|
CROCHET VEIN HOOK C
|
Facility
OP
|
$237.50
|
|
| Hospital Charge Code |
64903615
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$83.12 |
| Max. Negotiated Rate |
$190.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$130.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$118.75
|
| Rate for Payer: Aetna Government |
$118.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$190.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$161.50
|
| Rate for Payer: Group Health Inc Commercial |
$118.75
|
| Rate for Payer: Group Health Inc Medicare |
$83.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$118.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$118.75
|
|
|
CROMOLYN 4% OPHTHALMIC SOLN 10 ML
|
Facility
OP
|
$14.00
|
|
| Hospital Charge Code |
41651269
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$11.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.00
|
| Rate for Payer: Aetna Government |
$7.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.52
|
| Rate for Payer: Group Health Inc Commercial |
$7.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.10
|
|
|
CROMOLYN 4% OPHTHALMIC SOLN 10 ML
|
Facility
OP
|
$14.00
|
|
| Hospital Charge Code |
41641269
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$11.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.00
|
| Rate for Payer: Aetna Government |
$7.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.52
|
| Rate for Payer: Group Health Inc Commercial |
$7.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.10
|
|
|
CROSSCONNECTOR SPINAL 30-35MML
|
Facility
OP
|
$4,595.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64904439
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$4,825.67 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,527.73
|
| 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 |
$2,297.94
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,642.63
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,825.67
|
| Rate for Payer: Group Health Inc Commercial |
$2,297.94
|
| Rate for Payer: Group Health Inc Medicare |
$1,608.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,297.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,297.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,987.32
|
|
|
CROSSCONNECTOR SPINAL 30-35MML
|
Facility
IP
|
$4,595.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64904439
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,297.94 |
| Max. Negotiated Rate |
$2,297.94 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,297.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,297.94
|
|
|
CROSS CT FISSURE CARBIDE
|
Facility
OP
|
$17.83
|
|
| Hospital Charge Code |
64905195
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$14.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.81
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.92
|
| Rate for Payer: Aetna Government |
$8.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.12
|
| Rate for Payer: Group Health Inc Commercial |
$8.92
|
| Rate for Payer: Group Health Inc Medicare |
$6.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.92
|
|
|
CROSSLINK 35-44MM
|
Facility
IP
|
$4,595.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64902332
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,297.94 |
| Max. Negotiated Rate |
$2,297.94 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,297.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,297.94
|
|
|
CROSSLINK 35-44MM
|
Facility
OP
|
$4,595.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64902332
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$4,825.67 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,527.73
|
| 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 |
$2,297.94
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,642.63
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,825.67
|
| Rate for Payer: Group Health Inc Commercial |
$2,297.94
|
| Rate for Payer: Group Health Inc Medicare |
$1,608.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,297.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,297.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,987.32
|
|
|
CROSSLINK XIA 3 TI M-AX 53X73
|
Facility
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64906682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$2,100.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,100.00
|
| 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 |
$1,000.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,150.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,100.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,000.00
|
| Rate for Payer: Group Health Inc Medicare |
$700.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,000.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,000.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,300.00
|
|
|
CROSSLINK XIA 3 TI M-AX 53X73
|
Facility
IP
|
$2,000.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64906682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,000.00 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,000.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,000.00
|
|
|
CROSSMATCH
|
Facility
OP
|
$434.63
|
|
|
Service Code
|
HCPCS 86920
|
| Hospital Charge Code |
40701192
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.41 |
| Max. Negotiated Rate |
$239.05 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$239.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$197.52
|
| Rate for Payer: Aetna Government |
$197.52
|
| Rate for Payer: Cash Price |
$197.52
|
| Rate for Payer: Cash Price |
$197.52
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$197.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$26.48
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$22.41
|
| Rate for Payer: Elderplan Medicare Advantage |
$197.52
|
| Rate for Payer: EmblemHealth Commercial |
$197.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$167.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$175.79
|
| Rate for Payer: Fidelis Medicare Advantage |
$197.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$175.79
|
| Rate for Payer: Group Health Inc Commercial |
$197.52
|
| Rate for Payer: Group Health Inc Medicare |
$197.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$217.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$197.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$197.52
|
| Rate for Payer: Healthfirst QHP |
$197.52
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$197.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$197.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$158.02
|
| Rate for Payer: Wellcare Medicare |
$177.77
|
|
|
CROSSMATCH ELECTRONIC
|
Facility
OP
|
$434.63
|
|
|
Service Code
|
HCPCS 86923
|
| Hospital Charge Code |
40701183
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.86 |
| Max. Negotiated Rate |
$239.05 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$239.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$197.52
|
| Rate for Payer: Aetna Government |
$197.52
|
| Rate for Payer: Cash Price |
$197.52
|
| Rate for Payer: Cash Price |
$197.52
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$197.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$21.11
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.86
|
| Rate for Payer: Elderplan Medicare Advantage |
$197.52
|
| Rate for Payer: EmblemHealth Commercial |
$197.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$167.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$175.79
|
| Rate for Payer: Fidelis Medicare Advantage |
$197.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$175.79
|
| Rate for Payer: Group Health Inc Commercial |
$197.52
|
| Rate for Payer: Group Health Inc Medicare |
$197.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$217.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$197.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$197.52
|
| Rate for Payer: Healthfirst QHP |
$197.52
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$197.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$197.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$158.02
|
| Rate for Payer: Wellcare Medicare |
$177.77
|
|
|
CROSSMATCHING/HUMAN ANTIGLBLIN
|
Facility
OP
|
$434.63
|
|
|
Service Code
|
HCPCS 86922
|
| Hospital Charge Code |
40711065
