|
HC UNLISTED PREVENTIVE SERVICE
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
CPT 99429
|
| Hospital Charge Code |
5109942901
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$63.00
|
|
|
HC UNLISTED PROC, DENTOALVEOLAR STRUCTURE
|
Facility
|
OP
|
$616.00
|
|
|
Service Code
|
CPT 41899
|
| Hospital Charge Code |
4504189901
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$3,538.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,880.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$283.73
|
| Rate for Payer: Aetna Government |
$283.73
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,538.97
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,538.97
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,572.87
|
| Rate for Payer: Amida Care Medicaid |
$1,572.87
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$283.73
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$283.73
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$283.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$792.81
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$673.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$283.73
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$3,538.97
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$1,572.87
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,572.87
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,538.97
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,538.97
|
| Rate for Payer: Fidelis Medicare Advantage |
$283.73
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,651.50
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,572.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$283.73
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,572.87
|
| Rate for Payer: Healthfirst Essential Plan |
$3,538.97
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$2,563.77
|
| Rate for Payer: Humana Medicare |
$289.40
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$297.92
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$283.73
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,572.87
|
| Rate for Payer: SOMOS Essential |
$3,538.97
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$3,538.97
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$1,730.13
|
| Rate for Payer: United Healthcare Medicaid |
$1,572.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$283.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$283.73
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,572.87
|
| Rate for Payer: Wellcare Medicare |
$269.54
|
|
|
HC UNLISTED PROC, DENTOALVEOLAR STRUCTURE
|
Facility
|
IP
|
$616.00
|
|
|
Service Code
|
CPT 41899
|
| Hospital Charge Code |
4504189901
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$308.00 |
| Max. Negotiated Rate |
$308.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$308.00
|
|
|
HC UNLISTED PROCEDURE ANUS
|
Facility
|
OP
|
$2,313.00
|
|
|
Service Code
|
CPT 46999
|
| Hospital Charge Code |
3614699901
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$779.76 |
| Max. Negotiated Rate |
$3,092.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,113.95
|
| Rate for Payer: Aetna Government |
$1,113.95
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$779.76
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$779.76
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$779.76
|
| Rate for Payer: Brighton Health Commercial |
$1,734.75
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,113.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,092.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,628.64
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,113.95
|
| Rate for Payer: EmblemHealth Commercial |
$1,113.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,002.55
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$946.86
|
| Rate for Payer: Fidelis Essential Plan QHP |
$991.42
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,113.95
|
| Rate for Payer: Fidelis Qualified Health Plan |
$991.42
|
| Rate for Payer: Group Health Inc Commercial |
$1,113.95
|
| Rate for Payer: Group Health Inc Medicare |
$1,113.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,113.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,113.95
|
| Rate for Payer: Healthfirst Medicare Advantage |
$946.86
|
| Rate for Payer: Healthfirst QHP |
$1,113.95
|
| Rate for Payer: Humana Medicare |
$1,136.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,113.95
|
| Rate for Payer: United Healthcare Commercial |
$1,188.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,113.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,113.95
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,058.25
|
| Rate for Payer: Wellcare Medicare |
$1,058.25
|
|
|
HC UNLISTED PROCEDURE ANUS
|
Facility
|
IP
|
$2,313.00
|
|
|
Service Code
|
CPT 46999
|
| Hospital Charge Code |
3614699901
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,156.50 |
| Max. Negotiated Rate |
$1,156.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,156.50
|
|
|
HC UNLISTED PROCEDURE, RECTUM
|
Facility
|
IP
|
$2,313.00
|
|
|
Service Code
|
CPT 45999
|
| Hospital Charge Code |
7504599901
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$1,156.50 |
| Max. Negotiated Rate |
$1,156.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,156.50
|
|
|
HC UNLISTED PROCEDURE, RECTUM
|
Facility
|
OP
|
$2,313.00
|
|
|
Service Code
|
CPT 45999
|
| Hospital Charge Code |
7504599901
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$779.76 |
| Max. Negotiated Rate |
$3,092.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,113.95
|
| Rate for Payer: Aetna Government |
$1,113.95
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$779.76
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$779.76
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$779.76
|
| Rate for Payer: Brighton Health Commercial |
$1,734.75
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,113.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,092.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,628.64
