|
E078-IGE BUDGERIGAR FEATHER
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729775
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.22
|
| Rate for Payer: Aetna Government |
$5.22
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.65
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.65
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.65
|
| Rate for Payer: Brighton Health Commercial |
$9.79
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$5.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.01
|
| Rate for Payer: Elderplan Medicare Advantage |
$5.22
|
| Rate for Payer: EmblemHealth Commercial |
$5.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$5.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4.65
|
| Rate for Payer: Group Health Inc Commercial |
$5.22
|
| Rate for Payer: Group Health Inc Medicare |
$5.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.22
|
| Rate for Payer: Healthfirst QHP |
$5.22
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$5.22
|
| Rate for Payer: United Healthcare Commercial |
$6.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.18
|
| Rate for Payer: Wellcare Medicare |
$4.70
|
|
|
E078-IGE BUDGERIGAR FEATHER
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729775
|
|
Hospital Revenue Code
|
305
|
| Rate for Payer: Cash Price |
$5.22
|
|
|
E082-IGE RABBIT EPITHELIA
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729776
|
|
Hospital Revenue Code
|
305
|
| Rate for Payer: Cash Price |
$5.22
|
|
|
E082-IGE RABBIT EPITHELIA
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729776
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.22
|
| Rate for Payer: Aetna Government |
$5.22
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.65
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.65
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.65
|
| Rate for Payer: Brighton Health Commercial |
$9.79
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$5.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.01
|
| Rate for Payer: Elderplan Medicare Advantage |
$5.22
|
| Rate for Payer: EmblemHealth Commercial |
$5.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$5.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4.65
|
| Rate for Payer: Group Health Inc Commercial |
$5.22
|
| Rate for Payer: Group Health Inc Medicare |
$5.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.22
|
| Rate for Payer: Healthfirst QHP |
$5.22
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$5.22
|
| Rate for Payer: United Healthcare Commercial |
$6.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.18
|
| Rate for Payer: Wellcare Medicare |
$4.70
|
|
|
E084-IGE HAMSTER EPITHELIUM
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729777
|
|
Hospital Revenue Code
|
305
|
| Rate for Payer: Cash Price |
$5.22
|
|
|
E084-IGE HAMSTER EPITHELIUM
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729777
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.22
|
| Rate for Payer: Aetna Government |
$5.22
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.65
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.65
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.65
|
| Rate for Payer: Brighton Health Commercial |
$9.79
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$5.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.01
|
| Rate for Payer: Elderplan Medicare Advantage |
$5.22
|
| Rate for Payer: EmblemHealth Commercial |
$5.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$5.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4.65
|
| Rate for Payer: Group Health Inc Commercial |
$5.22
|
| Rate for Payer: Group Health Inc Medicare |
$5.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.22
|
| Rate for Payer: Healthfirst QHP |
$5.22
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$5.22
|
| Rate for Payer: United Healthcare Commercial |
$6.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.18
|
| Rate for Payer: Wellcare Medicare |
$4.70
|
|
|
E085-IGE CHICKEN FEATHERS
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729778
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.22
|
| Rate for Payer: Aetna Government |
$5.22
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.65
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.65
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.65
|
| Rate for Payer: Brighton Health Commercial |
$9.79
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$5.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.01
|
| Rate for Payer: Elderplan Medicare Advantage |
$5.22
|
| Rate for Payer: EmblemHealth Commercial |
$5.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$5.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4.65
|
| Rate for Payer: Group Health Inc Commercial |
$5.22
|
| Rate for Payer: Group Health Inc Medicare |
$5.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.22
|
| Rate for Payer: Healthfirst QHP |
$5.22
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$5.22
|
| Rate for Payer: United Healthcare Commercial |
$6.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.18
|
| Rate for Payer: Wellcare Medicare |
$4.70
|
|
|
E085-IGE CHICKEN FEATHERS
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729778
|
|
Hospital Revenue Code
|
305
|
| Rate for Payer: Cash Price |
$5.22
|
|
|
E086-IGE DUCK FEATHERS
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729310
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$5.22
|
|
|
E086-IGE DUCK FEATHERS
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729310
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.22
|
| Rate for Payer: Aetna Government |
$5.22
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.65
