57522
|
| Hospital Charge Code |
40054084
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$285.76 |
| Max. Negotiated Rate |
$3,783.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,615.39
|
| Rate for Payer: Aetna Government |
$3,615.39
|
| Rate for Payer: Cash Price |
$3,615.39
|
| Rate for Payer: Cash Price |
$3,615.39
|
| Rate for Payer: Cash Price |
$3,615.39
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,615.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$3,615.39
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$285.76
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,073.08
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,217.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,615.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,217.70
|
| Rate for Payer: Group Health Inc Commercial |
$3,615.39
|
| Rate for Payer: Group Health Inc Medicare |
$3,615.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,783.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,615.39
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$317.51
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,073.08
|
| Rate for Payer: Healthfirst QHP |
$3,615.39
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,615.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,615.39
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,892.31
|
| Rate for Payer: Wellcare Medicare |
$3,434.62
|
|
|
Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision
|
Facility
OP
|
$3,615.39
|
|
|
Service Code
|
CPT 57522
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$285.76 |
| Max. Negotiated Rate |
$3,615.39 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,615.39
|
| Rate for Payer: Aetna Government |
$3,615.39
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,615.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$3,615.39
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$285.76
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,073.08
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,217.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,615.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,217.70
|
| Rate for Payer: Group Health Inc Commercial |
$3,615.39
|
| Rate for Payer: Group Health Inc Medicare |
$3,615.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,615.39
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$317.51
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,073.08
|
| Rate for Payer: Healthfirst QHP |
$3,615.39
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,615.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,615.39
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,892.31
|
| Rate for Payer: Wellcare Medicare |
$3,434.62
|
|
|
CONJUGATED ESTROGENS 0.625 MG TAB
|
Facility
OP
|
$4.00
|
|
| Hospital Charge Code |
41653961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.00
|
| Rate for Payer: Aetna Government |
$2.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.72
|
| Rate for Payer: Group Health Inc Commercial |
$2.00
|
| Rate for Payer: Group Health Inc Medicare |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
|
|
CONJUGATED ESTROGENS 0.625 MG TAB
|
Facility
OP
|
$4.00
|
|
| Hospital Charge Code |
41643961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.00
|
| Rate for Payer: Aetna Government |
$2.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.72
|
| Rate for Payer: Group Health Inc Commercial |
$2.00
|
| Rate for Payer: Group Health Inc Medicare |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
|
|
CONJUGATED ESTROGENS 1.25 MG TAB
|
Facility
OP
|
$4.00
|
|
| Hospital Charge Code |
41644026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.00
|
| Rate for Payer: Aetna Government |
$2.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.72
|
| Rate for Payer: Group Health Inc Commercial |
$2.00
|
| Rate for Payer: Group Health Inc Medicare |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
|
|
CONJUGATED ESTROGENS 1.25 MG TAB
|
Facility
OP
|
$4.00
|
|
| Hospital Charge Code |
41654026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.00
|
| Rate for Payer: Aetna Government |
$2.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.72
|
| Rate for Payer: Group Health Inc Commercial |
$2.00
|
| Rate for Payer: Group Health Inc Medicare |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
|
|
CONJUGATED ESTROGENS 25 MG INJ
|
Facility
OP
|
$700.00
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
41650134
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$297.72 |
| Max. Negotiated Rate |
$455.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$385.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$372.15
|
| Rate for Payer: Aetna Government |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$372.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$350.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$402.50
|
| Rate for Payer: Elderplan Medicare Advantage |
$372.15
|
| Rate for Payer: EmblemHealth Commercial |
$372.15
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$372.15
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$372.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$390.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$372.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$390.75
|
| Rate for Payer: Group Health Inc Commercial |
$372.15
|
| Rate for Payer: Group Health Inc Medicare |
$372.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$350.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$350.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$371.89
|
| Rate for Payer: Healthfirst Medicare Advantage |
$316.32
|
| Rate for Payer: Healthfirst QHP |
$372.15
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$372.15
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$394.71
|
| Rate for Payer: SOMOS Essential |
$394.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$455.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$297.72
|
| Rate for Payer: Wellcare Medicare |
$353.54
|
|
|
CONJUGATED ESTROGENS 25 MG INJ
|
Facility
OP
|
$700.00
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
41640134
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$297.72 |
| Max. Negotiated Rate |
$455.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$385.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$372.15
|
| Rate for Payer: Aetna Government |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Cash Price |
$372.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$372.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$350.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$402.50
|
| Rate for Payer: Elderplan Medicare Advantage |
$372.15
|
| Rate for Payer: EmblemHealth Commercial |
$372.15
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$372.15
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$372.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$390.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$372.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$390.75
|
| Rate for Payer: Group Health Inc Commercial |
$372.15
|
| Rate for Payer: Group Health Inc Medicare |
$372.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$350.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$350.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$371.89
|
| Rate for Payer: Healthfirst Medicare Advantage |
$316.32
|
| Rate for Payer: Healthfirst QHP |
$372.15
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$372.15
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$394.71
|
| Rate for Payer: SOMOS Essential |
$394.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$455.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$297.72
|
| Rate for Payer: Wellcare Medicare |
$353.54
|
|