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,113.95
|
| Rate for Payer: EmblemHealth Commercial |
$1,113.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,002.55
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$946.86
|
| Rate for Payer: Fidelis Essential Plan QHP |
$991.42
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,113.95
|
| Rate for Payer: Fidelis Qualified Health Plan |
$991.42
|
| Rate for Payer: Group Health Inc Commercial |
$1,113.95
|
| Rate for Payer: Group Health Inc Medicare |
$1,113.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,113.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,113.95
|
| Rate for Payer: Healthfirst Medicare Advantage |
$946.86
|
| Rate for Payer: Healthfirst QHP |
$1,113.95
|
| Rate for Payer: Humana Medicare |
$1,136.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,113.95
|
| Rate for Payer: United Healthcare Commercial |
$1,188.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,113.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,113.95
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,058.25
|
| Rate for Payer: Wellcare Medicare |
$1,058.25
|
|
|
HC UNLISTED PROCEDURE - SKIN/MUCOUS MEMBRANE / SUBCUT TISSUE
|
Facility
|
IP
|
$552.00
|
|
|
Service Code
|
CPT 17999
|
| Hospital Charge Code |
3611799901
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$276.00 |
| Max. Negotiated Rate |
$276.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$276.00
|
|
|
HC UNLISTED PROCEDURE - SKIN/MUCOUS MEMBRANE / SUBCUT TISSUE
|
Facility
|
OP
|
$552.00
|
|
|
Service Code
|
CPT 17999
|
| Hospital Charge Code |
3611799901
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$169.95 |
| Max. Negotiated Rate |
$3,092.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$242.78
|
| Rate for Payer: Aetna Government |
$242.78
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$169.95
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$169.95
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$169.95
|
| Rate for Payer: Brighton Health Commercial |
$414.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$242.78
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,092.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,628.64
|
| Rate for Payer: Elderplan Medicare Advantage |
$242.78
|
| Rate for Payer: EmblemHealth Commercial |
$242.78
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$218.50
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$206.36
|
| Rate for Payer: Fidelis Essential Plan QHP |
$216.07
|
| Rate for Payer: Fidelis Medicare Advantage |
$242.78
|
| Rate for Payer: Fidelis Qualified Health Plan |
$216.07
|
| Rate for Payer: Group Health Inc Commercial |
$242.78
|
| Rate for Payer: Group Health Inc Medicare |
$242.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$242.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$242.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$206.36
|
| Rate for Payer: Healthfirst QHP |
$242.78
|
| Rate for Payer: Humana Medicare |
$247.64
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$242.78
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$242.78
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$230.64
|
| Rate for Payer: Wellcare Medicare |
$230.64
|
|
|
HC UNLISTED ULTRASOUND PROCEDURE
|
Facility
|
OP
|
$241.00
|
|
|
Service Code
|
CPT 76999 TC
|
| Hospital Charge Code |
4027699901
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$49.80 |
| Max. Negotiated Rate |
$180.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$132.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$120.50
|
| Rate for Payer: Aetna Government |
$120.50
|
| Rate for Payer: Brighton Health Commercial |
$180.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$133.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$112.12
|
| Rate for Payer: EmblemHealth Commercial |
$120.50
|
| Rate for Payer: Group Health Inc Commercial |
$120.50
|
| Rate for Payer: Group Health Inc Medicare |
$84.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$120.50
|
| Rate for Payer: United Healthcare Commercial |
$49.80
|
|
|
HC UNLISTED ULTRASOUND PROCEDURE
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
CPT 76999 TC
|
| Hospital Charge Code |
4027699901
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$120.50 |
| Max. Negotiated Rate |
$120.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.50
|
|
|
HC UNSCHED DIALYSIS ESRD PT HOS
|
Facility
|
OP
|
$1,891.00
|
|
|
Service Code
|
CPT G0257
|
| Hospital Charge Code |
829G025701
|
|
Hospital Revenue Code
|
829
|
| Min. Negotiated Rate |
$435.00 |
| Max. Negotiated Rate |
$1,512.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,040.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$854.93
|
| Rate for Payer: Aetna Government |
$854.93
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$598.45
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$598.45
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$598.45
|
| Rate for Payer: Brighton Health Commercial |
$1,418.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$854.93
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,512.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,285.88
|
| Rate for Payer: Elderplan Medicare Advantage |
$854.93
|
| Rate for Payer: EmblemHealth Commercial |
$650.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$769.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$726.69
|
| Rate for Payer: Fidelis Essential Plan QHP |
$760.89
|
| Rate for Payer: Fidelis Medicare Advantage |
$854.93
|
| Rate for Payer: Fidelis Qualified Health Plan |
$760.89
|
| Rate for Payer: Group Health Inc Commercial |
$650.00
|
| Rate for Payer: Group Health Inc Medicare |
$435.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$854.93
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$854.93
|
| Rate for Payer: Healthfirst Medicare Advantage |
$726.69
|
| Rate for Payer: Healthfirst QHP |
$854.93
|
| Rate for Payer: Humana Medicare |
