|
ALCOHOL REHAB. INITIAL CLINIC
|
Facility
OP
|
$397.85
|
|
|
Service Code
|
HCPCS 90791
|
| Hospital Charge Code |
30310002
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$147.50 |
| Max. Negotiated Rate |
$318.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$213.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$184.38
|
| Rate for Payer: Aetna Government |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$184.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$318.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.54
|
| Rate for Payer: Elderplan Medicare Advantage |
$184.38
|
| Rate for Payer: EmblemHealth Commercial |
$184.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$149.56
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$156.72
|
| Rate for Payer: Fidelis Essential Plan QHP |
$164.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$184.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$164.10
|
| Rate for Payer: Group Health Inc Commercial |
$184.38
|
| Rate for Payer: Group Health Inc Medicare |
$184.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$198.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$184.38
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$166.18
|
| Rate for Payer: Healthfirst Medicare Advantage |
$156.72
|
| Rate for Payer: Healthfirst QHP |
$184.38
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$184.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$184.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$184.38
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$147.50
|
| Rate for Payer: Wellcare Medicare |
$175.16
|
|
|
ALCOHOL/SBS ASSESS 30 MIN
|
Facility
OP
|
$237.88
|
|
|
Service Code
|
HCPCS G0397
|
| Hospital Charge Code |
30400231
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$130.83 |
| Max. Negotiated Rate |
$17,410.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$130.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$184.38
|
| Rate for Payer: Aetna Government |
$184.38
|
| Rate for Payer: Amida Care Medicaid |
$174.10
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$175.69
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$184.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$190.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$161.76
|
| Rate for Payer: Elderplan Medicare Advantage |
$184.38
|
| Rate for Payer: EmblemHealth Commercial |
$184.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$17,410.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$174.10
|
| Rate for Payer: Fidelis Essential Plan QHP |
$174.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$184.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$182.80
|
| Rate for Payer: Group Health Inc Commercial |
$184.38
|
| Rate for Payer: Group Health Inc Medicare |
$184.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$174.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$184.38
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$174.10
|
| Rate for Payer: Healthfirst Essential Plan |
$391.72
|
| Rate for Payer: Healthfirst Medicare Advantage |
$156.72
|
| Rate for Payer: Healthfirst QHP |
$174.10
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$175.69
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$184.38
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$395.30
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$395.30
|
| Rate for Payer: Optum Medicaid |
$175.69
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$184.38
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$174.10
|
| Rate for Payer: SOMOS Essential |
$391.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$184.38
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$147.50
|
| Rate for Payer: Wellcare Medicare |
$175.16
|
|
|
ALCOHOL/SBS INTER 15-30 MIN
|
Facility
OP
|
$82.75
|
|
|
Service Code
|
HCPCS G0396
|
| Hospital Charge Code |
30400230
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$26.54 |
| Max. Negotiated Rate |
$13,057.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$45.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$33.18
|
| Rate for Payer: Aetna Government |
$33.18
|
| Rate for Payer: Amida Care Medicaid |
$130.57
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$131.76
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$33.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$66.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$56.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$33.18
|
| Rate for Payer: EmblemHealth Commercial |
$33.18
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$13,057.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$130.57
|
| Rate for Payer: Fidelis Essential Plan QHP |
$130.57
|
| Rate for Payer: Fidelis Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$137.10
|
| Rate for Payer: Group Health Inc Commercial |
$33.18
|
| Rate for Payer: Group Health Inc Medicare |
$33.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$130.57
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$33.18
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$130.57
|
| Rate for Payer: Healthfirst Essential Plan |
$293.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.20
|
| Rate for Payer: Healthfirst QHP |
$130.57
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$131.76
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$33.18
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$296.46
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$296.46
|
| Rate for Payer: Optum Medicaid |
$131.76
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$33.18
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$130.57
|
| Rate for Payer: SOMOS Essential |
$293.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$33.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.54
|
| Rate for Payer: Wellcare Medicare |
$31.52
|
|
|
ALCOHOL/SBSTANCE INTER PT 25 MIN
|
Facility
OP
|
$397.85
|
|
|
Service Code
|
HCPCS 90832
|
| Hospital Charge Code |
30400200
|
|
Hospital Revenue Code
|
914
|
| Min. Negotiated Rate |
$65.70 |
| Max. Negotiated Rate |
$318.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$188.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$184.38
|
| Rate for Payer: Aetna Government |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$184.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$318.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.54
|
| Rate for Payer: Elderplan Medicare Advantage |
$184.38
|
| Rate for Payer: EmblemHealth Commercial |
$184.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$65.70
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$156.72
|
| Rate for Payer: Fidelis Essential Plan QHP |
$164.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$184.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$164.10
|
| Rate for Payer: Group Health Inc Commercial |
$184.38
|
| Rate for Payer: Group Health Inc Medicare |
$184.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$198.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$184.38
