|
EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IJ SOLN [189064]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 14789001401
|
| Hospital Charge Code |
14789001401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$14.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.00
|
| Rate for Payer: Aetna Government |
$9.00
|
| Rate for Payer: Brighton Health Commercial |
$13.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12.24
|
| Rate for Payer: Group Health Inc Commercial |
$9.00
|
| Rate for Payer: Group Health Inc Medicare |
$6.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.70
|
|
|
EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN [132566]
|
Facility
|
IP
|
$59.11
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
00781326971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$29.56 |
| Max. Negotiated Rate |
$29.56 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$29.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$29.56
|
|
|
EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN [132566]
|
Facility
|
OP
|
$34.85
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
42023021625
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12.20 |
| Max. Negotiated Rate |
$36.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.42
|
| Rate for Payer: Aetna Government |
$17.42
|
| Rate for Payer: Brighton Health Commercial |
$20.91
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$17.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$20.04
|
| Rate for Payer: EmblemHealth Commercial |
$17.42
|
| Rate for Payer: Fidelis Medicare Advantage |
$36.59
|
| Rate for Payer: Group Health Inc Commercial |
$17.42
|
| Rate for Payer: Group Health Inc Medicare |
$12.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$22.65
|
|
|
EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN [132566]
|
Facility
|
IP
|
$30.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
70756061125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15.01 |
| Max. Negotiated Rate |
$15.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.01
|
|
|
EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN [132566]
|
Facility
|
IP
|
$30.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
00641623825
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15.01 |
| Max. Negotiated Rate |
$15.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.01
|
|
|
EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN [132566]
|
Facility
|
OP
|
$59.11
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
00781326971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20.69 |
| Max. Negotiated Rate |
$62.07 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$32.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$29.56
|
| Rate for Payer: Aetna Government |
$29.56
|
| Rate for Payer: Brighton Health Commercial |
$35.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$29.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$33.99
|
| Rate for Payer: EmblemHealth Commercial |
$29.56
|
| Rate for Payer: Fidelis Medicare Advantage |
$62.07
|
| Rate for Payer: Group Health Inc Commercial |
$29.56
|
| Rate for Payer: Group Health Inc Medicare |
$20.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$29.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$29.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$38.42
|
|
|
EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN [132566]
|
Facility
|
IP
|
$34.85
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
42023021625
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.42 |
| Max. Negotiated Rate |
$17.42 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.42
|
|
|
EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN [132566]
|
Facility
|
IP
|
$29.52
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
55150037325
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$14.76 |
| Max. Negotiated Rate |
$14.76 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.76
|
|
|
EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN [132566]
|
Facility
|
OP
|
$30.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
00641623825
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$31.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$15.01
|
| Rate for Payer: Aetna Government |
$15.01
|
| Rate for Payer: Brighton Health Commercial |
$18.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.26
|
| Rate for Payer: EmblemHealth Commercial |
$15.01
|
| Rate for Payer: Fidelis Medicare Advantage |
$31.51
|
| Rate for Payer: Group Health Inc Commercial |
$15.01
|
| Rate for Payer: Group Health Inc Medicare |
$10.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.51
|
|
|
EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN [132566]
|
Facility
|
OP
|
$29.52
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
55150037325
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10.33 |
| Max. Negotiated Rate |
$31.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$14.76
|
| Rate for Payer: Aetna Government |
$14.76
|
| Rate for Payer: Brighton Health Commercial |
$17.71
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.76
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.97
|
| Rate for Payer: EmblemHealth Commercial |
$14.76
|
| Rate for Payer: Fidelis Medicare Advantage |
$31.00
|
| Rate for Payer: Group Health Inc Commercial |
$14.76
|
| Rate for Payer: Group Health Inc Medicare |
$10.33
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.19
|
|
|
EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN [132566]
|
Facility
|
OP
|
$56.75
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
70121163707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19.86 |
| Max. Negotiated Rate |
$59.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$31.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$28.37