$872.03
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$854.93
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$854.93
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$854.93
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$812.18
|
| Rate for Payer: Wellcare Medicare |
$812.18
|
|
|
HC UNSCHED DIALYSIS ESRD PT HOS
|
Facility
|
IP
|
$1,891.00
|
|
|
Service Code
|
CPT G0257
|
| Hospital Charge Code |
829G025701
|
|
Hospital Revenue Code
|
829
|
| Min. Negotiated Rate |
$945.50 |
| Max. Negotiated Rate |
$945.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$945.50
|
|
|
HC UNSPECIFIED ENDODONTIC PROCEDURE,
|
Facility
|
OP
|
$358.00
|
|
|
Service Code
|
CPT D3999
|
| Hospital Charge Code |
361D399901
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$196.90 |
| Max. Negotiated Rate |
$2,072.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$196.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,031.43
|
| Rate for Payer: Aetna Government |
$2,031.43
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,422.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,422.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,422.00
|
| Rate for Payer: Brighton Health Commercial |
$268.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2,031.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$286.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$243.44
|
| Rate for Payer: Elderplan Medicare Advantage |
$2,031.43
|
| Rate for Payer: EmblemHealth Commercial |
$2,031.43
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,828.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,726.72
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,807.97
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,031.43
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,807.97
|
| Rate for Payer: Group Health Inc Commercial |
$2,031.43
|
| Rate for Payer: Group Health Inc Medicare |
$2,031.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,031.43
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,031.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,726.72
|
| Rate for Payer: Healthfirst QHP |
$2,031.43
|
| Rate for Payer: Humana Medicare |
$2,072.06
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,031.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,031.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,031.43
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,929.86
|
| Rate for Payer: Wellcare Medicare |
$1,929.86
|
|
|
HC UNSPECIFIED ENDODONTIC PROCEDURE,
|
Facility
|
IP
|
$358.00
|
|
|
Service Code
|
CPT D3999
|
| Hospital Charge Code |
361D399901
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$179.00 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$179.00
|
|
|
HC UNSPECIFIED ORAL SURGERY PROCEDUR
|
Facility
|
OP
|
$425.00
|
|
|
Service Code
|
CPT D7999
|
| Hospital Charge Code |
361D799901
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$148.75 |
| Max. Negotiated Rate |
$340.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$233.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$212.50
|
| Rate for Payer: Aetna Government |
$212.50
|
| Rate for Payer: Brighton Health Commercial |
$318.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$340.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$289.00
|
| Rate for Payer: EmblemHealth Commercial |
$212.50
|
| 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
|
|
|
HC UNSPECIFIED ORAL SURGERY PROCEDUR
|
Facility
|
IP
|
$425.00
|
|
|
Service Code
|
CPT D7999
|
| Hospital Charge Code |
361D799901
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$212.50 |
| Max. Negotiated Rate |
$212.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$212.50
|
|
|
HC UPGRADE PACEMAKER SYS, SING TO DUAL
|
Facility
|
OP
|
$31,050.00
|
|
|
Service Code
|
CPT 33214
|
| Hospital Charge Code |
3613321401
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$557.21 |
| Max. Negotiated Rate |
$23,287.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$22,108.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12,786.75
|
| Rate for Payer: Aetna Government |
$12,786.75
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$8,950.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$8,950.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$8,950.73
|
| Rate for Payer: Brighton Health Commercial |
$23,287.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$12,786.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,092.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,628.64
|
| Rate for Payer: Elderplan Medicare Advantage |
$12,786.75
|
| Rate for Payer: EmblemHealth Commercial |
$12,786.75
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$11,508.08
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$10,868.74
|
| Rate for Payer: Fidelis Essential Plan QHP |
$11,380.21
|
| Rate for Payer: Fidelis Medicare Advantage |
$12,786.75
|
| Rate for Payer: Fidelis Qualified Health Plan |
$11,380.21
|
| Rate for Payer: Group Health Inc Commercial |
$12,786.75
|
| Rate for Payer: Group Health Inc Medicare |
$12,786.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12,786.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7,595.40
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$557.21
|
| Rate for Payer: Healthfirst Medicare Advantage |
$10,868.74
|
| Rate for Payer: Healthfirst QHP |
$12,786.75
|
| Rate for Payer: Humana Medicare |
$13,042.49
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$12,786.75
|
| Rate for Payer: United Healthcare Commercial |
$3,047.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,786.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12,786.75
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$12,147.41
|
| Rate for Payer: Wellcare Medicare |
$12,147.41
|
|
|
HC UPGRADE PACEMAKER SYS, SING TO DUAL
|
Facility
|
IP
|
$31,050.00
|
|
|
Service Code
|
CPT 33214
|
| Hospital Charge Code |
3613321401
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$15,525.00 |
| Max. Negotiated Rate |
