|
HC FOOT OR TOE SURGERY - UNLISTED
|
Facility
|
OP
|
$634.00
|
|
|
Service Code
|
CPT 28899
|
| Hospital Charge Code |
3612889901
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$205.16 |
| Max. Negotiated Rate |
$3,092.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$293.09
|
| Rate for Payer: Aetna Government |
$293.09
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$205.16
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$205.16
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$205.16
|
| Rate for Payer: Brighton Health Commercial |
$475.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$293.09
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,092.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,628.64
|
| Rate for Payer: Elderplan Medicare Advantage |
$293.09
|
| Rate for Payer: EmblemHealth Commercial |
$293.09
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$263.78
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$249.13
|
| Rate for Payer: Fidelis Essential Plan QHP |
$260.85
|
| Rate for Payer: Fidelis Medicare Advantage |
$293.09
|
| Rate for Payer: Fidelis Qualified Health Plan |
$260.85
|
| Rate for Payer: Group Health Inc Commercial |
$293.09
|
| Rate for Payer: Group Health Inc Medicare |
$293.09
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$293.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$293.09
|
| Rate for Payer: Healthfirst Medicare Advantage |
$249.13
|
| Rate for Payer: Healthfirst QHP |
$293.09
|
| Rate for Payer: Humana Medicare |
$298.95
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$293.09
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$293.09
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$293.09
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$278.44
|
| Rate for Payer: Wellcare Medicare |
$278.44
|
|
|
HC FORESKIN MANIP INCLUDING LYSIS
|
Facility
|
IP
|
$711.00
|
|
|
Service Code
|
CPT 54450
|
| Hospital Charge Code |
3615445001
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$355.50 |
| Max. Negotiated Rate |
$355.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$355.50
|
|
|
HC FORESKIN MANIP INCLUDING LYSIS
|
Facility
|
OP
|
$711.00
|
|
|
Service Code
|
CPT 54450
|
| Hospital Charge Code |
3615445001
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$64.93 |
| Max. Negotiated Rate |
$3,092.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$297.16
|
| Rate for Payer: Aetna Government |
$297.16
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$208.01
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$208.01
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$208.01
|
| Rate for Payer: Brighton Health Commercial |
$533.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$297.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,092.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,628.64
|
| Rate for Payer: Elderplan Medicare Advantage |
$297.16
|
| Rate for Payer: EmblemHealth Commercial |
$297.16
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$267.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$252.59
|
| Rate for Payer: Fidelis Essential Plan QHP |
$264.47
|
| Rate for Payer: Fidelis Medicare Advantage |
$297.16
|
| Rate for Payer: Fidelis Qualified Health Plan |
$264.47
|
| Rate for Payer: Group Health Inc Commercial |
$297.16
|
| Rate for Payer: Group Health Inc Medicare |
$297.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$297.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$130.70
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$64.93
|
| Rate for Payer: Healthfirst Medicare Advantage |
$252.59
|
| Rate for Payer: Healthfirst QHP |
$297.16
|
| Rate for Payer: Humana Medicare |
$303.10
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$297.16
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$297.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$297.16
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$282.30
|
| Rate for Payer: Wellcare Medicare |
$282.30
|
|
|
HC FRENULOTOMY PENIS
|
Facility
|
IP
|
$1,454.00
|
|
|
Service Code
|
CPT 54164
|
| Hospital Charge Code |
3615416401
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$727.00 |
| Max. Negotiated Rate |
$727.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$727.00
|
|
|
HC FRENULOTOMY PENIS
|
Facility
|
OP
|
$1,454.00
|
|
|
Service Code
|
CPT 54164
|
| Hospital Charge Code |
3615416401
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$225.91 |
| Max. Negotiated Rate |
$3,092.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,502.91
|
| Rate for Payer: Aetna Government |
$2,502.91
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,752.04
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,752.04
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,752.04
|
| Rate for Payer: Brighton Health Commercial |
$1,090.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2,502.91
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,092.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,628.64
|
| Rate for Payer: Elderplan Medicare Advantage |
$2,502.91
|
| Rate for Payer: EmblemHealth Commercial |
$2,502.91
