|
Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children
|
Facility
OP
|
$2,915.00
|
|
|
Service Code
|
CPT 15115
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$762.01 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,108.87
|
| Rate for Payer: Aetna Government |
$2,108.87
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2,108.87
|
| 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 |
$2,108.87
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$762.01
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,792.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,876.89
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,108.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,876.89
|
| Rate for Payer: Group Health Inc Commercial |
$2,108.87
|
| Rate for Payer: Group Health Inc Medicare |
$2,108.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,108.87
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$846.68
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,792.54
|
| Rate for Payer: Healthfirst QHP |
$2,108.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,108.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,108.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,687.10
|
| Rate for Payer: Wellcare Medicare |
$2,003.43
|
|
|
EPIDIDYMECTOMY
|
Facility
OP
|
$9,142.40
|
|
|
Service Code
|
HCPCS 54861
|
| Hospital Charge Code |
40122985
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$613.62 |
| Max. Negotiated Rate |
$4,571.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,485.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,031.47
|
| Rate for Payer: Aetna Government |
$4,031.47
|
| Rate for Payer: Cash Price |
$4,031.47
|
| Rate for Payer: Cash Price |
$4,031.47
|
| Rate for Payer: Cash Price |
$4,031.47
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4,031.47
|
| 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 |
$4,031.47
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$613.62
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,426.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,588.01
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,031.47
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,588.01
|
| Rate for Payer: Group Health Inc Commercial |
$4,031.47
|
| Rate for Payer: Group Health Inc Medicare |
$4,031.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,571.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,031.47
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$681.80
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,426.75
|
| Rate for Payer: Healthfirst QHP |
$4,031.47
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4,031.47
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4,031.47
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3,225.18
|
| Rate for Payer: Wellcare Medicare |
$3,829.90
|
|
|
EPIDURAL BLOOD CLOT PATCH
|
Facility
OP
|
$1,893.13
|
|
|
Service Code
|
HCPCS 62273
|
| Hospital Charge Code |
40009628
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$120.58 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$799.72
|
| Rate for Payer: Aetna Government |
$799.72
|
| Rate for Payer: Cash Price |
$799.72
|
| Rate for Payer: Cash Price |
$799.72
|
| Rate for Payer: Cash Price |
$799.72
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$799.72
|
| 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 |
$799.72
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$120.58
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$679.76
|
| Rate for Payer: Fidelis Essential Plan QHP |
$711.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$799.72
|
| Rate for Payer: Fidelis Qualified Health Plan |
$711.75
|
| Rate for Payer: Group Health Inc Commercial |
$799.72
|
| Rate for Payer: Group Health Inc Medicare |
$799.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$946.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$799.72
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$133.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$679.76
|
| Rate for Payer: Healthfirst QHP |
$799.72
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$799.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$799.72
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$639.78
|
| Rate for Payer: Wellcare Medicare |
$759.73
|
|
|
EPIDURAL BLOOD PATCH
|
Facility
OP
|
$1,893.13
|
|
|
Service Code
|
HCPCS 62273
|
| Hospital Charge Code |
41101549
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$120.58 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$799.72
|
| Rate for Payer: Aetna Government |
$799.72
|
| Rate for Payer: Cash Price |
$799.72
|
| Rate for Payer: Cash Price |
$799.72
|
| Rate for Payer: Cash Price |
$799.72
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$799.72
|
| 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 |
$799.72
|
| Rate for Payer: EmblemHealth Commercial |
$799.72
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$120.58
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$679.76
|
| Rate for Payer: Fidelis Essential Plan QHP |
$711.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$799.72
|
| Rate for Payer: Fidelis Qualified Health Plan |
$711.75
|
| Rate for Payer: Group Health Inc Commercial |
$799.72
|
| Rate for Payer: Group Health Inc Medicare |
$799.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$946.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$799.72
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$133.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$679.76
|
| Rate for Payer: Healthfirst QHP |
$799.72
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$799.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$799.72
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$639.78
|
| Rate for Payer: Wellcare Medicare |
$759.73
|
|
|
EPIDURAL LYSIS ON SINGLE DAY
|
Facility
OP
|
$2,459.50
|
|
|
Service Code
|
HCPCS 62264
|
| Hospital Charge Code |
40004069
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$260.55 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,054.06
|
| Rate for Payer: Aetna Government |
$1,054.06
|
| Rate for Payer: Cash Price |
$1,054.06
|
| Rate for Payer: Cash Price |
$1,054.06
|
| Rate for Payer: Cash Price |
$1,054.06
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,054.06
|
| 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 |
$1,054.06
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$260.55
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$895.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$938.11
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,054.06
|
| Rate for Payer: Fidelis Qualified Health Plan |
$938.11
|
| Rate for Payer: Group Health Inc Commercial |
$1,054.06
|
| Rate for Payer: Group Health Inc Medicare |
$1,054.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,229.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,054.06
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$289.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$895.95
|
| Rate for Payer: Healthfirst QHP |
$1,054.06
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,054.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,054.06