$15,525.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15,525.00
|
|
|
HC UPR/L XTREMITY ART 2 LEVELS - CV US ANKLE BRACHIAL INDICES EXTRM CMP
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
CPT 93922
|
| Hospital Charge Code |
9219392201
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$95.16 |
| Max. Negotiated Rate |
$271.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$186.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$157.49
|
| Rate for Payer: Aetna Government |
$157.49
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$110.24
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$110.24
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$110.24
|
| Rate for Payer: Brighton Health Commercial |
$254.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$157.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$271.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$230.52
|
| Rate for Payer: Elderplan Medicare Advantage |
$157.49
|
| Rate for Payer: EmblemHealth Commercial |
$157.49
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$141.74
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$133.87
|
| Rate for Payer: Fidelis Essential Plan QHP |
$140.17
|
| Rate for Payer: Fidelis Medicare Advantage |
$157.49
|
| Rate for Payer: Fidelis Qualified Health Plan |
$140.17
|
| Rate for Payer: Group Health Inc Commercial |
$157.49
|
| Rate for Payer: Group Health Inc Medicare |
$157.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$157.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$157.49
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$95.16
|
| Rate for Payer: Healthfirst Medicare Advantage |
$133.87
|
| Rate for Payer: Healthfirst QHP |
$157.49
|
| Rate for Payer: Humana Medicare |
$160.64
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$157.49
|
| Rate for Payer: United Healthcare Commercial |
$169.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$157.49
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$157.49
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$149.62
|
| Rate for Payer: Wellcare Medicare |
$149.62
|
|
|
HC UPR/L XTREMITY ART 2 LEVELS - CV US ANKLE BRACHIAL INDICES EXTRM CMP
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
CPT 93922
|
| Hospital Charge Code |
9219392201
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$169.50 |
| Max. Negotiated Rate |
$169.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$169.50
|
|
|
HC UPR/L XTREMITY ART 2 LEVELS - TRANSCUTANEOUS O2 MEASUREMENT
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
CPT 93922
|
| Hospital Charge Code |
9219392202
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$95.16 |
| Max. Negotiated Rate |
$271.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$186.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$157.49
|
| Rate for Payer: Aetna Government |
$157.49
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$110.24
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$110.24
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$110.24
|
| Rate for Payer: Brighton Health Commercial |
$254.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$157.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$271.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$230.52
|
| Rate for Payer: Elderplan Medicare Advantage |
$157.49
|
| Rate for Payer: EmblemHealth Commercial |
$157.49
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$141.74
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$133.87
|
| Rate for Payer: Fidelis Essential Plan QHP |
$140.17
|
| Rate for Payer: Fidelis Medicare Advantage |
$157.49
|
| Rate for Payer: Fidelis Qualified Health Plan |
$140.17
|
| Rate for Payer: Group Health Inc Commercial |
$157.49
|
| Rate for Payer: Group Health Inc Medicare |
$157.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$157.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$157.49
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$95.16
|
| Rate for Payer: Healthfirst Medicare Advantage |
$133.87
|
| Rate for Payer: Healthfirst QHP |
$157.49
|
| Rate for Payer: Humana Medicare |
$160.64
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$157.49
|
| Rate for Payer: United Healthcare Commercial |
$169.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$157.49
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$157.49
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$149.62
|
| Rate for Payer: Wellcare Medicare |
$149.62
|
|
|
HC UPR/L XTREMITY ART 2 LEVELS - TRANSCUTANEOUS O2 MEASUREMENT
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
CPT 93922
|
| Hospital Charge Code |
9219392202
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$169.50 |
| Max. Negotiated Rate |
$169.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$169.50
|
|
|
HC URETERAL EMBOLIZATION/OCCLUSION W/IMG GID RS&I
|
Facility
|
IP
|
$2,804.00
|
|
|
Service Code
|
CPT 50705
|
| Hospital Charge Code |
3615070501
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,402.00 |
| Max. Negotiated Rate |
$1,402.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,402.00
|
|
|
HC URETERAL EMBOLIZATION/OCCLUSION W/IMG GID RS&I
|
Facility
|
OP
|
$2,804.00
|
|
|
Service Code
|
CPT 50705
|
| Hospital Charge Code |
3615070501
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$197.68 |
| Max. Negotiated Rate |
$3,092.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$247.02
|
| Rate for Payer: Aetna Government |
$247.02
|
| Rate for Payer: Brighton Health Commercial |
$2,103.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,092.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,628.64
|
| Rate for Payer: EmblemHealth Commercial |
$1,402.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,402.00
|
| Rate for Payer: Group Health Inc Medicare |
$981.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,402.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,402.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$197.68
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
|