|
| Rate for Payer: Aetna Government |
$28.37
|
| Rate for Payer: Brighton Health Commercial |
$34.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.37
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$32.63
|
| Rate for Payer: EmblemHealth Commercial |
$28.37
|
| Rate for Payer: Fidelis Medicare Advantage |
$59.59
|
| Rate for Payer: Group Health Inc Commercial |
$28.37
|
| Rate for Payer: Group Health Inc Medicare |
$19.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$28.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$28.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$36.89
|
|
|
EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN [132566]
|
Facility
|
IP
|
$56.75
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
70121163707
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$28.37 |
| Max. Negotiated Rate |
$28.37 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$28.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$28.37
|
|
|
EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN [132566]
|
Facility
|
OP
|
$30.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
70756061125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$31.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$15.01
|
| Rate for Payer: Aetna Government |
$15.01
|
| Rate for Payer: Brighton Health Commercial |
$18.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.26
|
| Rate for Payer: EmblemHealth Commercial |
$15.01
|
| Rate for Payer: Fidelis Medicare Advantage |
$31.51
|
| Rate for Payer: Group Health Inc Commercial |
$15.01
|
| Rate for Payer: Group Health Inc Medicare |
$10.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.51
|
|
|
EP ICD IMP INST OR REPO ELEC
|
Facility
|
IP
|
$98,886.00
|
|
|
Service Code
|
HCPCS 33249
|
| Hospital Charge Code |
66574531
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$38,045.24
|
|
|
EP ICD IMP INST OR REPO ELEC
|
Facility
|
OP
|
$98,886.00
|
|
|
Service Code
|
HCPCS 33249
|
| Hospital Charge Code |
66574531
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,477.75 |
| Max. Negotiated Rate |
$74,164.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$44,507.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$38,045.24
|
| Rate for Payer: Aetna Government |
$38,045.24
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$26,631.67
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$26,631.67
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$26,631.67
|
| Rate for Payer: Brighton Health Commercial |
$74,164.50
|
| Rate for Payer: Cash Price |
$38,045.24
|
| Rate for Payer: Cash Price |
$38,045.24
|
| Rate for Payer: Cash Price |
$38,045.24
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$38,045.24
|
| 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 |
$38,045.24
|
| Rate for Payer: EmblemHealth Commercial |
$38,045.24
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$32,338.45
|
| Rate for Payer: Fidelis Essential Plan QHP |
$33,860.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$38,045.24
|
| Rate for Payer: Fidelis Qualified Health Plan |
$33,860.26
|
| Rate for Payer: Group Health Inc Commercial |
$38,045.24
|
| Rate for Payer: Group Health Inc Medicare |
$38,045.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$49,443.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$38,045.24
|
| Rate for Payer: Healthfirst Medicare Advantage |
$32,338.45
|
| Rate for Payer: Healthfirst QHP |
$38,045.24
|
| Rate for Payer: Humana Medicare |
$38,806.14
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$38,045.24
|
| Rate for Payer: United Healthcare Commercial |
$4,446.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38,045.24
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$38,045.24
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$30,436.19
|
| Rate for Payer: Wellcare Medicare |
$36,142.98
|
|
|
EPICORD 1 SQ CM
|
Facility
|
IP
|
$535.00
|
|
|
Service Code
|
HCPCS Q4187
|
| Hospital Charge Code |
42501057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$267.50 |
| Max. Negotiated Rate |
$267.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.50
|
|
|
EPICORD 1 SQ CM
|
Facility
|
IP
|
$535.00
|
|
|
Service Code
|
HCPCS Q4187
|
| Hospital Charge Code |
30307933
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$267.50 |
| Max. Negotiated Rate |
$267.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.50
|
|
|
EPICORD 1 SQ CM
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
HCPCS Q4187
|
| Hospital Charge Code |
30307933
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$187.25 |
| Max. Negotiated Rate |
$347.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$294.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$223.17
|
| Rate for Payer: Aetna Government |
$223.17
|
| Rate for Payer: Brighton Health Commercial |
$321.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$267.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$307.62
|
| Rate for Payer: Group Health Inc Commercial |
$267.50
|
| Rate for Payer: Group Health Inc Medicare |
$187.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$263.27
|
| Rate for Payer: SOMOS Essential |
$263.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$347.75
|
|
|
EPICORD 1 SQ CM
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
HCPCS Q4187
|
| Hospital Charge Code |
42501057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$187.25 |
| Max. Negotiated Rate |
$347.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$294.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$223.17
|
| Rate for Payer: Aetna Government |
$223.17
|
| Rate for Payer: Brighton Health Commercial |
$321.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$267.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$307.62
|
| Rate for Payer: Group Health Inc Commercial |
