|
DENTAL CASE MGMT SPECIAL NEEDS
|
Facility
OP
|
$530.00
|
|
|
Service Code
|
HCPCS D9997
|
| Hospital Charge Code |
42301001
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$65.75 |
| Max. Negotiated Rate |
$6,575.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$291.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$265.00
|
| Rate for Payer: Aetna Government |
$265.00
|
| Rate for Payer: Amida Care Medicaid |
$65.75
|
| 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: Fidelis CHP/HARP/Medicaid |
$6,575.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$65.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$65.75
|
| Rate for Payer: Fidelis Qualified Health Plan |
$69.04
|
| Rate for Payer: Group Health Inc Commercial |
$265.00
|
| Rate for Payer: Group Health Inc Medicare |
$185.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$65.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$265.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$65.75
|
| Rate for Payer: Healthfirst Essential Plan |
$147.94
|
| Rate for Payer: Healthfirst QHP |
$65.75
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$65.75
|
| Rate for Payer: SOMOS Essential |
$147.94
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$65.75
|
|
|
DENTAL GUARD
|
Facility
OP
|
$10.82
|
|
| Hospital Charge Code |
64904309
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$8.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.41
|
| Rate for Payer: Aetna Government |
$5.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.36
|
| Rate for Payer: Group Health Inc Commercial |
$5.41
|
| Rate for Payer: Group Health Inc Medicare |
$3.79
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.41
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.41
|
|
|
DENTAL SURGERY
|
Facility
OP
|
$651.23
|
|
|
Service Code
|
HCPCS 41899
|
| Hospital Charge Code |
42301002
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$225.98 |
| Max. Negotiated Rate |
$142,987.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,880.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$282.47
|
| Rate for Payer: Aetna Government |
$282.47
|
| Rate for Payer: Amida Care Medicaid |
$1,429.87
|
| Rate for Payer: Cash Price |
$282.47
|
| Rate for Payer: Cash Price |
$282.47
|
| Rate for Payer: Cash Price |
$282.47
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$282.47
|
| 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 |
$282.47
|
| Rate for Payer: EmblemHealth Commercial |
$282.47
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$142,987.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,429.87
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,429.87
|
| Rate for Payer: Fidelis Medicare Advantage |
$282.47
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,501.36
|
| Rate for Payer: Group Health Inc Commercial |
$282.47
|
| Rate for Payer: Group Health Inc Medicare |
$282.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,429.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$282.47
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,429.87
|
| Rate for Payer: Healthfirst Essential Plan |
$3,217.21
|
| Rate for Payer: Healthfirst Medicare Advantage |
$240.10
|
| Rate for Payer: Healthfirst QHP |
$1,429.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$282.47
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,429.87
|
| Rate for Payer: SOMOS Essential |
$3,217.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$282.47
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$225.98
|
| Rate for Payer: Wellcare Medicare |
$268.35
|
|
|
DEPRESSIVE NEUROSES
|
Facility
IP
|
$20,296.58
|
|
|
Service Code
|
MS-DRG 881
|
| Min. Negotiated Rate |
$905.00 |
| Max. Negotiated Rate |
$20,296.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,859.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19,898.61
|
| Rate for Payer: Aetna Government |
$19,898.61
|
| Rate for Payer: Brighton Health Commercial |
$13,144.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$20,296.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15,654.35
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12,918.64
|
| Rate for Payer: Elderplan Medicare Advantage |
$18,903.68
|
| Rate for Payer: EmblemHealth Commercial |
$905.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$19,898.61
|
| Rate for Payer: Group Health Inc Commercial |
$19,898.61
|
| Rate for Payer: Group Health Inc Medicare |
$19,898.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19,898.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$9,252.85
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$19,898.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19,898.61
|
| Rate for Payer: Wellcare Medicare |
$18,903.68
|
|
|
DEPUY 1745-70-000
|
Facility
OP
|
$920.00
|
|
| Hospital Charge Code |
40029566
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$322.00 |
| Max. Negotiated Rate |
$736.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$506.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$460.00
|
| Rate for Payer: Aetna Government |
$460.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$736.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$625.60
|
| Rate for Payer: Group Health Inc Commercial |
$460.00
|
| Rate for Payer: Group Health Inc Medicare |
$322.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$460.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$460.00
|
|
|
DEPUY 7X40MM POLY SCREW
|
Facility
OP
|
$3,930.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40205631
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$4,126.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,161.50
|
| 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 |
$1,965.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,259.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,126.50