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.02 |
| Max. Negotiated Rate |
$239.05 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$239.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$197.52
|
| Rate for Payer: Aetna Government |
$197.52
|
| Rate for Payer: Cash Price |
$197.52
|
| Rate for Payer: Cash Price |
$197.52
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$197.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.39
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.02
|
| Rate for Payer: Elderplan Medicare Advantage |
$197.52
|
| Rate for Payer: EmblemHealth Commercial |
$197.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$167.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$175.79
|
| Rate for Payer: Fidelis Medicare Advantage |
$197.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$175.79
|
| Rate for Payer: Group Health Inc Commercial |
$197.52
|
| Rate for Payer: Group Health Inc Medicare |
$197.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$217.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$197.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$197.52
|
| Rate for Payer: Healthfirst QHP |
$197.52
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$197.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$197.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$158.02
|
| Rate for Payer: Wellcare Medicare |
$177.77
|
|
|
CROSS PIN 1.7X10MM
|
Facility
OP
|
$113.30
|
|
| Hospital Charge Code |
64906002
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$39.66 |
| Max. Negotiated Rate |
$90.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$62.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$56.65
|
| Rate for Payer: Aetna Government |
$56.65
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$90.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$77.04
|
| Rate for Payer: Group Health Inc Commercial |
$56.65
|
| Rate for Payer: Group Health Inc Medicare |
$39.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.65
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$56.65
|
|
|
CROSS PIN 1.7X3MM
|
Facility
OP
|
$127.33
|
|
| Hospital Charge Code |
64906003
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$44.57 |
| Max. Negotiated Rate |
$101.86 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$70.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$63.66
|
| Rate for Payer: Aetna Government |
$63.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$101.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$86.58
|
| Rate for Payer: Group Health Inc Commercial |
$63.66
|
| Rate for Payer: Group Health Inc Medicare |
$44.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$63.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$63.66
|
|
|
CROTALIDAE ANTIVENOM 10 ML INJ - NF
|
Facility
OP
|
$1,172.00
|
|
| Hospital Charge Code |
41642303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$410.20 |
| Max. Negotiated Rate |
$937.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$644.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$586.00
|
| Rate for Payer: Aetna Government |
$586.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$937.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$796.96
|
| Rate for Payer: Group Health Inc Commercial |
$586.00
|
| Rate for Payer: Group Health Inc Medicare |
$410.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$586.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$586.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$761.80
|
|
|
CROTALIDAE ANTIVENOM 10 ML INJ - NF
|
Facility
OP
|
$1,172.00
|
|
| Hospital Charge Code |
41652303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$410.20 |
| Max. Negotiated Rate |
$937.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$644.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$586.00
|
| Rate for Payer: Aetna Government |
$586.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$937.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$796.96
|
| Rate for Payer: Group Health Inc Commercial |
$586.00
|
| Rate for Payer: Group Health Inc Medicare |
$410.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$586.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$586.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$761.80
|
|
|
CROWN 3/4 BASE METAL/BRIDGE
|
Facility
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS D6781
|
| Hospital Charge Code |
42303356
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$310.41 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$550.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$310.41
|
| Rate for Payer: Aetna Government |
$310.41
|
| 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 |
$500.00
|
| Rate for Payer: Group Health Inc Medicare |
$350.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$500.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$500.00
|
|
|
CROWN 3/4 NOBLE METAL/BRIDGE
|
Facility
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS D6782
|
| Hospital Charge Code |
42303357
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$288.22 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$550.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$288.22
|
| Rate for Payer: Aetna Government |
$288.22
|
| 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 |
$500.00
|
| Rate for Payer: Group Health Inc Medicare |
$350.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$500.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$500.00
|
|
|
CROWN 3/4 PORC/CERAM/BRIDGE
|
Facility
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS D6783
|
| Hospital Charge Code |
42303358
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$319.66 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$550.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$319.66
|
| Rate for Payer: Aetna Government |
$319.66
|
| 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 |
$500.00
|
| Rate for Payer: Group Health Inc Medicare |
$350.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$500.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$500.00
|
|
|
CROWN-BRIDGE RETAINER-RESIN PREDO
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D6721
|
| Hospital Charge Code |
42301535
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$304.96 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$687.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$304.96
|
| Rate for Payer: Aetna Government |
$304.96
|
| 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 |
$625.00
|
| Rate for Payer: Group Health Inc Medicare |
$437.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$625.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$625.00
|
|
|
CROWN-BRIDGE RETAINER-RESIN W/ HI
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D6720
|
| Hospital Charge Code |
42301530
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$321.08 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$687.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$321.08
|
| Rate for Payer: Aetna Government |
$321.08
|
| 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 |
$625.00
|
| Rate for Payer: Group Health Inc Medicare |
$437.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$625.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$625.00
|
|
|
CROWN-FULL CAST HIGH NOBLE METAL
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D2790
|
| Hospital Charge Code |
42300565
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$625.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$687.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$625.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
CROWN-FULL CAST NOBLE METAL
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D2792
|
| Hospital Charge Code |
42300575
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$625.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$687.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$625.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
CROWN-FULL CAST PREDOMINANTLY BAS
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D2791
|
| Hospital Charge Code |
42300570
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$625.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$687.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$625.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
