|
ALUMINA C-TAPE HEAD
|
Facility
OP
|
$3,596.00
|
|
| Hospital Charge Code |
40200569
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,258.60 |
| Max. Negotiated Rate |
$2,876.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,977.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,798.00
|
| Rate for Payer: Aetna Government |
$1,798.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,876.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,445.28
|
| Rate for Payer: Group Health Inc Commercial |
$1,798.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,258.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,798.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,798.00
|
|
|
ALUMINA C-TAPER HEAD
|
Facility
OP
|
$3,596.00
|
|
| Hospital Charge Code |
40200351
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,258.60 |
| Max. Negotiated Rate |
$2,876.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,977.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,798.00
|
| Rate for Payer: Aetna Government |
$1,798.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,876.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,445.28
|
| Rate for Payer: Group Health Inc Commercial |
$1,798.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,258.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,798.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,798.00
|
|
|
ALUMINA INSERT
|
Facility
OP
|
$3,229.80
|
|
| Hospital Charge Code |
40200354
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,130.43 |
| Max. Negotiated Rate |
$2,583.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,776.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,614.90
|
| Rate for Payer: Aetna Government |
$1,614.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,583.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,196.26
|
| Rate for Payer: Group Health Inc Commercial |
$1,614.90
|
| Rate for Payer: Group Health Inc Medicare |
$1,130.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,614.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,614.90
|
|
|
ALUMINUM BLOOD
|
Facility
OP
|
$63.70
|
|
|
Service Code
|
HCPCS 82108
|
| Hospital Charge Code |
40607069
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$40.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$35.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$25.48
|
| Rate for Payer: Aetna Government |
$25.48
|
| Rate for Payer: Cash Price |
$25.48
|
| Rate for Payer: Cash Price |
$25.48
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$25.48
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$40.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$34.26
|
| Rate for Payer: Elderplan Medicare Advantage |
$25.48
|
| Rate for Payer: EmblemHealth Commercial |
$25.48
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$22.93
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$21.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$22.68
|
| Rate for Payer: Fidelis Medicare Advantage |
$25.48
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22.68
|
| Rate for Payer: Group Health Inc Commercial |
$25.48
|
| Rate for Payer: Group Health Inc Medicare |
$25.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$25.48
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$25.48
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.48
|
| Rate for Payer: Healthfirst QHP |
$25.48
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$25.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$25.48
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20.38
|
| Rate for Payer: Wellcare Medicare |
$22.93
|
|
|
ALUMINUM CHLORIDE 20% 60ML TOP
|
Facility
OP
|
$14.00
|
|
| Hospital Charge Code |
41658006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$11.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.00
|
| Rate for Payer: Aetna Government |
$7.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.52
|
| Rate for Payer: Group Health Inc Commercial |
$7.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.10
|
|
|
ALUMINUM CHLORIDE 20% 60ML TOP
|
Facility
OP
|
$14.00
|
|
| Hospital Charge Code |
41648006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$11.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.00
|
| Rate for Payer: Aetna Government |
$7.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.52
|
| Rate for Payer: Group Health Inc Commercial |
$7.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.10
|
|
|
ALUMINUM HYDROXIDE 1920 MG/30 ML SUSP
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41653374
|
|
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: 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
|
|
|
ALUMINUM HYDROXIDE 1920 MG/30 ML SUSP
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41643374
|
|
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: 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
|
|
|
ALUMINUM HYDROX + MAG HYDROX + SIMETHICO
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41644453
|
|
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: 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
|
|
|
ALUMINUM HYDROX + MAG HYDROX + SIMETHICO
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41654453
|
|
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: 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
|
|
|
ALUMINUM, PLASMA/SERUM
|
Facility
OP
|
$63.70
|
|
|
Service Code
|
HCPCS 82108
|
| Hospital Charge Code |
40609041
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$40.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$35.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$25.48
|
| Rate for Payer: Aetna Government |
$25.48
|
| Rate for Payer: Cash Price |
$25.48
|
| Rate for Payer: Cash Price |
$25.48
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$25.48