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$2,252.62
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2,127.47
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2,227.59
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,502.91
|
| Rate for Payer: Fidelis Qualified Health Plan |
$2,227.59
|
| Rate for Payer: Group Health Inc Commercial |
$2,502.91
|
| Rate for Payer: Group Health Inc Medicare |
$2,502.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,502.91
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$959.88
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$225.91
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2,127.47
|
| Rate for Payer: Healthfirst QHP |
$2,502.91
|
| Rate for Payer: Humana Medicare |
$2,552.97
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,502.91
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,502.91
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,502.91
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,377.76
|
| Rate for Payer: Wellcare Medicare |
$2,377.76
|
|
|
HC FRESH FROZEN PLASMA, EACH UNIT
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
CPT P9017
|
| Hospital Charge Code |
383P901701
|
|
Hospital Revenue Code
|
383
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$51.00
|
|
|
HC FRESH FROZEN PLASMA, EACH UNIT
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
CPT P9017
|
| Hospital Charge Code |
383P901701
|
|
Hospital Revenue Code
|
383
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$105.05 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$56.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$102.99
|
| Rate for Payer: Aetna Government |
$102.99
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$72.09
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$72.09
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$72.09
|
| Rate for Payer: Brighton Health Commercial |
$102.99
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$102.99
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$81.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$69.36
|
| Rate for Payer: Elderplan Medicare Advantage |
$102.99
|
| Rate for Payer: EmblemHealth Commercial |
$102.99
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$92.69
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$87.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$91.66
|
| Rate for Payer: Fidelis Medicare Advantage |
$102.99
|
| Rate for Payer: Fidelis Qualified Health Plan |
$91.66
|
| Rate for Payer: Group Health Inc Commercial |
$102.99
|
| Rate for Payer: Group Health Inc Medicare |
$102.99
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$102.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$102.99
|
| Rate for Payer: Healthfirst Medicare Advantage |
$87.54
|
| Rate for Payer: Healthfirst QHP |
$102.99
|
| Rate for Payer: Humana Medicare |
$105.05
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$102.99
|
| Rate for Payer: United Healthcare Commercial |
$51.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$102.99
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$102.99
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$97.84
|
| Rate for Payer: Wellcare Medicare |
$92.69
|
|
|
HC FRESH FROZEN PLASMA, THAWING, EACH UNIT
|
Facility
|
IP
|
$459.00
|
|
|
Service Code
|
CPT 86927
|
| Hospital Charge Code |
3008692701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$229.50 |
| Max. Negotiated Rate |
$229.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$229.50
|
|
|
HC FRESH FROZEN PLASMA, THAWING, EACH UNIT
|
Facility
|
OP
|
$459.00
|
|
|
Service Code
|
CPT 86927
|
| Hospital Charge Code |
3008692701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$344.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$252.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$209.37
|
| Rate for Payer: Aetna Government |
$209.37
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$146.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$146.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$146.56
|
| Rate for Payer: Brighton Health Commercial |
$344.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$209.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.47
|
| Rate for Payer: Elderplan Medicare Advantage |
$209.37
|
| Rate for Payer: EmblemHealth Commercial |
$209.37
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$188.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$177.96
|
| Rate for Payer: Fidelis Essential Plan QHP |
$186.34
|
| Rate for Payer: Fidelis Medicare Advantage |
$209.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$186.34
|
| Rate for Payer: Group Health Inc Commercial |
$209.37
|
| Rate for Payer: Group Health Inc Medicare |
$209.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$209.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$209.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$209.37
|
| Rate for Payer: Healthfirst QHP |
$209.37
|
| Rate for Payer: Humana Medicare |
$213.56
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$209.37
|
| Rate for Payer: United Healthcare Commercial |