|
| Rate for Payer: Group Health Inc Commercial |
$1,965.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,375.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,965.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,965.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,554.50
|
|
|
DEPUY 7X40MM POLY SCREW
|
Facility
IP
|
$3,930.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40205631
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,965.00 |
| Max. Negotiated Rate |
$1,965.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,965.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,965.00
|
|
|
DEPUY ANGLED HOOK
|
Facility
OP
|
$2,050.00
|
|
| Hospital Charge Code |
40024017
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$717.50 |
| Max. Negotiated Rate |
$1,640.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,127.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,025.00
|
| Rate for Payer: Aetna Government |
$1,025.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,640.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,394.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,025.00
|
| Rate for Payer: Group Health Inc Medicare |
$717.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,025.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,025.00
|
|
|
DEPUY ANGLED SPR LAM HOOK
|
Facility
OP
|
$2,050.00
|
|
| Hospital Charge Code |
40029555
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$717.50 |
| Max. Negotiated Rate |
$1,640.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,127.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,025.00
|
| Rate for Payer: Aetna Government |
$1,025.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,640.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,394.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,025.00
|
| Rate for Payer: Group Health Inc Medicare |
$717.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,025.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,025.00
|
|
|
DEPUY ARTICULEZE HEAD 28-5
|
Facility
IP
|
$2,090.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40029551
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,045.00 |
| Max. Negotiated Rate |
$1,045.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,045.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,045.00
|
|
|
DEPUY ARTICULEZE HEAD 28-5
|
Facility
OP
|
$2,090.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40029551
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$2,194.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,149.50
|
| 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 |
$1,045.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,201.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,194.50
|
| Rate for Payer: Group Health Inc Commercial |
$1,045.00
|
| Rate for Payer: Group Health Inc Medicare |
$731.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,045.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,045.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,358.50
|
|
|
DEPUY ASSEMBLY CONNECTOR TRANSV
|
Facility
OP
|
$1,360.00
|
|
| Hospital Charge Code |
40029559
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$476.00 |
| Max. Negotiated Rate |
$1,088.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$748.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$680.00
|
| Rate for Payer: Aetna Government |
$680.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,088.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$924.80
|
| Rate for Payer: Group Health Inc Commercial |
$680.00
|
| Rate for Payer: Group Health Inc Medicare |
$476.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$680.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$680.00
|
|
|
DEPUY CONDUCT 10CC
|
Facility
OP
|
$1,500.00
|
|
| Hospital Charge Code |
40029558
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$825.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$750.00
|
| Rate for Payer: Aetna Government |
$750.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,200.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,020.00
|
| Rate for Payer: Group Health Inc Commercial |
$750.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$750.00
|
|
|
DEPUY CONDUCT 50
|
Facility
OP
|
$2,400.00
|
|
| Hospital Charge Code |
40029549
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,320.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,200.00
|
| Rate for Payer: Aetna Government |
$1,200.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,920.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,632.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,200.00
|
| Rate for Payer: Group Health Inc Medicare |
$840.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,200.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,200.00
|
|
|
DEPUY CONDUIT TCP 10CC
|
Facility
OP
|
$1,200.00
|
|
| Hospital Charge Code |
40009358
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$420.00 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$660.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$600.00
|
| Rate for Payer: Aetna Government |
$600.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$960.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$816.00
|
| Rate for Payer: Group Health Inc Commercial |
$600.00
|
| Rate for Payer: Group Health Inc Medicare |
$420.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$600.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$600.00
|
|
|
DEPUY CONDUIT TCP 10CC
|
Facility
OP
|
$1,200.00
|
|
| Hospital Charge Code |
40203374
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$420.00 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$660.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$600.00
