|
DERM PROCEDURE MICROSCOPIC
|
Facility
|
IP
|
$10.68
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
42201200
|
|
Hospital Revenue Code
|
306
|
| Rate for Payer: Cash Price |
$4.27
|
|
|
DERM PROCEDURE MICROSCOPIC
|
Facility
|
OP
|
$10.68
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
42201200
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$8.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.87
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.27
|
| Rate for Payer: Aetna Government |
$4.27
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2.99
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2.99
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2.99
|
| Rate for Payer: Brighton Health Commercial |
$8.01
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4.27
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.79
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.74
|
| Rate for Payer: Elderplan Medicare Advantage |
$4.27
|
| Rate for Payer: EmblemHealth Commercial |
$4.27
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3.63
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3.80
|
| Rate for Payer: Fidelis Medicare Advantage |
$4.27
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3.80
|
| Rate for Payer: Group Health Inc Commercial |
$4.27
|
| Rate for Payer: Group Health Inc Medicare |
$4.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.27
|
| Rate for Payer: Healthfirst Medicare Advantage |
$4.27
|
| Rate for Payer: Healthfirst QHP |
$4.27
|
| Rate for Payer: Humana Medicare |
$4.36
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4.27
|
| Rate for Payer: United Healthcare Commercial |
$5.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.27
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3.42
|
| Rate for Payer: Wellcare Medicare |
$3.84
|
|
|
DERM PROCEDURE SCLEROSIS VEIN
|
Facility
|
IP
|
$529.23
|
|
|
Service Code
|
HCPCS 36468
|
| Hospital Charge Code |
42201230
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
DERM PROCEDURE SCLEROSIS VEIN
|
Facility
|
OP
|
$529.23
|
|
|
Service Code
|
HCPCS 36468
|
| Hospital Charge Code |
42201230
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$264.62 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$396.92
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$461.12
|
| 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 |
$461.12
|
| Rate for Payer: EmblemHealth Commercial |
$461.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$461.12
|
| Rate for Payer: Group Health Inc Medicare |
$461.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$264.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$391.95
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
DESAMETHASONE .2MG/ML ORAL PED
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
41657081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.50
|
| Rate for Payer: Aetna Government |
$1.50
|
| Rate for Payer: Brighton Health Commercial |
$2.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.04
|
| Rate for Payer: Group Health Inc Commercial |
$1.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.95
|
|
|
DESENSITIZING RESIN, PER TOOTH
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS D9911
|
| Hospital Charge Code |
42303375
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.95
|
| Rate for Payer: Aetna Government |
$17.95
|
| Rate for Payer: Brighton Health Commercial |
$26.25
|
| 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: Group Health Inc Commercial |
$17.50
|
| Rate for Payer: Group Health Inc Medicare |
$12.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.50
|
|
|
DESIC,CUR FACE- 15 OR MORE LESION
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 17004
|
| Hospital Charge Code |
42201410
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$322.78 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$725.80
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$461.12
|
| 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 |
$461.12
|
| Rate for Payer: EmblemHealth Commercial |
$461.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$461.12
|
| Rate for Payer: Group Health Inc Medicare |
$461.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$391.95
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
DESIC,CUR FACE- 15 OR MORE LESION
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 17004
|
| Hospital Charge Code |
42201410
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
DESIC, CUR FACE 2-3 LARGE
|
Facility
|
OP
|
$264.62
|
|
|
Service Code
|
HCPCS 17003
|
| Hospital Charge Code |
42201405
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.17
|
| Rate for Payer: Aetna Government |
$2.17
|
| Rate for Payer: Brighton Health Commercial |
$198.46
|
| 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: Group Health Inc Commercial |
$132.31
|
| Rate for Payer: Group Health Inc Medicare |
$92.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$132.31
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$132.31
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
|
|
DESIC, CUR FACE SINGLE SMALL
|
Facility
|
IP
|
$529.23
|
|
|
Service Code
|
HCPCS 17000
|
| Hospital Charge Code |
42201400
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$231.52
|
|
|
DESIC, CUR FACE SINGLE SMALL
|
Facility
|
OP
|
$529.23
|
|
|
Service Code
|
HCPCS 17000
|
| Hospital Charge Code |
42201400
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$162.06 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$231.52
|
| Rate for Payer: Aetna Government |
$231.52
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$162.06
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$162.06
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$162.06
|
| Rate for Payer: Brighton Health Commercial |
$396.92
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$231.52
|
| 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 |
$231.52
|
| Rate for Payer: EmblemHealth Commercial |
$231.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$196.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$206.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$231.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$206.05
|
| Rate for Payer: Group Health Inc Commercial |
$231.52
|
| Rate for Payer: Group Health Inc Medicare |
$231.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$264.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$231.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$196.79
|
| Rate for Payer: Healthfirst QHP |
$231.52
|
| Rate for Payer: Humana Medicare |
$236.15
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$231.52
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$231.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$231.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$185.22
|
| Rate for Payer: Wellcare Medicare |
$219.94
|
|
|
DESIC,CUR OTHER-15 OR MORE LESION
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 17004
|
| Hospital Charge Code |
42201425
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
DESIC,CUR OTHER-15 OR MORE LESION
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 17004
|
| Hospital Charge Code |
42201425
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$322.78 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$725.80
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$461.12
|