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$73.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$156.72
|
| Rate for Payer: Healthfirst QHP |
$184.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$184.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$184.38
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$147.50
|
| Rate for Payer: Wellcare Medicare |
$175.16
|
|
|
ALCOHOL/SBSTANCE INTER PT 45 MIN
|
Facility
OP
|
$397.85
|
|
|
Service Code
|
HCPCS 90834
|
| Hospital Charge Code |
30400201
|
|
Hospital Revenue Code
|
914
|
| Min. Negotiated Rate |
$87.45 |
| Max. Negotiated Rate |
$318.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$188.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$184.38
|
| Rate for Payer: Aetna Government |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$184.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$318.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.54
|
| Rate for Payer: Elderplan Medicare Advantage |
$184.38
|
| Rate for Payer: EmblemHealth Commercial |
$184.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$87.45
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$156.72
|
| Rate for Payer: Fidelis Essential Plan QHP |
$164.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$184.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$164.10
|
| Rate for Payer: Group Health Inc Commercial |
$184.38
|
| Rate for Payer: Group Health Inc Medicare |
$184.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$198.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$184.38
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$97.17
|
| Rate for Payer: Healthfirst Medicare Advantage |
$156.72
|
| Rate for Payer: Healthfirst QHP |
$184.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$184.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$184.38
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$147.50
|
| Rate for Payer: Wellcare Medicare |
$175.16
|
|
|
ALCOHOL/SBSTANCE INTER PT 45 MIN
|
Facility
OP
|
$358.63
|
|
|
Service Code
|
HCPCS 90834
|
| Hospital Charge Code |
30400203
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$87.45 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$188.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$184.38
|
| Rate for Payer: Aetna Government |
$184.38
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$184.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$184.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$87.45
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$156.72
|
| Rate for Payer: Fidelis Essential Plan QHP |
$164.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$184.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$164.10
|
| 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 |
$179.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$184.38
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$97.17
|
| Rate for Payer: Healthfirst Medicare Advantage |
$156.72
|
| Rate for Payer: Healthfirst QHP |
$184.38
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$184.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$184.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$184.38
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$147.50
|
| Rate for Payer: Wellcare Medicare |
$175.16
|
|
|
ALCOHOL/SUBS ASSESS > 30 MIN
|
Facility
OP
|
$237.88
|
|
|
Service Code
|
HCPCS G0397
|
| Hospital Charge Code |
30305703
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$130.83 |
| Max. Negotiated Rate |
$17,410.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$130.83
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$184.38
|
| Rate for Payer: Aetna Government |
$184.38
|
| Rate for Payer: Amida Care Medicaid |
$174.10
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$175.69
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Cash Price |
$184.38
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$184.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$190.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$161.76
|
| Rate for Payer: Elderplan Medicare Advantage |
$184.38
|
| Rate for Payer: EmblemHealth Commercial |
$184.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$17,410.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$174.10
|
| Rate for Payer: Fidelis Essential Plan QHP |
$174.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$184.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$182.80
|
| Rate for Payer: Group Health Inc Commercial |
$184.38
|
| Rate for Payer: Group Health Inc Medicare |
$184.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$174.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$184.38
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$174.10
|
| Rate for Payer: Healthfirst Essential Plan |
$391.72
|
| Rate for Payer: Healthfirst Medicare Advantage |
$156.72
|
| Rate for Payer: Healthfirst QHP |
$174.10
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$175.69
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$184.38
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$395.30
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$395.30
|
| Rate for Payer: Optum Medicaid |
$175.69
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$184.38
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$174.10
|
| Rate for Payer: SOMOS Essential |
$391.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$184.38
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$147.50
|
| Rate for Payer: Wellcare Medicare |
$175.16
|
|
|
ALCOHOL/SUBS INTER 15-30 MIN
|
Facility
OP
|
$82.75
|
|
|
Service Code
|
HCPCS G0396
|
| Hospital Charge Code |
30305702
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$26.54 |
| Max. Negotiated Rate |
$13,057.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$45.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$33.18
|
| Rate for Payer: Aetna Government |
$33.18
|
| Rate for Payer: Amida Care Medicaid |
$130.57
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$131.76
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$33.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$66.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$56.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$33.18
|
| Rate for Payer: EmblemHealth Commercial |
$33.18
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$13,057.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$130.57
|
| Rate for Payer: Fidelis Essential Plan QHP |
$130.57
|
| Rate for Payer: Fidelis Medicare Advantage |
$33.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$137.10
|
| Rate for Payer: Group Health Inc Commercial |
$33.18
|
| Rate for Payer: Group Health Inc Medicare |
$33.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$130.57
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$33.18
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$130.57
|
| Rate for Payer: Healthfirst Essential Plan |