$13.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$209.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$209.37
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$198.90
|
| Rate for Payer: Wellcare Medicare |
$188.43
|
|
|
HC FROZEN BLOOD, EACH UNIT, FREEZING & THAWING
|
Facility
|
OP
|
$101.00
|
|
|
Service Code
|
CPT 86932
|
| Hospital Charge Code |
3008693201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.57 |
| Max. Negotiated Rate |
$80.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$55.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$47.96
|
| Rate for Payer: Aetna Government |
$47.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$33.57
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$33.57
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$33.57
|
| Rate for Payer: Brighton Health Commercial |
$75.75
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$47.96
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$80.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$67.71
|
| Rate for Payer: Elderplan Medicare Advantage |
$47.96
|
| Rate for Payer: EmblemHealth Commercial |
$47.96
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$43.16
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$40.77
|
| Rate for Payer: Fidelis Essential Plan QHP |
$42.68
|
| Rate for Payer: Fidelis Medicare Advantage |
$47.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$42.68
|
| Rate for Payer: Group Health Inc Commercial |
$47.96
|
| Rate for Payer: Group Health Inc Medicare |
$47.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$47.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$47.96
|
| Rate for Payer: Healthfirst Medicare Advantage |
$47.96
|
| Rate for Payer: Healthfirst QHP |
$47.96
|
| Rate for Payer: Humana Medicare |
$48.92
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$47.96
|
| Rate for Payer: United Healthcare Commercial |
$43.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$47.96
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$45.56
|
| Rate for Payer: Wellcare Medicare |
$43.16
|
|
|
HC FROZEN BLOOD, EACH UNIT, FREEZING & THAWING
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
CPT 86932
|
| Hospital Charge Code |
3008693201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$50.50 |
| Max. Negotiated Rate |
$50.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$50.50
|
|
|
HC FROZEN BLOOD, THAWING, EACH UNIT
|
Facility
|
OP
|
$388.00
|
|
|
Service Code
|
CPT 86931
|
| Hospital Charge Code |
3008693101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.76 |
| Max. Negotiated Rate |
$291.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$213.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$209.37
|
| Rate for Payer: Aetna Government |
$209.37
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$146.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$146.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$146.56
|
| Rate for Payer: Brighton Health Commercial |
$291.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$209.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$70.99
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$59.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$209.37
|
| Rate for Payer: EmblemHealth Commercial |
$209.37
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$188.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$177.96
|
| Rate for Payer: Fidelis Essential Plan QHP |
$186.34
|
| Rate for Payer: Fidelis Medicare Advantage |
$209.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$186.34
|
| Rate for Payer: Group Health Inc Commercial |
$209.37
|
| Rate for Payer: Group Health Inc Medicare |
$209.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$209.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$209.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$209.37
|
| Rate for Payer: Healthfirst QHP |
$209.37
|
| Rate for Payer: Humana Medicare |
$213.56
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$209.37
|
| Rate for Payer: United Healthcare Commercial |
$43.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$209.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$209.37
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$198.90
|
| Rate for Payer: Wellcare Medicare |
$188.43
|
|
|
HC FROZEN BLOOD, THAWING, EACH UNIT
|
Facility
|
IP
|
$388.00
|
|
|
Service Code
|
CPT 86931
|
| Hospital Charge Code |
3008693101
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$194.00 |
| Max. Negotiated Rate |
$194.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$194.00
|
|
|
HC FULL MOUTH X-RAY OF TEETH - XR TEETH FULL MOUTH
|
Facility
|
IP
|
$705.00
|
|
|
Service Code
|
CPT 70320 TC
|
| Hospital Charge Code |
3207032001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$352.50 |
| Max. Negotiated Rate |
$352.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$352.50
|
|
|
HC FULL MOUTH X-RAY OF TEETH - XR TEETH FULL MOUTH
|
Facility
|
OP
|
$705.00
|
|
|
Service Code
|
CPT 70320 TC
|
| Hospital Charge Code |
3207032001
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$31.66 |
| Max. Negotiated Rate |