|
| Rate for Payer: Aetna Government |
$600.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$960.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$816.00
|
| Rate for Payer: Group Health Inc Commercial |
$600.00
|
| Rate for Payer: Group Health Inc Medicare |
$420.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$600.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$600.00
|
|
|
DEPUY EXTENDED BODY HOOK
|
Facility
OP
|
$2,050.00
|
|
| Hospital Charge Code |
40024018
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$717.50 |
| Max. Negotiated Rate |
$1,640.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,127.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,025.00
|
| Rate for Payer: Aetna Government |
$1,025.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,640.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,394.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,025.00
|
| Rate for Payer: Group Health Inc Medicare |
$717.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,025.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,025.00
|
|
|
DEPUY F/A SCREWS 14MM
|
Facility
IP
|
$3,400.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40200941
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,700.00 |
| Max. Negotiated Rate |
$1,700.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,700.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,700.00
|
|
|
DEPUY F/A SCREWS 14MM
|
Facility
OP
|
$3,400.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40200941
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$3,570.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,870.00
|
| 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 |
$1,700.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,955.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,570.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,700.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,190.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,700.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,700.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,210.00
|
|
|
DEPUY FEMORAL HEAD
|
Facility
OP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40200942
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$3,675.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,925.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,750.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,012.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,675.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,750.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,225.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,750.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,275.00
|
|
|
DEPUY FEMORAL HEAD
|
Facility
IP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40200942
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,750.00 |
| Max. Negotiated Rate |
$1,750.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,750.00
|
|
|
DEPUY GRANLS CONDUIT TCP 30CC
|
Facility
OP
|
$2,400.00
|
|
| Hospital Charge Code |
40029550
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,320.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,200.00
|
| Rate for Payer: Aetna Government |
$1,200.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,920.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,632.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,200.00
|
| Rate for Payer: Group Health Inc Medicare |
$840.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,200.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,200.00
|
|
|
DEPUY GRANULES CONDUIT TCP 30CC V
|
Facility
OP
|
$2,310.00
|
|
| Hospital Charge Code |
40009351
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$808.50 |
| Max. Negotiated Rate |
$1,848.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,270.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,155.00
|
| Rate for Payer: Aetna Government |
$1,155.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,848.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,570.80
|
| Rate for Payer: Group Health Inc Commercial |
$1,155.00
|
| Rate for Payer: Group Health Inc Medicare |
$808.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,155.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,155.00
|
|
|
DEPUY GRANULES CONDUIT TCP 30CC V
|
Facility
OP
|
$2,310.00
|
|
| Hospital Charge Code |
40203368
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$808.50 |
| Max. Negotiated Rate |
$1,848.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,270.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,155.00
|
| Rate for Payer: Aetna Government |
$1,155.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,848.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,570.80
|
| Rate for Payer: Group Health Inc Commercial |
$1,155.00
|
| Rate for Payer: Group Health Inc Medicare |
$808.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,155.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,155.00
|
|
|
DEPUY HOOK LAM ANG BLD 5.0 SS
|
Facility
OP
|
$1,240.00
|
|
| Hospital Charge Code |
40029564
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$434.00 |
| Max. Negotiated Rate |
$992.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$682.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$620.00
|
| Rate for Payer: Aetna Government |
$620.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$992.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$843.20
|
| Rate for Payer: Group Health Inc Commercial |
$620.00
|
| Rate for Payer: Group Health Inc Medicare |
$434.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$620.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$620.00
|
|