| 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 |
$461.12
|
| Rate for Payer: EmblemHealth Commercial |
$461.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$461.12
|
| Rate for Payer: Group Health Inc Medicare |
$461.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$391.95
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
DESIC,CUR OTHER,2-14 LESIONS,EACH
|
Facility
|
OP
|
$264.62
|
|
|
Service Code
|
HCPCS 17003
|
| Hospital Charge Code |
42201420
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.17
|
| Rate for Payer: Aetna Government |
$2.17
|
| Rate for Payer: Brighton Health Commercial |
$198.46
|
| 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: Group Health Inc Commercial |
$132.31
|
| Rate for Payer: Group Health Inc Medicare |
$92.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$132.31
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$132.31
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
|
|
DESIC,CUR OTHER -FIRST LESION
|
Facility
|
IP
|
$529.23
|
|
|
Service Code
|
HCPCS 17000
|
| Hospital Charge Code |
42201415
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$231.52
|
|
|
DESIC,CUR OTHER -FIRST LESION
|
Facility
|
OP
|
$529.23
|
|
|
Service Code
|
HCPCS 17000
|
| Hospital Charge Code |
42201415
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$162.06 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$231.52
|
| Rate for Payer: Aetna Government |
$231.52
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$162.06
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$162.06
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$162.06
|
| Rate for Payer: Brighton Health Commercial |
$396.92
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$231.52
|
| 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 |
$231.52
|
| Rate for Payer: EmblemHealth Commercial |
$231.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$196.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$206.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$231.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$206.05
|
| Rate for Payer: Group Health Inc Commercial |
$231.52
|
| Rate for Payer: Group Health Inc Medicare |
$231.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$264.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$231.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$196.79
|
| Rate for Payer: Healthfirst QHP |
$231.52
|
| Rate for Payer: Humana Medicare |
$236.15
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$231.52
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$231.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$231.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$185.22
|
| Rate for Payer: Wellcare Medicare |
$219.94
|
|
|
DESIGN MLC DEVICE(S) PER IMRT PLN
|
Facility
|
OP
|
$1,015.13
|
|
|
Service Code
|
HCPCS 77338 TC
|
| Hospital Charge Code |
66542945
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$279.92 |
| Max. Negotiated Rate |
$812.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$558.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$427.29
|
| Rate for Payer: Aetna Government |
$427.29
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$299.10
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$299.10
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$299.10
|
| Rate for Payer: Brighton Health Commercial |
$761.35
|
| Rate for Payer: Cash Price |
$427.29
|
| Rate for Payer: Cash Price |
$427.29
|
| Rate for Payer: Cash Price |
$427.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$427.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$812.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$690.29
|
| Rate for Payer: Elderplan Medicare Advantage |
$427.29
|
| Rate for Payer: EmblemHealth Commercial |
$427.29
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$427.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$427.29
|
| Rate for Payer: Group Health Inc Medicare |
$427.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$507.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$427.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$384.56
|
| Rate for Payer: Healthfirst Medicare Advantage |
$427.29
|
| Rate for Payer: Healthfirst QHP |
$427.29
|
| Rate for Payer: Humana Medicare |
$435.84
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$427.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$427.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$427.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$341.83
|
| Rate for Payer: Wellcare Medicare |
$405.93
|
|
|
DESIGN MLC DEVICE(S) PER IMRT PLN
|
Facility
|
IP
|
$1,015.13
|
|
|
Service Code
|
HCPCS 77338 TC
|
| Hospital Charge Code |
66542945
|
|
Hospital Revenue Code
|
333
|
| Rate for Payer: Cash Price |
$427.29
|
|
|
DESIPRAMINE 10 MG TAB
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41641075
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
DESIPRAMINE 10 MG TAB
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
41651075
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
DESIPRAMINE 25 MG TAB
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
41643519
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.00
|
| Rate for Payer: Aetna Government |
$1.00
|
| Rate for Payer: Brighton Health Commercial |
$1.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.36
|
| Rate for Payer: Group Health Inc Commercial |
$1.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.30
|
|
|
DESIPRAMINE 25 MG TAB
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
41653519
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.00
|
| Rate for Payer: Aetna Government |
$1.00
|
| Rate for Payer: Brighton Health Commercial |
$1.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.36
|
| Rate for Payer: Group Health Inc Commercial |
$1.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.30
|
|
|
DESIPRAMINE HCL 25 MG PO TABS [2286]
|
Facility
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 50742011301
|
| Hospital Charge Code |
50742011301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.00
|
| Rate for Payer: Aetna Government |
$1.00
|
| Rate for Payer: Brighton Health Commercial |
$1.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.36
|
| Rate for Payer: Group Health Inc Commercial |
$1.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.30
|
|
|
DESMOPRESSIN 0.1 MG TAB
|
Facility
|
OP
|
$1.93
|
|
| Hospital Charge Code |
41644625
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.97
|
| Rate for Payer: Aetna Government |
$0.97
|
| Rate for Payer: Brighton Health Commercial |
$1.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.31
|
| Rate for Payer: Group Health Inc Commercial |
$0.97
|
| Rate for Payer: Group Health Inc Medicare |
$0.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.97
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.25
|
|
|
DESMOPRESSIN 0.1 MG TAB
|
Facility
|
OP
|
$1.93
|
|
| Hospital Charge Code |
41654625
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.97
|
| Rate for Payer: Aetna Government |
$0.97
|
| Rate for Payer: Brighton Health Commercial |
$1.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.31
|
| Rate for Payer: Group Health Inc Commercial |
$0.97
|
| Rate for Payer: Group Health Inc Medicare |
$0.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.97
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.25
|
|