$528.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$387.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$31.66
|
| Rate for Payer: Aetna Government |
$31.66
|
| Rate for Payer: Brighton Health Commercial |
$528.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$65.23
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$54.91
|
| Rate for Payer: EmblemHealth Commercial |
$45.62
|
| Rate for Payer: Group Health Inc Commercial |
$352.50
|
| Rate for Payer: Group Health Inc Medicare |
$246.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$352.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$352.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$45.62
|
| Rate for Payer: Healthfirst Essential Plan |
$84.15
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$37.40
|
|
|
HC FUNCTIONAL STATUS ASSESSED
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
CPT 1170F
|
| Hospital Charge Code |
9691170F01
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.00
|
|
|
HC FUNCTIONAL STATUS ASSESSED
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
CPT 1170F
|
| Hospital Charge Code |
9691170F01
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$7.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.80
|
| Rate for Payer: EmblemHealth Commercial |
$5.00
|
| Rate for Payer: Group Health Inc Commercial |
$5.00
|
| Rate for Payer: Group Health Inc Medicare |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.00
|
|
|
HC FUNDAL PHOTOGRAPHY - AUTOFLUORESCENCE - OD - RIGHT EYE
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
CPT 92250
|
| Hospital Charge Code |
9209225002
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$41.41 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$181.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$157.49
|
| Rate for Payer: Aetna Government |
$157.49
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$110.24
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$110.24
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$110.24
|
| Rate for Payer: Brighton Health Commercial |
$247.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$157.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$264.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$224.40
|
| Rate for Payer: Elderplan Medicare Advantage |
$157.49
|
| Rate for Payer: EmblemHealth Commercial |
$157.49
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$141.74
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$133.87
|
| Rate for Payer: Fidelis Essential Plan QHP |
$140.17
|
| Rate for Payer: Fidelis Medicare Advantage |
$157.49
|
| Rate for Payer: Fidelis Qualified Health Plan |
$140.17
|
| Rate for Payer: Group Health Inc Commercial |
$157.49
|
| Rate for Payer: Group Health Inc Medicare |
$157.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$157.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$157.49
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$41.41
|
| Rate for Payer: Healthfirst Medicare Advantage |
$133.87
|
| Rate for Payer: Healthfirst QHP |
$157.49
|
| Rate for Payer: Humana Medicare |
$160.64
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$157.49
|
| Rate for Payer: United Healthcare Commercial |
$94.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$157.49
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$157.49
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$149.62
|
| Rate for Payer: Wellcare Medicare |
$149.62
|
|
|
HC FUNDAL PHOTOGRAPHY - AUTOFLUORESCENCE - OD - RIGHT EYE
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
CPT 92250
|
| Hospital Charge Code |
9209225002
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$165.00
|
|
|
HC FUNDAL PHOTOGRAPHY - AUTOFLUORESCENCE - OS - LEFT EYE
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
CPT 92250
|
| Hospital Charge Code |
9209225003
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$165.00
|
|
|
HC FUNDAL PHOTOGRAPHY - AUTOFLUORESCENCE - OS - LEFT EYE
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
CPT 92250
|
| Hospital Charge Code |
9209225003
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$41.41 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$181.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$157.49
|
| Rate for Payer: Aetna Government |
$157.49
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$110.24
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$110.24
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$110.24
|
| Rate for Payer: Brighton Health Commercial |
$247.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$157.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$264.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$224.40
|
| Rate for Payer: Elderplan Medicare Advantage |
$157.49
|
| Rate for Payer: EmblemHealth Commercial |
$157.49
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$141.74
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$133.87
|
| Rate for Payer: Fidelis Essential Plan QHP |
$140.17
|
| Rate for Payer: Fidelis Medicare Advantage |
$157.49
|
| Rate for Payer: Fidelis Qualified Health Plan |
$140.17
|
| Rate for Payer: Group Health Inc Commercial |
$157.49
|