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$843.25
|
| Rate for Payer: Wellcare Medicare |
$1,001.36
|
|
|
EPIFIX 14MM DISK
|
Facility
IP
|
$53.00
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
64905605
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.50 |
| Max. Negotiated Rate |
$26.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.50
|
|
|
EPIFIX 14MM DISK
|
Facility
OP
|
$53.00
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
64905605
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.55 |
| Max. Negotiated Rate |
$162.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$29.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$155.49
|
| Rate for Payer: Aetna Government |
$155.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$26.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$30.48
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$133.94
|
| Rate for Payer: Group Health Inc Commercial |
$26.50
|
| Rate for Payer: Group Health Inc Medicare |
$18.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$148.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$162.66
|
| Rate for Payer: SOMOS Essential |
$162.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34.45
|
|
|
EPIFIX 1 SQ CM
|
Facility
IP
|
$535.00
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
42501056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$267.50 |
| Max. Negotiated Rate |
$267.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.50
|
|
|
EPIFIX 1 SQ CM
|
Facility
OP
|
$535.00
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
30307932
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.94 |
| Max. Negotiated Rate |
$347.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$294.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$155.49
|
| Rate for Payer: Aetna Government |
$155.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$267.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$307.62
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$133.94
|
| Rate for Payer: Group Health Inc Commercial |
$267.50
|
| Rate for Payer: Group Health Inc Medicare |
$187.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$148.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$162.66
|
| Rate for Payer: SOMOS Essential |
$162.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$347.75
|
|
|
EPIFIX 1 SQ CM
|
Facility
IP
|
$535.00
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
30307932
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$267.50 |
| Max. Negotiated Rate |
$267.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.50
|
|
|
EPIFIX 1 SQ CM
|
Facility
OP
|
$535.00
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
42501056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.94 |
| Max. Negotiated Rate |
$347.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$294.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$155.49
|
| Rate for Payer: Aetna Government |
$155.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$267.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$307.62
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$133.94
|
| Rate for Payer: Group Health Inc Commercial |
$267.50
|
| Rate for Payer: Group Health Inc Medicare |
$187.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$148.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$162.66
|
| Rate for Payer: SOMOS Essential |
$162.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$347.75
|
|
|
EPIFIX 2 X 3 CM
|
Facility
OP
|
$497.92
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
64903221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.94 |
| Max. Negotiated Rate |
$323.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$273.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$155.49
|
| Rate for Payer: Aetna Government |
$155.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$248.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$286.30
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$133.94
|
| Rate for Payer: Group Health Inc Commercial |
$248.96
|
| Rate for Payer: Group Health Inc Medicare |
$174.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$248.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$248.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$148.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$162.66
|
| Rate for Payer: SOMOS Essential |
$162.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$323.65
|
|
|
EPIFIX 2 X 3 CM
|
Facility
IP
|
$497.92
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
64903221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$248.96 |
| Max. Negotiated Rate |
$248.96 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$248.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$248.96
|
|
|
EPIFIX 4 X 4CM
|
Facility
OP
|
$529.22
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
64903222
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.94 |
| Max. Negotiated Rate |
$343.99 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$291.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$155.49
|
| Rate for Payer: Aetna Government |
$155.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$264.61
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$304.30
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$133.94
|
| Rate for Payer: Group Health Inc Commercial |
$264.61
|
| Rate for Payer: Group Health Inc Medicare |
$185.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$264.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$264.61
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$148.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$162.66
|
| Rate for Payer: SOMOS Essential |
$162.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$343.99
|
|
|
EPIFIX 4 X 4CM
|
Facility
IP
|
$529.22
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
64903222
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$264.61 |
| Max. Negotiated Rate |
$264.61 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$264.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$264.61
|
|
|
EPIFIX 5X6CM (GS-5560)
|
Facility
OP
|
$108.33
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
64901198
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.92 |
| Max. Negotiated Rate |
$162.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$59.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$155.49
|
| Rate for Payer: Aetna Government |
$155.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$54.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$62.29
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$133.94
|
| Rate for Payer: Group Health Inc Commercial |
$54.16
|
| Rate for Payer: Group Health Inc Medicare |
$37.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$54.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$54.16
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$148.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$162.66
|
| Rate for Payer: SOMOS Essential |
$162.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$70.41
|
|
|
EPIFIX 5X6CM (GS-5560)
|
Facility
IP
|
$108.33
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
