|
CROWN LENGTHENING-HARD & SOFT TIS
|
Facility
OP
|
$728.60
|
|
|
Service Code
|
HCPCS D4249
|
| Hospital Charge Code |
42300860
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$171.11 |
| Max. Negotiated Rate |
$17,111.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$400.73
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Amida Care Medicaid |
$171.11
|
| 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 CHP/HARP/Medicaid |
$17,111.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$171.11
|
| Rate for Payer: Fidelis Essential Plan QHP |
$171.11
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$179.67
|
| 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 |
$171.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$171.11
|
| Rate for Payer: Healthfirst Essential Plan |
$385.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$171.11
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$171.11
|
| Rate for Payer: SOMOS Essential |
$385.00
|
| 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 PORCELAIN/CERAMIC BRIDGE
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D6740
|
| Hospital Charge Code |
42303328
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$337.82 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$687.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$337.82
|
| Rate for Payer: Aetna Government |
$337.82
|
| 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-PORCELAIN/CERAMIC SUBSTRATE
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D2740
|
| Hospital Charge Code |
42300545
|
|
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-PORCELAIN FUSED TO HIGH NOB
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D2750
|
| Hospital Charge Code |
42300550
|
|
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-PORCELAIN FUSED TO NOBLE ME
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D2752
|
| Hospital Charge Code |
42300560
|
|
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-PORCELAIN FUSED TO TITANIUM
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D2753
|
| Hospital Charge Code |
42300718
|
|
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-PORC FUSED TO PREDOMINANTLY
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D2751
|
| Hospital Charge Code |
42300555
|
|
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 REPAIR, BY REPORT
|
Facility
OP
|
$354.38
|
|
|
Service Code
|
HCPCS D2980
|
| Hospital Charge Code |
42300685
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$177.19 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$194.91
|
| 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 |
$177.19
|
| 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-RESIN-LABORATORY
|
Facility
OP
|
$725.00
|
|
|
Service Code
|
HCPCS D2710
|
| Hospital Charge Code |
42300520
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$362.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$398.75
|
| 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 |
$362.50
|
| 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-RESIN WITH HIGH NOBLE METAL
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D2720
|
| Hospital Charge Code |
42300530
|
|
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-RESIN WITH NOBLE METAL
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D2722
|
| Hospital Charge Code |
42300540
|
|
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-RESIN WITH PREDOMINANTLY BA
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D2721
|
| Hospital Charge Code |
42300535
|
|
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-RETAINER 3/4 CAST HIGH NOBL
|
Facility
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS D6780
|
| Hospital Charge Code |
42301560
|
|
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-RETAINER-FULL CAST HIGH NOB
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D6790
|
| Hospital Charge Code |
42301565
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$317.64 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$687.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$317.64
|
| Rate for Payer: Aetna Government |
$317.64
|
| 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 |
$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-RETAINER-FULL CAST NOBLE ME
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D6792
|
| Hospital Charge Code |
42301575
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$312.20 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$687.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$312.20
|
| Rate for Payer: Aetna Government |
$312.20
|
| 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-RETAINER-FULL CAST PREDOM.
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D6791
|
| Hospital Charge Code |
42301570
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$300.90 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$687.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$300.90
|
| Rate for Payer: Aetna Government |
$300.90
|
| 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-RETAINER-PORCELAIN FUSED HI
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D6750
|
| Hospital Charge Code |
42301545
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$328.79 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$687.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$328.79
|
| Rate for Payer: Aetna Government |
$328.79
|
| 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-RETAINER-PORCELAIN FUSED PR
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D6751
|
| Hospital Charge Code |
42301550
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$307.45 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$687.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$307.45
|
| Rate for Payer: Aetna Government |
$307.45
|
| 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-RETAINER-PORCELAIN FUSED TO
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D6752
|
| Hospital Charge Code |
42301555
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$314.69 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$687.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$314.69
|
| Rate for Payer: Aetna Government |
$314.69
|
| 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-RETAINER-RESIN WITH NOBLE M
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D6722
|
| Hospital Charge Code |
42301540
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$310.41 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$687.50
|
| 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 |
$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-TITANIUM AND TITANIUM ALLOY
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS D2794
|
| Hospital Charge Code |
42300719
|
|
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
|
|
|
CRTD DTMB1D1 AMPLIA
|
Facility
OP
|
$52,900.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
64907324
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$18,515.00 |
| Max. Negotiated Rate |
$55,545.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$29,095.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26,450.00
|
| Rate for Payer: Aetna Government |
$26,450.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$26,450.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$30,417.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$55,545.00
|
| Rate for Payer: Group Health Inc Commercial |
$26,450.00
|
| Rate for Payer: Group Health Inc Medicare |
$18,515.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26,450.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26,450.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34,385.00
|
|
|
CRTD DTMB1D1 AMPLIA
|
Facility
IP
|
$52,900.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
64907324
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$26,450.00 |
| Max. Negotiated Rate |
$26,450.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26,450.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26,450.00
|
|
|
CRUCIATE RETAINING 14MM
|
Facility
OP
|
$4,192.63
|
|
| Hospital Charge Code |
64906057
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,467.42 |
| Max. Negotiated Rate |
$3,354.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,305.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,096.32
|
| Rate for Payer: Aetna Government |
$2,096.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,354.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,850.99
|
| Rate for Payer: Group Health Inc Commercial |
$2,096.32
|
| Rate for Payer: Group Health Inc Medicare |
$1,467.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,096.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,096.32
|
|
|
CRYOCAUTERY OF CERVIX
|
Facility
OP
|
$819.95
|
|
|
Service Code
|
HCPCS 57511
|
| Hospital Charge Code |
30301250
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$164.83 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$370.99
|
| Rate for Payer: Aetna Government |
$370.99
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$370.99
|
| Rate for Payer: Cash Price |
$370.99
|
| Rate for Payer: Cash Price |
$370.99
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$370.99
|
| 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 |
$370.99
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$164.83
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$315.34
|
| Rate for Payer: Fidelis Essential Plan QHP |
$330.18
|
| Rate for Payer: Fidelis Medicare Advantage |
$370.99
|
| Rate for Payer: Fidelis Qualified Health Plan |
$330.18
|
| 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 |
$409.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$370.99
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$183.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$315.34
|
| Rate for Payer: Healthfirst QHP |
$370.99
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$370.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$370.99
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$370.99
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$296.79
|
| Rate for Payer: Wellcare Medicare |
$352.44
|
|