| Rate for Payer: Group Health Inc Medicare |
$157.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$157.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$157.49
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$41.41
|
| Rate for Payer: Healthfirst Medicare Advantage |
$133.87
|
| Rate for Payer: Healthfirst QHP |
$157.49
|
| Rate for Payer: Humana Medicare |
$160.64
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$157.49
|
| Rate for Payer: United Healthcare Commercial |
$94.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$157.49
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$157.49
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$149.62
|
| Rate for Payer: Wellcare Medicare |
$149.62
|
|
|
HC FUNDAL PHOTOGRAPHY - AUTOFLUORESCENCE - OU - BOTH EYES
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
CPT 92250
|
| Hospital Charge Code |
9209225004
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$165.00
|
|
|
HC FUNDAL PHOTOGRAPHY - AUTOFLUORESCENCE - OU - BOTH EYES
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
CPT 92250
|
| Hospital Charge Code |
9209225004
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$41.41 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$181.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$157.49
|
| Rate for Payer: Aetna Government |
$157.49
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$110.24
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$110.24
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$110.24
|
| Rate for Payer: Brighton Health Commercial |
$247.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$157.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$264.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$224.40
|
| Rate for Payer: Elderplan Medicare Advantage |
$157.49
|
| Rate for Payer: EmblemHealth Commercial |
$157.49
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$141.74
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$133.87
|
| Rate for Payer: Fidelis Essential Plan QHP |
$140.17
|
| Rate for Payer: Fidelis Medicare Advantage |
$157.49
|
| Rate for Payer: Fidelis Qualified Health Plan |
$140.17
|
| Rate for Payer: Group Health Inc Commercial |
$157.49
|
| Rate for Payer: Group Health Inc Medicare |
$157.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$157.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$157.49
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$41.41
|
| Rate for Payer: Healthfirst Medicare Advantage |
$133.87
|
| Rate for Payer: Healthfirst QHP |
$157.49
|
| Rate for Payer: Humana Medicare |
$160.64
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$157.49
|
| Rate for Payer: United Healthcare Commercial |
$94.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$157.49
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$157.49
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$149.62
|
| Rate for Payer: Wellcare Medicare |
$149.62
|
|
|
HC FUNDAL PHOTOGRAPHY - FUNDUS PHOTOS - OD - RIGHT EYE
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
CPT 92250
|
| Hospital Charge Code |
9209225005
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$41.41 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$181.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$157.49
|
| Rate for Payer: Aetna Government |
$157.49
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$110.24
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$110.24
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$110.24
|
| Rate for Payer: Brighton Health Commercial |
$247.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$157.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$264.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$224.40
|
| Rate for Payer: Elderplan Medicare Advantage |
$157.49
|
| Rate for Payer: EmblemHealth Commercial |
$157.49
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$141.74
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$133.87
|
| Rate for Payer: Fidelis Essential Plan QHP |
$140.17
|
| Rate for Payer: Fidelis Medicare Advantage |
$157.49
|
| Rate for Payer: Fidelis Qualified Health Plan |
$140.17
|
| Rate for Payer: Group Health Inc Commercial |
$157.49
|
| Rate for Payer: Group Health Inc Medicare |
$157.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$157.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$157.49
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$41.41
|
| Rate for Payer: Healthfirst Medicare Advantage |
$133.87
|
| Rate for Payer: Healthfirst QHP |
$157.49
|
| Rate for Payer: Humana Medicare |
$160.64
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$157.49
|
| Rate for Payer: United Healthcare Commercial |
$94.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$157.49
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$157.49
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$149.62
|
| Rate for Payer: Wellcare Medicare |
$149.62
|
|
|
HC FUNDAL PHOTOGRAPHY - FUNDUS PHOTOS - OD - RIGHT EYE
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
CPT 92250
|
| Hospital Charge Code |
9209225005
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$165.00
|
|