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$40.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$34.26
|
| Rate for Payer: Elderplan Medicare Advantage |
$25.48
|
| Rate for Payer: EmblemHealth Commercial |
$25.48
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$22.93
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$21.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$22.68
|
| Rate for Payer: Fidelis Medicare Advantage |
$25.48
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22.68
|
| Rate for Payer: Group Health Inc Commercial |
$25.48
|
| Rate for Payer: Group Health Inc Medicare |
$25.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$25.48
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$25.48
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.48
|
| Rate for Payer: Healthfirst QHP |
$25.48
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$25.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$25.48
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$20.38
|
| Rate for Payer: Wellcare Medicare |
$22.93
|
|
|
ALUMINUM SULFATE-CA ACETATE POWDER
|
Facility
OP
|
$2.00
|
|
| Hospital Charge Code |
41651036
|
|
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: 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
|
|
|
ALUMINUM SULFATE-CA ACETATE POWDER
|
Facility
OP
|
$2.00
|
|
| Hospital Charge Code |
41641036
|
|
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: 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
|
|
|
ALUMINUM, URINE
|
Facility
OP
|
$12.95
|
|
|
Service Code
|
HCPCS 82570
|
| Hospital Charge Code |
40609841
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.14 |
| Max. Negotiated Rate |
$8.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.18
|
| Rate for Payer: Aetna Government |
$5.18
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$5.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.23
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.96
|
| Rate for Payer: Elderplan Medicare Advantage |
$5.18
|
| Rate for Payer: EmblemHealth Commercial |
$5.18
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.40
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4.61
|
| Rate for Payer: Fidelis Medicare Advantage |
$5.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4.61
|
| Rate for Payer: Group Health Inc Commercial |
$5.18
|
| Rate for Payer: Group Health Inc Medicare |
$5.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.18
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$5.18
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.18
|
| Rate for Payer: Healthfirst QHP |
$5.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$5.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.14
|
| Rate for Payer: Wellcare Medicare |
$4.66
|
|
|
ALVELOUS-STABILIZATION, OPEN
|
Facility
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS D7671
|
| Hospital Charge Code |
42303452
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,000.00 |
| Max. Negotiated Rate |
$6,772.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,100.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,772.21
|
| Rate for Payer: Aetna Government |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,772.21
|
| 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 |
$6,772.21
|
| Rate for Payer: EmblemHealth Commercial |
$6,772.21
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,756.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6,027.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,772.21
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6,027.27
|
| Rate for Payer: Group Health Inc Commercial |
$6,772.21
|
| Rate for Payer: Group Health Inc Medicare |
$6,772.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,000.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,772.21
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5,756.38
|
| Rate for Payer: Healthfirst QHP |
$6,772.21
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,772.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,772.21
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,417.77
|
| Rate for Payer: Wellcare Medicare |
$6,433.60
|
|
|
ALVEOLOPLASTY IN CONJUNC WITH EXT
|
Facility
OP
|
$175.00
|
|
|
Service Code
|
HCPCS D7310
|
| Hospital Charge Code |
42301735
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$96.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,763.60
|
| Rate for Payer: Aetna Government |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,763.60
|
| 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 |
$1,763.60
|
| Rate for Payer: EmblemHealth Commercial |
$1,763.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,499.06
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,569.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,763.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,569.60
|
| Rate for Payer: Group Health Inc Commercial |
$1,763.60
|
| Rate for Payer: Group Health Inc Medicare |
$1,763.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$87.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,763.60
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,499.06
|
| Rate for Payer: Healthfirst QHP |
$1,763.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,763.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,763.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,410.88
|
| Rate for Payer: Wellcare Medicare |
$1,675.42
|
|
|
ALVEOLOPLASTY NOT IN CONJUNC WITH
|
Facility
OP
|
$287.50
|
|
|
Service Code
|
HCPCS D7320
|
| Hospital Charge Code |
42301740
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$100.62 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$158.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$119.37
|
| Rate for Payer: Aetna Government |
$119.37
|
| 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 |
$143.75
|
