|
ADH
|
Facility
|
IP
|
$84.85
|
|
|
Service Code
|
HCPCS 84588
|
| Hospital Charge Code |
40609128
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$33.94
|
|
|
ADHESION SEPRA FILM
|
Facility
|
IP
|
$497.00
|
|
|
Service Code
|
HCPCS C1765
|
| Hospital Charge Code |
40209707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$248.50 |
| Max. Negotiated Rate |
$248.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$248.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$248.50
|
|
|
ADHESION SEPRA FILM
|
Facility
|
OP
|
$497.00
|
|
|
Service Code
|
HCPCS C1765
|
| Hospital Charge Code |
40209707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$173.95 |
| Max. Negotiated Rate |
$521.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$273.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$459.79
|
| Rate for Payer: Aetna Government |
$459.79
|
| Rate for Payer: Brighton Health Commercial |
$298.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$248.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$285.78
|
| Rate for Payer: EmblemHealth Commercial |
$248.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$521.85
|
| Rate for Payer: Group Health Inc Commercial |
$248.50
|
| Rate for Payer: Group Health Inc Medicare |
$173.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$248.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$248.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$323.05
|
|
|
ADHESIVE DERMABOND
|
Facility
|
OP
|
$58.24
|
|
| Hospital Charge Code |
64902453
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$46.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$32.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$29.12
|
| Rate for Payer: Aetna Government |
$29.12
|
| Rate for Payer: Brighton Health Commercial |
$43.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$46.59
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$39.60
|
| Rate for Payer: Group Health Inc Commercial |
$29.12
|
| Rate for Payer: Group Health Inc Medicare |
$20.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$29.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$29.12
|
|
|
ADHESIVE DERMABOND MINI
|
Facility
|
OP
|
$30.75
|
|
| Hospital Charge Code |
64901096
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.76 |
| Max. Negotiated Rate |
$24.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$15.38
|
| Rate for Payer: Aetna Government |
$15.38
|
| Rate for Payer: Brighton Health Commercial |
$23.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$20.91
|
| Rate for Payer: Group Health Inc Commercial |
$15.38
|
| Rate for Payer: Group Health Inc Medicare |
$10.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.38
|
|
|
ADHESIVE DERMABOND PEN
|
Facility
|
OP
|
$51.25
|
|
| Hospital Charge Code |
64901612
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.94 |
| Max. Negotiated Rate |
$41.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$28.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$25.62
|
| Rate for Payer: Aetna Government |
$25.62
|
| Rate for Payer: Brighton Health Commercial |
$38.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$41.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$34.85
|
| Rate for Payer: Group Health Inc Commercial |
$25.62
|
| Rate for Payer: Group Health Inc Medicare |
$17.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$25.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$25.62
|
|
|
ADHESIVE REMOVER
|
Facility
|
OP
|
$23.04
|
|
| Hospital Charge Code |
40200307
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.06 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.67
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.52
|
| Rate for Payer: Aetna Government |
$11.52
|
| Rate for Payer: Brighton Health Commercial |
$17.28
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18.43
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.67
|
| Rate for Payer: Group Health Inc Commercial |
$11.52
|
| Rate for Payer: Group Health Inc Medicare |
$8.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.52
|
|
|
ADHESIVE SKN TPCL LQBND .8ML
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
64906332
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.00
|
| Rate for Payer: Aetna Government |
$10.00
|
| Rate for Payer: Brighton Health Commercial |
$15.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.60
|
| Rate for Payer: Group Health Inc Commercial |
$10.00
|
| Rate for Payer: Group Health Inc Medicare |
$7.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.00
|
|
|
ADIT/DAST OVER 30 MIN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS 99409
|
| Hospital Charge Code |
30307886
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$49.53
|
| Rate for Payer: Aetna Government |
$49.53
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less
|
Facility
|
OP
|
$2,915.00
|
|
|
Service Code
|
CPT 14060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,409.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,108.87
|
| Rate for Payer: Aetna Government |
$2,108.87
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,476.21
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,476.21
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,476.21
|
| 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 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 Medicare Advantage |
$1,792.54
|
| Rate for Payer: Healthfirst QHP |
$2,108.87
|
| Rate for Payer: Humana Medicare |
$2,151.05
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,108.87
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare 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
|
|
|
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm
|
Facility
|
OP
|
$2,915.00
|
|
|
Service Code
|
CPT 14041
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,409.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,108.87
|
| Rate for Payer: Aetna Government |
$2,108.87
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,476.21
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,476.21
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,476.21
|
| 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 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 Medicare Advantage |
$1,792.54
|
| Rate for Payer: Healthfirst QHP |
$2,108.87
|
| Rate for Payer: Humana Medicare |
$2,151.05
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,108.87
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare 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
|
|
|
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less
|
Facility
|
OP
|
$2,915.00
|
|
|
Service Code
|
CPT 14040
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,409.00 |
| 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: Affinity Essential Plan 1&2 |
$1,476.21
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,476.21
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,476.21
|
| 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 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 Medicare Advantage |
$1,792.54
|
| Rate for Payer: Healthfirst QHP |
$2,108.87
|
