|
EYE EXAM W ANESTH, COMPLETE
|
Facility
|
IP
|
$5,861.23
|
|
|
Service Code
|
HCPCS 92018
|
| Hospital Charge Code |
42102000
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$2,702.32
|
|
|
EYE EXAM W ANESTH, COMPLETE
|
Facility
|
OP
|
$5,861.23
|
|
|
Service Code
|
HCPCS 92018
|
| Hospital Charge Code |
42102000
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,468.00 |
| Max. Negotiated Rate |
$4,395.92 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3,223.68
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,702.32
|
| Rate for Payer: Aetna Government |
$2,702.32
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,891.62
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,891.62
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,891.62
|
| Rate for Payer: Brighton Health Commercial |
$4,395.92
|
| Rate for Payer: Cash Price |
$2,702.32
|
| Rate for Payer: Cash Price |
$2,702.32
|
| Rate for Payer: Cash Price |
$2,702.32
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2,702.32
|
| 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 |
$2,702.32
|
| Rate for Payer: EmblemHealth Commercial |
$2,702.32
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2,296.97
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2,405.06
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,702.32
|
| Rate for Payer: Fidelis Qualified Health Plan |
$2,405.06
|
| Rate for Payer: Group Health Inc Commercial |
$2,702.32
|
| Rate for Payer: Group Health Inc Medicare |
$2,702.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,930.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,702.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2,296.97
|
| Rate for Payer: Healthfirst QHP |
$2,702.32
|
| Rate for Payer: Humana Medicare |
$2,756.37
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,702.32
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,702.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,702.32
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,161.86
|
| Rate for Payer: Wellcare Medicare |
$2,567.20
|
|
|
EYE IRRIGATION SET
|
Facility
|
OP
|
$14.53
|
|
| Hospital Charge Code |
40201520
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.09 |
| Max. Negotiated Rate |
$11.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.99
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.26
|
| Rate for Payer: Aetna Government |
$7.26
|
| Rate for Payer: Brighton Health Commercial |
$10.90
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.88
|
| Rate for Payer: Group Health Inc Commercial |
$7.26
|
| Rate for Payer: Group Health Inc Medicare |
$5.09
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.26
|
|
|
EYE IRRIGATION SOL 120ML
|
Facility
|
OP
|
$2.34
|
|
| Hospital Charge Code |
41658036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.17
|
| Rate for Payer: Aetna Government |
$1.17
|
| Rate for Payer: Brighton Health Commercial |
$1.76
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.87
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.59
|
| Rate for Payer: Group Health Inc Commercial |
$1.17
|
| Rate for Payer: Group Health Inc Medicare |
$0.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.52
|
|
|
EYE IRRIGATION SOL 120ML
|
Facility
|
OP
|
$2.34
|
|
| Hospital Charge Code |
41648036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.29
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.17
|
| Rate for Payer: Aetna Government |
$1.17
|
| Rate for Payer: Brighton Health Commercial |
$1.76
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.87
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.59
|
| Rate for Payer: Group Health Inc Commercial |
$1.17
|
| Rate for Payer: Group Health Inc Medicare |
$0.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.52
|
|
|
EYEJET TYPE SIZE 10 (MR14)
|
Facility
|
OP
|
$199.00
|
|
| Hospital Charge Code |
64906307
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$69.65 |
| Max. Negotiated Rate |
$159.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$109.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$99.50
|
| Rate for Payer: Aetna Government |
$99.50
|
| Rate for Payer: Brighton Health Commercial |
$149.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$159.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$135.32
|
| Rate for Payer: Group Health Inc Commercial |
$99.50
|
| Rate for Payer: Group Health Inc Medicare |
$69.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$99.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$99.50
|
|
|
EYEJET TYPE SIZE 11 (MR14C)
|
Facility
|
OP
|
$199.00
|
|
| Hospital Charge Code |
64906308
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$69.65 |
| Max. Negotiated Rate |
$159.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$109.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$99.50
|
| Rate for Payer: Aetna Government |
$99.50
|
| Rate for Payer: Brighton Health Commercial |
$149.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$159.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$135.32
|
| Rate for Payer: Group Health Inc Commercial |
$99.50
|
| Rate for Payer: Group Health Inc Medicare |
$69.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$99.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$99.50
|
|
|
EYEJET TYPE SIZE 12 (MR14A)
|
Facility
|
OP
|
$199.00
|
|
| Hospital Charge Code |
64906309
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$69.65 |
| Max. Negotiated Rate |
$159.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$109.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$99.50
|
| Rate for Payer: Aetna Government |
$99.50
|
| Rate for Payer: Brighton Health Commercial |
$149.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$159.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$135.32
|
| Rate for Payer: Group Health Inc Commercial |
$99.50
|
| Rate for Payer: Group Health Inc Medicare |
$69.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$99.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$99.50
|
|
|
EYE SERVICE OR PROCEDURE
|
Facility
|
OP
|
$69.63
|
|
|
Service Code
|
HCPCS 92499 TC
|
| Hospital Charge Code |
30301222
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.10 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$34.43
|
| Rate for Payer: Aetna Government |
$34.43
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$24.10
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$24.10
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$24.10
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$34.43
|
| Rate for Payer: Cash Price |
$34.43
|
| Rate for Payer: Cash Price |
$34.43
|
| Rate for Payer: Cash Price |
$34.43
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$34.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$34.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$29.27
|
| Rate for Payer: Fidelis Essential Plan QHP |
$30.64
|