| Rate for Payer: Group Health Inc Medicare |
$100.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$143.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$143.75
|
|
|
ALVEOLUS-STABILIZE TEETH, CLOSED
|
Facility
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS D7771
|
| Hospital Charge Code |
42303453
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$750.00 |
| Max. Negotiated Rate |
$3,723.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$825.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,723.23
|
| Rate for Payer: Aetna Government |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,723.23
|
| 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 |
$3,723.23
|
| Rate for Payer: EmblemHealth Commercial |
$3,723.23
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,164.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,313.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,723.23
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,313.67
|
| Rate for Payer: Group Health Inc Commercial |
$3,723.23
|
| Rate for Payer: Group Health Inc Medicare |
$3,723.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,723.23
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,164.75
|
| Rate for Payer: Healthfirst QHP |
$3,723.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,723.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,723.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,978.58
|
| Rate for Payer: Wellcare Medicare |
$3,537.07
|
|
|
ALVEOLUS-STABIL TEETH, OPEN RED/1
|
Facility
OP
|
$2,729.00
|
|
|
Service Code
|
HCPCS D7770
|
| Hospital Charge Code |
42301930
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,364.50 |
| Max. Negotiated Rate |
$6,772.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,500.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,772.21
|
| Rate for Payer: Aetna Government |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,772.21
|
| 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 |
$6,772.21
|
| Rate for Payer: EmblemHealth Commercial |
$6,772.21
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,756.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6,027.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,772.21
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6,027.27
|
| Rate for Payer: Group Health Inc Commercial |
$6,772.21
|
| Rate for Payer: Group Health Inc Medicare |
$6,772.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,364.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,772.21
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5,756.38
|
| Rate for Payer: Healthfirst QHP |
$6,772.21
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,772.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,772.21
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,417.77
|
| Rate for Payer: Wellcare Medicare |
$6,433.60
|
|
|
ALVEOLUS-STABIL TEETH, OPEN REDUC
|
Facility
OP
|
$507.50
|
|
|
Service Code
|
HCPCS D7670
|
| Hospital Charge Code |
42301890
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$253.75 |
| Max. Negotiated Rate |
$3,723.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$279.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,723.23
|
| Rate for Payer: Aetna Government |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,723.23
|
| 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 |
$3,723.23
|
| Rate for Payer: EmblemHealth Commercial |
$3,723.23
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,164.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,313.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,723.23
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,313.67
|
| Rate for Payer: Group Health Inc Commercial |
$3,723.23
|
| Rate for Payer: Group Health Inc Medicare |
$3,723.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$253.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,723.23
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,164.75
|
| Rate for Payer: Healthfirst QHP |
$3,723.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,723.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,723.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,978.58
|
| Rate for Payer: Wellcare Medicare |
$3,537.07
|
|
|
AMALGAM-FOUR OR MORE SURFACES, PE
|
Facility
OP
|
$245.00
|
|
|
Service Code
|
HCPCS D2161
|
| Hospital Charge Code |
42300360
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$134.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
AMALGAM-ONE SURFACE,PERMANENT
|
Facility
OP
|
$125.00
|
|
|
Service Code
|
HCPCS D2140
|
| Hospital Charge Code |
42300340
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$62.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$68.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$62.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
AMALGAM-THREE SURFACES, PERMANENT
|
Facility
OP
|
$205.00
|
|
|
Service Code
|
HCPCS D2160
|
| Hospital Charge Code |
42300355
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$102.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$112.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$102.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
AMALGAM-TWO SURFACES, PERMANENT
|
Facility
OP
|
$167.50
|
|
|
Service Code
|
HCPCS D2150
|
| Hospital Charge Code |
42300350
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$83.75 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$92.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| 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 |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$83.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
AMANTADINE 100 MG CAP
|
Facility
OP
|
$2.00
|
|
| Hospital Charge Code |
41640859
|
|
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: 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
|
|