$267.50
|
| Rate for Payer: Group Health Inc Medicare |
$187.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$263.27
|
| Rate for Payer: SOMOS Essential |
$263.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$347.75
|
|
|
EPIC VASC 6X40X120
|
Facility
|
OP
|
$3,250.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
64903767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$3,412.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,787.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Brighton Health Commercial |
$1,950.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,625.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,868.75
|
| Rate for Payer: EmblemHealth Commercial |
$1,625.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,412.50
|
| Rate for Payer: Group Health Inc Commercial |
$1,625.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,137.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,625.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,625.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,112.50
|
|
|
EPIC VASC 6X40X120
|
Facility
|
IP
|
$3,250.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
64903767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,625.00 |
| Max. Negotiated Rate |
$1,625.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,625.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,625.00
|
|
|
EPIC VASC 6X60X120
|
Facility
|
OP
|
$3,250.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
64903769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$3,412.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,787.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Brighton Health Commercial |
$1,950.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,625.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,868.75
|
| Rate for Payer: EmblemHealth Commercial |
$1,625.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,412.50
|
| Rate for Payer: Group Health Inc Commercial |
$1,625.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,137.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,625.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,625.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,112.50
|
|
|
EPIC VASC 6X60X120
|
Facility
|
IP
|
$3,250.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
64903769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,625.00 |
| Max. Negotiated Rate |
$1,625.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,625.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,625.00
|
|
|
Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children
|
Facility
|
OP
|
$2,915.00
|
|
|
Service Code
|
CPT 15115
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,409.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,108.87
|
| Rate for Payer: Aetna Government |
$2,108.87
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,476.21
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,476.21
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,476.21
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2,108.87
|
| 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 |
$2,108.87
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,792.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,876.89
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,108.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,876.89
|
| Rate for Payer: Group Health Inc Commercial |
$2,108.87
|
| Rate for Payer: Group Health Inc Medicare |
$2,108.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,108.87
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,792.54
|
| Rate for Payer: Healthfirst QHP |
$2,108.87
|
| Rate for Payer: Humana Medicare |
$2,151.05
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,108.87
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,108.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,108.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,687.10
|
| Rate for Payer: Wellcare Medicare |
$2,003.43
|
|
|
EPIDIDYMECTOMY
|
Facility
|
OP
|
$9,142.40
|
|
|
Service Code
|
HCPCS 54861
|
| Hospital Charge Code |
40122985
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,468.00 |
| Max. Negotiated Rate |
$6,856.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,485.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,031.47
|
| Rate for Payer: Aetna Government |
$4,031.47
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,822.03
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,822.03
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,822.03
|
| Rate for Payer: Brighton Health Commercial |
$6,856.80
|
| Rate for Payer: Cash Price |
$4,031.47
|
| Rate for Payer: Cash Price |
$4,031.47
|
| Rate for Payer: Cash Price |
$4,031.47
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4,031.47
|
| 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 |
$4,031.47
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,426.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,588.01
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,031.47
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,588.01
|
| Rate for Payer: Group Health Inc Commercial |
$4,031.47
|
| Rate for Payer: Group Health Inc Medicare |
$4,031.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,571.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,031.47
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,426.75
|
| Rate for Payer: Healthfirst QHP |
$4,031.47
|
| Rate for Payer: Humana Medicare |
$4,112.10
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4,031.47
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,031.47
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4,031.47
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3,225.18
|
| Rate for Payer: Wellcare Medicare |
$3,829.90
|
|