$293.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.20
|
| Rate for Payer: Healthfirst QHP |
$130.57
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$131.76
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$33.18
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$296.46
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$296.46
|
| Rate for Payer: Optum Medicaid |
$131.76
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$33.18
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$130.57
|
| Rate for Payer: SOMOS Essential |
$293.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$33.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$26.54
|
| Rate for Payer: Wellcare Medicare |
$31.52
|
|
|
ALCOHOL SUBSTANCE ABUSE
|
Facility
OP
|
$100.00
|
|
|
Service Code
|
HCPCS T1012
|
| Hospital Charge Code |
30306405
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$11.22 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$55.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.22
|
| Rate for Payer: Aetna Government |
$11.22
|
| 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 |
$50.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$50.00
|
|
|
ALCOHOL-U
|
Facility
OP
|
$155.35
|
|
|
Service Code
|
HCPCS 80361
|
| Hospital Charge Code |
40602434
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$124.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$85.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$124.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$105.64
|
| Rate for Payer: Group Health Inc Commercial |
$77.68
|
| Rate for Payer: Group Health Inc Medicare |
$54.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$77.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$77.68
|
|
|
ALCON 11.0D
|
Facility
OP
|
$350.00
|
|
| Hospital Charge Code |
40208184
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$175.00
|
| Rate for Payer: Aetna Government |
$175.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
ALCON/AMO LENS INTRAOCULAR
|
Facility
OP
|
$425.00
|
|
|
Service Code
|
HCPCS C1780
|
| Hospital Charge Code |
40209080
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$446.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$233.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.26
|
| Rate for Payer: Aetna Government |
$2.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$340.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$289.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$446.25
|
| Rate for Payer: Group Health Inc Commercial |
$212.50
|
| Rate for Payer: Group Health Inc Medicare |
$148.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$212.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$212.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$276.25
|
|
|
ALCON LENS GLIDE
|
Facility
OP
|
$320.40
|
|
| Hospital Charge Code |
40200483
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$112.14 |
| Max. Negotiated Rate |
$256.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$176.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$160.20
|
| Rate for Payer: Aetna Government |
$160.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$256.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$217.87
|
| Rate for Payer: Group Health Inc Commercial |
$160.20
|
| Rate for Payer: Group Health Inc Medicare |
$112.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$160.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$160.20
|
|
|
ALCON LENS INTRA 25.5 D
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C1780
|
| Hospital Charge Code |
40209375
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.26
|
| Rate for Payer: Aetna Government |
$2.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
ALCON LENS INTRAOCULAR 11.0 D
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C1780
|
| Hospital Charge Code |
40209368
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.26
|
| Rate for Payer: Aetna Government |
$2.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
ALCON LENS INTRAOCULAR18.5 D
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C1780
|
| Hospital Charge Code |
40209370
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.26
|
| Rate for Payer: Aetna Government |
$2.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
ALCON LENS INTRAOCULAR 19.0 D
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C1840
|
| Hospital Charge Code |
40209374
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$648.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$648.95
|
| Rate for Payer: Aetna Government |
$648.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
ALCON LENS INTRAOCULAR 19.5 D
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C1780
|
| Hospital Charge Code |
40209371
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.26
|
| Rate for Payer: Aetna Government |
$2.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
ALCON LENS INTRAOCULAR 20.0 D
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C1840
|
| Hospital Charge Code |
40209372
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$648.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$648.95
|
| Rate for Payer: Aetna Government |
$648.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
ALCON LENS INTRAOCULAR 20.5 D
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C1780
|
| Hospital Charge Code |
40209381
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.26
|
| Rate for Payer: Aetna Government |
$2.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
ALCON LENS INTRAOCULAR 21.5 D
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C1780
|
| Hospital Charge Code |
40209369
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.26
|
| Rate for Payer: Aetna Government |
$2.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
ALCON LENS INTRAOCULAR 22.0D
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C1840
|
| Hospital Charge Code |
40209376
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$648.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$648.95
|
| Rate for Payer: Aetna Government |
$648.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
ALCON LENS INTRAOCULAR 22.5D
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C1780
|
| Hospital Charge Code |
40209377
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.26
|
| Rate for Payer: Aetna Government |
$2.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
ALCON LENS INTRAOCULAR 23.0D
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C1780
|
| Hospital Charge Code |
40209378
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.26
|
| Rate for Payer: Aetna Government |
$2.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
ALCON LENS INTRAOCULAR 26.0D
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C1780
|
| Hospital Charge Code |
40209379
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.26
|
| Rate for Payer: Aetna Government |
$2.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$238.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