| Rate for Payer: Humana Medicare |
$2,151.05
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,108.87
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare 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
|
|
|
Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm
|
Facility
|
OP
|
$2,915.00
|
|
|
Service Code
|
CPT 14001
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,409.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,108.87
|
| Rate for Payer: Aetna Government |
$2,108.87
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,476.21
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,476.21
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,476.21
|
| 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 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 Medicare Advantage |
$1,792.54
|
| Rate for Payer: Healthfirst QHP |
$2,108.87
|
| Rate for Payer: Humana Medicare |
$2,151.05
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,108.87
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare 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
|
|
|
ADJUST BONE FIXATION DEVICE
|
Facility
|
OP
|
$18,117.83
|
|
|
Service Code
|
HCPCS 20693
|
| Hospital Charge Code |
40029995
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$13,588.37 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8,273.12
|
| Rate for Payer: Aetna Government |
$8,273.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5,791.18
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5,791.18
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5,791.18
|
| Rate for Payer: Brighton Health Commercial |
$13,588.37
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$8,273.12
|
| 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 |
$8,273.12
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$7,032.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7,363.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$8,273.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7,363.08
|
| Rate for Payer: Group Health Inc Commercial |
$8,273.12
|
| Rate for Payer: Group Health Inc Medicare |
$8,273.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9,058.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,273.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7,032.15
|
| Rate for Payer: Healthfirst QHP |
$8,273.12
|
| Rate for Payer: Humana Medicare |
$8,438.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$8,273.12
|
| Rate for Payer: United Healthcare Commercial |
$1,835.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,273.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,273.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6,618.50
|
| Rate for Payer: Wellcare Medicare |
$7,859.46
|
|
|
ADJUST BONE FIXATION DEVICE
|
Facility
|
IP
|
$18,117.83
|
|
|
Service Code
|
HCPCS 20693
|
| Hospital Charge Code |
40029995
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$8,273.12
|
|
|
ADJUST COMPLETE DENTURE-LOWER
|
Facility
|
OP
|
$62.50
|
|
|
Service Code
|
HCPCS D5411
|
| Hospital Charge Code |
42301035
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$21.88 |
| Max. Negotiated Rate |
$9,760.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$21.96
|
| Rate for Payer: Aetna Government |
$21.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$219.60
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$219.60
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$97.60
|
| Rate for Payer: Amida Care Medicaid |
$97.60
|
| Rate for Payer: Brighton Health Commercial |
$46.88
|
| 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 |
$9,760.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$97.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$97.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$102.48
|
| Rate for Payer: Group Health Inc Commercial |
$31.25
|
| Rate for Payer: Group Health Inc Medicare |
$21.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$97.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.25
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$97.60
|
| Rate for Payer: Healthfirst Essential Plan |
$219.60
|
| Rate for Payer: Healthfirst QHP |
$97.60
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$97.60
|
| Rate for Payer: SOMOS Essential |
$219.60
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$219.60
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$107.36
|
| Rate for Payer: United Healthcare Medicaid |
$97.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$97.60
|
|
|
ADJUST COMPLETE DENTURE-UPPER
|
Facility
|
OP
|
$62.50
|
|
|
Service Code
|
HCPCS D5410
|
| Hospital Charge Code |
42301030
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$21.88 |
| Max. Negotiated Rate |
$9,760.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$21.96
|
| Rate for Payer: Aetna Government |
$21.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$219.60
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$219.60
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$97.60
|
| Rate for Payer: Amida Care Medicaid |
$97.60
|
| Rate for Payer: Brighton Health Commercial |
$46.88
|
| 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 |
$9,760.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$97.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$97.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$102.48
|
| Rate for Payer: Group Health Inc Commercial |
$31.25
|
| Rate for Payer: Group Health Inc Medicare |
$21.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$97.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.25
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$97.60
|
| Rate for Payer: Healthfirst Essential Plan |
$219.60
|
| Rate for Payer: Healthfirst QHP |
$97.60
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$97.60
|
| Rate for Payer: SOMOS Essential |
$219.60
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$219.60
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$107.36
|
| Rate for Payer: United Healthcare Medicaid |
$97.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$97.60
|
|
|
ADJUST EYE SHUNT (DRAINAGE)
|
Facility
|
OP
|
$6,476.70
|
|
|
Service Code
|
HCPCS 66185
|
| Hospital Charge Code |
30302054
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$3,238.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,694.88
|
| Rate for Payer: Aetna Government |
$2,694.88
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,886.42
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,886.42
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,886.42
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$2,694.88
|
| Rate for Payer: Cash Price |
$2,694.88
|
| Rate for Payer: Cash Price |
$2,694.88
|
| Rate for Payer: Cash Price |
$2,694.88
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2,694.88
|
| 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 |
$2,694.88
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2,290.65
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2,398.44
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,694.88
|
| Rate for Payer: Fidelis Qualified Health Plan |
$2,398.44
|