| Rate for Payer: Fidelis Medicare Advantage |
$34.43
|
| Rate for Payer: Fidelis Qualified Health Plan |
$30.64
|
| 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 |
$34.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$34.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$29.27
|
| Rate for Payer: Healthfirst QHP |
$34.43
|
| Rate for Payer: Humana Medicare |
$35.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$34.43
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$34.43
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$34.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34.43
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$27.54
|
| Rate for Payer: Wellcare Medicare |
$32.71
|
|
|
EYE SERVICE OR PROCEDURE
|
Facility
|
IP
|
$69.63
|
|
|
Service Code
|
HCPCS 92499 TC
|
| Hospital Charge Code |
30301222
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$34.43
|
|
|
EYE SERVICE OR PROCEDURE
|
Facility
|
IP
|
$69.63
|
|
|
Service Code
|
HCPCS 92499 TC
|
| Hospital Charge Code |
30103243
|
|
Hospital Revenue Code
|
920
|
| Rate for Payer: Cash Price |
$34.43
|
|
|
EYE SERVICE OR PROCEDURE
|
Facility
|
OP
|
$69.63
|
|
|
Service Code
|
HCPCS 92499 TC
|
| Hospital Charge Code |
30103243
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$24.10 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$34.43
|
| Rate for Payer: Aetna Government |
$34.43
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$24.10
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$24.10
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$24.10
|
| Rate for Payer: Brighton Health Commercial |
$52.22
|
| Rate for Payer: Cash Price |
$34.43
|
| Rate for Payer: Cash Price |
$34.43
|
| Rate for Payer: Cash Price |
$34.43
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$34.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$55.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$47.35
|
| Rate for Payer: Elderplan Medicare Advantage |
$34.43
|
| Rate for Payer: EmblemHealth Commercial |
$34.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$29.27
|
| Rate for Payer: Fidelis Essential Plan QHP |
$30.64
|
| Rate for Payer: Fidelis Medicare Advantage |
$34.43
|
| Rate for Payer: Fidelis Qualified Health Plan |
$30.64
|
| Rate for Payer: Group Health Inc Commercial |
$34.43
|
| Rate for Payer: Group Health Inc Medicare |
$34.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$34.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$34.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$29.27
|
| Rate for Payer: Healthfirst QHP |
$34.43
|
| Rate for Payer: Humana Medicare |
$35.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$34.43
|
| Rate for Payer: United Healthcare Commercial |
$94.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$34.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34.43
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$27.54
|
| Rate for Payer: Wellcare Medicare |
$32.71
|
|
|
EYE WASH OP SOLN [3000]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 00536122497
|
| Hospital Charge Code |
00536122497
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.02
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.02
|
| Rate for Payer: Aetna Government |
$0.02
|
| Rate for Payer: Brighton Health Commercial |
$0.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.02
|
| Rate for Payer: Group Health Inc Commercial |
$0.02
|
| Rate for Payer: Group Health Inc Medicare |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.02
|
|
|
EZ45 EDOSCOPIC LINEAR CUTTER
|
Facility
|
OP
|
$1,608.00
|
|
| Hospital Charge Code |
40200432
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$562.80 |
| Max. Negotiated Rate |
$1,286.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$884.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$804.00
|
| Rate for Payer: Aetna Government |
$804.00
|
| Rate for Payer: Brighton Health Commercial |
$1,206.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,286.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,093.44
|
| Rate for Payer: Group Health Inc Commercial |
$804.00
|
| Rate for Payer: Group Health Inc Medicare |
$562.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$804.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$804.00
|
|
|
EZ45RELOADS BLUE 45MM
|
Facility
|
OP
|
$2,804.00
|
|
| Hospital Charge Code |
40200433
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$981.40 |
| Max. Negotiated Rate |
$2,243.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,542.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,402.00
|
| Rate for Payer: Aetna Government |
$1,402.00
|
| Rate for Payer: Brighton Health Commercial |
$2,103.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,243.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,906.72
|
| 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
|
|
|
EZ FRAME
|
Facility
|
OP
|
$15,470.00
|
|
| Hospital Charge Code |
64906016
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5,414.50 |
| Max. Negotiated Rate |
$12,376.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8,508.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7,735.00
|
| Rate for Payer: Aetna Government |
$7,735.00
|
| Rate for Payer: Brighton Health Commercial |
$11,602.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12,376.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10,519.60
|
| Rate for Payer: Group Health Inc Commercial |
$7,735.00
|
| Rate for Payer: Group Health Inc Medicare |
$5,414.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7,735.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7,735.00
|
|
|
F001-IGE EGG WHITE
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729267
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$5.22
|
|
|
F001-IGE EGG WHITE
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729267
|
|
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
|
|
|
F002-IGE MILK
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729279
|
|
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
|
|
|
F002-IGE MILK
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729279
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$5.22
|
|
|
F003-IGE CODFISH
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729283
|
|
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
|
|
|
F003-IGE CODFISH
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729283
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$5.22
|
|
|
F004-IGE WHEAT
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729282
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$5.22
|
|
|
F004-IGE WHEAT
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729282
|
|
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
|
|
|
F005-IGE RYE
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
40729768
|
|
Hospital Revenue Code
|
305
|
| Rate for Payer: Cash Price |
$5.22
|
|