64901198
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.16 |
| Max. Negotiated Rate |
$54.16 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$54.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$54.16
|
|
|
EPIFIX, PER SQ CM
|
Facility
OP
|
$535.00
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
30305451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.94 |
| Max. Negotiated Rate |
$347.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$294.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$155.49
|
| Rate for Payer: Aetna Government |
$155.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$267.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$307.62
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$133.94
|
| Rate for Payer: Group Health Inc Commercial |
$267.50
|
| Rate for Payer: Group Health Inc Medicare |
$187.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$148.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$162.66
|
| Rate for Payer: SOMOS Essential |
$162.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$347.75
|
|
|
EPIFIX, PER SQ CM
|
Facility
OP
|
$219.52
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
42500457
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.83 |
| Max. Negotiated Rate |
$162.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$155.49
|
| Rate for Payer: Aetna Government |
$155.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$109.76
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$126.22
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$133.94
|
| Rate for Payer: Group Health Inc Commercial |
$109.76
|
| Rate for Payer: Group Health Inc Medicare |
$76.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$109.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$109.76
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$148.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$162.66
|
| Rate for Payer: SOMOS Essential |
$162.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$142.69
|
|
|
EPIFIX, PER SQ CM
|
Facility
IP
|
$219.52
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
42500457
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.76 |
| Max. Negotiated Rate |
$109.76 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$109.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$109.76
|
|
|
EPIFIX, PER SQ CM
|
Facility
IP
|
$535.00
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
30305451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$267.50 |
| Max. Negotiated Rate |
$267.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.50
|
|
|
EPILATION BY FORCEPS
|
Facility
OP
|
$330.23
|
|
|
Service Code
|
HCPCS 67820
|
| Hospital Charge Code |
42101701
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$23.18 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$147.72
|
| Rate for Payer: Aetna Government |
$147.72
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$147.72
|
| Rate for Payer: Cash Price |
$147.72
|
| Rate for Payer: Cash Price |
$147.72
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$147.72
|
| 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 |
$147.72
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$23.18
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$125.56
|
| Rate for Payer: Fidelis Essential Plan QHP |
$131.47
|
| Rate for Payer: Fidelis Medicare Advantage |
$147.72
|
| Rate for Payer: Fidelis Qualified Health Plan |
$131.47
|
| 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 |
$165.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$147.72
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$25.75
|
| Rate for Payer: Healthfirst Medicare Advantage |
$125.56
|
| Rate for Payer: Healthfirst QHP |
$147.72
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$147.72
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$147.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$147.72
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$118.18
|
| Rate for Payer: Wellcare Medicare |
$140.33
|
|
|
EP IMPLANTABLE LOOP
|
Facility
OP
|
$23,145.25
|
|
|
Service Code
|
HCPCS 33285
|
| Hospital Charge Code |
66574537
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$100.14 |
| Max. Negotiated Rate |
$16,751.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16,751.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9,824.59
|
| Rate for Payer: Aetna Government |
$9,824.59
|
| Rate for Payer: Cash Price |
$9,824.59
|
| Rate for Payer: Cash Price |
$9,824.59
|
| Rate for Payer: Cash Price |
$9,824.59
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$9,824.59
|
| 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 |
$9,824.59
|
| Rate for Payer: EmblemHealth Commercial |
$9,824.59
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$100.14
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$8,350.90
|
| Rate for Payer: Fidelis Essential Plan QHP |
$8,743.89
|
| Rate for Payer: Fidelis Medicare Advantage |
$9,824.59
|
| Rate for Payer: Fidelis Qualified Health Plan |
$8,743.89
|
| Rate for Payer: Group Health Inc Commercial |
$9,824.59
|
| Rate for Payer: Group Health Inc Medicare |
$9,824.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11,572.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9,824.59
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$111.27
|
| Rate for Payer: Healthfirst Medicare Advantage |
$8,350.90
|
| Rate for Payer: Healthfirst QHP |
$9,824.59
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$9,824.59
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9,824.59
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$7,859.67
|
| Rate for Payer: Wellcare Medicare |
$9,333.36
|
|
|
EPINASTINE 0.05% OPHTHALMIC SOLN
|
Facility
OP
|
$155.56
|
|
| Hospital Charge Code |
41644686
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.45 |
| Max. Negotiated Rate |
$124.45 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$85.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$77.78
|
| Rate for Payer: Aetna Government |
$77.78
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$124.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$105.78
|
| Rate for Payer: Group Health Inc Commercial |
$77.78
|
| Rate for Payer: Group Health Inc Medicare |
$54.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$77.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$77.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$101.11
|
|
|
EPINASTINE 0.05% OPHTHALMIC SOLN
|
Facility
OP
|
$155.56
|
|
| Hospital Charge Code |
41654686
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.45 |
| Max. Negotiated Rate |
$124.45 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$85.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$77.78
|
| Rate for Payer: Aetna Government |
$77.78
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$124.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$105.78
|
| Rate for Payer: Group Health Inc Commercial |
$77.78
|
| Rate for Payer: Group Health Inc Medicare |
$54.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$77.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$77.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$101.11
|
|