| 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 |
$3,238.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,694.88
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2,290.65
|
| Rate for Payer: Healthfirst QHP |
$2,694.88
|
| Rate for Payer: Humana Medicare |
$2,748.78
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2,694.88
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,694.88
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,694.88
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,694.88
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,155.90
|
| Rate for Payer: Wellcare Medicare |
$2,560.14
|
|
|
ADJUST EYE SHUNT (DRAINAGE)
|
Facility
|
IP
|
$6,476.70
|
|
|
Service Code
|
HCPCS 66185
|
| Hospital Charge Code |
30302054
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$2,694.88
|
|
|
ADJUST PARTIAL DENTURE-LOWER
|
Facility
|
OP
|
$62.50
|
|
|
Service Code
|
HCPCS D5422
|
| Hospital Charge Code |
42301045
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$21.88 |
| Max. Negotiated Rate |
$9,760.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$21.96
|
| Rate for Payer: Aetna Government |
$21.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$219.60
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$219.60
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$97.60
|
| Rate for Payer: Amida Care Medicaid |
$97.60
|
| Rate for Payer: Brighton Health Commercial |
$46.88
|
| 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 |
$9,760.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$97.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$97.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$102.48
|
| Rate for Payer: Group Health Inc Commercial |
$31.25
|
| Rate for Payer: Group Health Inc Medicare |
$21.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$97.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.25
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$97.60
|
| Rate for Payer: Healthfirst Essential Plan |
$219.60
|
| Rate for Payer: Healthfirst QHP |
$97.60
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$97.60
|
| Rate for Payer: SOMOS Essential |
$219.60
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$219.60
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$107.36
|
| Rate for Payer: United Healthcare Medicaid |
$97.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$97.60
|
|
|
ADJUST PARTIAL DENTURE-UPPER
|
Facility
|
OP
|
$62.50
|
|
|
Service Code
|
HCPCS D5421
|
| Hospital Charge Code |
42301040
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$21.88 |
| Max. Negotiated Rate |
$9,760.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$21.96
|
| Rate for Payer: Aetna Government |
$21.96
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$219.60
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$219.60
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$97.60
|
| Rate for Payer: Amida Care Medicaid |
$97.60
|
| Rate for Payer: Brighton Health Commercial |
$46.88
|
| 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 |
$9,760.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$97.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$97.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$102.48
|
| Rate for Payer: Group Health Inc Commercial |
$31.25
|
| Rate for Payer: Group Health Inc Medicare |
$21.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$97.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.25
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$97.60
|
| Rate for Payer: Healthfirst Essential Plan |
$219.60
|
| Rate for Payer: Healthfirst QHP |
$97.60
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$97.60
|
| Rate for Payer: SOMOS Essential |
$219.60
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$219.60
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$107.36
|
| Rate for Payer: United Healthcare Medicaid |
$97.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$97.60
|
|
|
ADJV TRTMT CHEMO HER2
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS G2206
|
| Hospital Charge Code |
30300334
|
|
Hospital Revenue Code
|
929
|
| Max. Negotiated Rate |
$94.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$94.00
|
|
|
ADL TRAINING
|
Facility
|
OP
|
$99.85
|
|
|
Service Code
|
HCPCS 97535
|
| Hospital Charge Code |
41701002
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$21.18 |
| Max. Negotiated Rate |
$5,078.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$54.92
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$21.18
|
| Rate for Payer: Aetna Government |
$21.18
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$114.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$114.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$50.78
|
| Rate for Payer: Amida Care Medicaid |
$50.78
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$5,078.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$50.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$50.78
|
| Rate for Payer: Fidelis Qualified Health Plan |
$53.32
|
| Rate for Payer: Group Health Inc Commercial |
$49.92
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$50.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$49.92
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$50.78
|
| Rate for Payer: Healthfirst Essential Plan |
$114.26
|
| Rate for Payer: Healthfirst QHP |
$50.78
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$50.78
|
| Rate for Payer: SOMOS Essential |
$114.26
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$114.26
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$55.86
|
| Rate for Payer: United Healthcare Medicaid |
$50.78
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$50.78
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
ADM. EACH ADDL. INJECTION VACCINE
|
Facility
|
OP
|
$109.89
|
|
|
Service Code
|
HCPCS 90472
|
| Hospital Charge Code |
30303092
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$60.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.00
|
| Rate for Payer: Aetna Government |
$11.00
|
| Rate for Payer: Brighton Health Commercial |
$82.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$87.91
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$74.73
|
| 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 |
$54.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$54.94
|
| Rate for Payer: United Healthcare Commercial |
$44.00
|
|
|
ADMIN 1ST DOSE 6MONS-5YRS PFIZER
|
Facility
|
OP
|
$102.55
|
|
|
Service Code
|
HCPCS 0081A
|
| Hospital Charge Code |
30300261
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$44.00 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$56.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$51.28
|
| Rate for Payer: Aetna Government |
$51.28
|
| Rate for Payer: Brighton Health Commercial |
$76.91
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$82.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$69.73
|
| 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 |
$51.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$51.28
|
| Rate for Payer: United Healthcare Commercial |
$44.00
|
|