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.65
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.65
|
| Rate for Payer: Brighton Health Commercial |
$9.79
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Cash Price |
$5.22
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$5.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.01
|
| Rate for Payer: Elderplan Medicare Advantage |
$5.22
|
| Rate for Payer: EmblemHealth Commercial |
$5.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$5.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4.65
|
| Rate for Payer: Group Health Inc Commercial |
$5.22
|
| Rate for Payer: Group Health Inc Medicare |
$5.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.22
|
| Rate for Payer: Healthfirst QHP |
$5.22
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$5.22
|
| Rate for Payer: United Healthcare Commercial |
$6.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.18
|
| Rate for Payer: Wellcare Medicare |
$4.70
|
|
|
EA. ADD'1 SEQ. IV PUSH NEW SUBSTA
|
Facility
|
OP
|
$115.43
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
40509891
|
|
Hospital Revenue Code
|
269
|
| Min. Negotiated Rate |
$38.45 |
| Max. Negotiated Rate |
$92.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$63.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$54.93
|
| Rate for Payer: Aetna Government |
$54.93
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$38.45
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$38.45
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$38.45
|
| Rate for Payer: Brighton Health Commercial |
$86.57
|
| Rate for Payer: Cash Price |
$54.93
|
| Rate for Payer: Cash Price |
$54.93
|
| Rate for Payer: Cash Price |
$54.93
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$54.93
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$92.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$78.49
|
| Rate for Payer: Elderplan Medicare Advantage |
$54.93
|
| Rate for Payer: EmblemHealth Commercial |
$54.93
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$46.69
|
| Rate for Payer: Fidelis Essential Plan QHP |
$48.89
|
| Rate for Payer: Fidelis Medicare Advantage |
$54.93
|
| Rate for Payer: Fidelis Qualified Health Plan |
$48.89
|
| Rate for Payer: Group Health Inc Commercial |
$54.93
|
| Rate for Payer: Group Health Inc Medicare |
$54.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$57.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$54.93
|
| Rate for Payer: Healthfirst Medicare Advantage |
$46.69
|
| Rate for Payer: Healthfirst QHP |
$54.93
|
| Rate for Payer: Humana Medicare |
$56.03
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$54.93
|
| Rate for Payer: United Healthcare Commercial |
$76.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$54.93
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$54.93
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$43.94
|
| Rate for Payer: Wellcare Medicare |
$52.18
|
|
|
EA. ADD'1 SEQ. IV PUSH NEW SUBSTA
|
Facility
|
IP
|
$115.43
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
40509891
|
|
Hospital Revenue Code
|
269
|
| Rate for Payer: Cash Price |
$54.93
|
|
|
EA ADD'1 SQ IVPUSH SAME SUBSTANCE
|
Facility
|
OP
|
$74.38
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
40509902
|
|
Hospital Revenue Code
|
269
|
| Min. Negotiated Rate |
$12.94 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$40.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.94
|
| Rate for Payer: Aetna Government |
$12.94
|
| Rate for Payer: Brighton Health Commercial |
$55.78
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$59.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$50.58
|
| Rate for Payer: Group Health Inc Commercial |
$37.19
|
| Rate for Payer: Group Health Inc Medicare |
$26.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.19
|
| Rate for Payer: United Healthcare Commercial |
$76.00
|
|
|
EA ADDITIONAL VACCINE
|
Facility
|
OP
|
$30.45
|
|
| Hospital Charge Code |
40501005
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$10.66 |
| Max. Negotiated Rate |
$24.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$15.22
|
| Rate for Payer: Aetna Government |
$15.22
|
| Rate for Payer: Brighton Health Commercial |
$22.84
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$20.71
|
| Rate for Payer: Group Health Inc Commercial |
$15.22
|
| Rate for Payer: Group Health Inc Medicare |
$10.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.22
|
| Rate for Payer: United Healthcare Commercial |
$15.22
|
|
|
EA ADD'TL 100 SQ CM
|
Facility
|
OP
|
$949.08
|
|
|
Service Code
|
HCPCS 15003
|
| Hospital Charge Code |
42500191
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$40.21 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$40.21
|
| Rate for Payer: Aetna Government |
$40.21
|
| Rate for Payer: Brighton Health Commercial |
$711.81
|
| 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 |
$474.54
|
| Rate for Payer: Group Health Inc Medicare |
$332.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$474.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$474.54
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
|
|
EACH ADD. CAST POST - SAME TOOTH
|
Facility
|
OP
|
$248.06
|
|
|
Service Code
|
HCPCS D2953
|
| Hospital Charge Code |
42303297
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$55.05 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$136.43
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$55.05
|
| Rate for Payer: Aetna Government |
$55.05
|
| Rate for Payer: Brighton Health Commercial |
$186.04
|
| 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 |
$124.03
|
| Rate for Payer: Group Health Inc Medicare |
$86.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$124.03
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$124.03
|
|
|
EACH ADDITIONAL 30 MINUTES.92607
|
Facility
|
OP
|
$151.08
|
|
|
Service Code
|
HCPCS 92608
|
| Hospital Charge Code |
41905004
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$45.63 |
| Max. Negotiated Rate |
$9,463.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$83.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$45.63
|
| Rate for Payer: Aetna Government |
$45.63
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$212.92
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$212.92
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$94.63
|
| Rate for Payer: Amida Care Medicaid |
$94.63
|
| Rate for Payer: Brighton Health Commercial |
$182.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$9,463.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$94.63
|
| Rate for Payer: Fidelis Essential Plan QHP |
$94.63
|
| Rate for Payer: Fidelis Qualified Health Plan |
$99.36
|
| Rate for Payer: Group Health Inc Commercial |
$75.54
|
| Rate for Payer: Group Health Inc Medicare |
$120.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$94.63
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$75.54
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$94.63
|
| Rate for Payer: Healthfirst Essential Plan |
$212.92
|
| Rate for Payer: Healthfirst QHP |
$94.63
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$94.63
|
| Rate for Payer: SOMOS Essential |
$212.92
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$212.92
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$104.09
|
| Rate for Payer: United Healthcare Medicaid |
$94.63
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$94.63
|
| Rate for Payer: Wellcare Medicare |
$55.00
|
|
|
EACH ADDITIONAL INJ
|
Facility
|
OP
|
$109.89
|
|
|
Service Code
|
HCPCS 90472
|
| Hospital Charge Code |
30105046
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$60.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.00
|
| Rate for Payer: Aetna Government |
$11.00
|
| Rate for Payer: Brighton Health Commercial |
$82.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$87.91
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$74.73
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$54.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$54.94
|
| Rate for Payer: United Healthcare Commercial |
$44.00
|
|
|
EACH ADDITIONAL INJECTION
|
Facility
|
OP
|
$109.89
|
|
|
Service Code
|
HCPCS 90472
|
| Hospital Charge Code |
30305046
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$60.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.00
|
| Rate for Payer: Aetna Government |
$11.00
|
| Rate for Payer: Brighton Health Commercial |
$82.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$87.91
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$74.73
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$54.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$54.94
|
| Rate for Payer: United Healthcare Commercial |
$44.00
|
|
|
EACH ADDITIONAL INJECTION
|
Facility
|
OP
|
$109.89
|
|
|
Service Code
|
HCPCS 90472
|
| Hospital Charge Code |
30101126
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$60.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.00
|
| Rate for Payer: Aetna Government |
$11.00
|
| Rate for Payer: Brighton Health Commercial |
$82.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$87.91
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$74.73
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$54.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$54.94
|
| Rate for Payer: United Healthcare Commercial |
$44.00
|
|
|
EACH ADD. PREFAB. POST SAME TOOTH
|
Facility
|
IP
|
$248.06
|
|
|
Service Code
|
HCPCS D2957
|
| Hospital Charge Code |
42303299
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
EACH ADD. PREFAB. POST SAME TOOTH
|
Facility
|
OP
|
$248.06
|
|
|
Service Code
|
HCPCS D2957
|
| Hospital Charge Code |
42303299
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$124.03 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$136.43
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$186.04
|
| 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 |
$124.03
|
| 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: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare 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
|
|
|
EACH ADD'TL 100 SQ CM
|
Facility
|
OP
|
$949.08
|
|
|
Service Code
|
HCPCS 15005
|
| Hospital Charge Code |
42500193
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$79.96 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$79.96
|
| Rate for Payer: Aetna Government |
$79.96
|
| Rate for Payer: Brighton Health Commercial |
$711.81
|
| 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 |
$474.54
|
| Rate for Payer: Group Health Inc Medicare |
$332.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$474.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$474.54
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
|
|
EACH SUBS 90 DAYS
|
Facility
|
OP
|
$330.23
|
|
|
Service Code
|
HCPCS 99364
|
| Hospital Charge Code |
30301322
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$165.12 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$181.63
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$165.12
|
| Rate for Payer: Aetna Government |
$165.12
|
| 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 |
$165.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$165.12
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
|
|
E ANTIGEN TYPE
|
Facility
|
IP
|
$858.38
|
|
|
Service Code
|
HCPCS 86905
|
| Hospital Charge Code |
40701251
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$415.67
|
|
