|
ALUMINUM, PLASMA/SERUM
|
Facility
|
IP
|
$63.70
|
|
|
Service Code
|
HCPCS 82108
|
| Hospital Charge Code |
40609041
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$25.48
|
|
|
ALUMINUM SULFATE-CA ACETATE POWDER
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
41641036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.00
|
| Rate for Payer: Aetna Government |
$1.00
|
| Rate for Payer: Brighton Health Commercial |
$1.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.36
|
| Rate for Payer: Group Health Inc Commercial |
$1.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.30
|
|
|
ALUMINUM SULFATE-CA ACETATE POWDER
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
41651036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.00
|
| Rate for Payer: Aetna Government |
$1.00
|
| Rate for Payer: Brighton Health Commercial |
$1.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.36
|
| Rate for Payer: Group Health Inc Commercial |
$1.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.30
|
|
|
ALUMINUM, URINE
|
Facility
|
IP
|
$12.95
|
|
|
Service Code
|
HCPCS 82570
|
| Hospital Charge Code |
40609841
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$5.18
|
|
|
ALUMINUM, URINE
|
Facility
|
OP
|
$12.95
|
|
|
Service Code
|
HCPCS 82570
|
| Hospital Charge Code |
40609841
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.63 |
| Max. Negotiated Rate |
$9.71 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.18
|
| Rate for Payer: Aetna Government |
$5.18
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.63
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.63
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.63
|
| Rate for Payer: Brighton Health Commercial |
$9.71
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$5.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.23
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.96
|
| Rate for Payer: Elderplan Medicare Advantage |
$5.18
|
| Rate for Payer: EmblemHealth Commercial |
$5.18
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$4.40
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4.61
|
| Rate for Payer: Fidelis Medicare Advantage |
$5.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4.61
|
| Rate for Payer: Group Health Inc Commercial |
$5.18
|
| Rate for Payer: Group Health Inc Medicare |
$5.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.18
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.18
|
| Rate for Payer: Healthfirst QHP |
$5.18
|
| Rate for Payer: Humana Medicare |
$5.28
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$5.18
|
| Rate for Payer: United Healthcare Commercial |
$6.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.14
|
| Rate for Payer: Wellcare Medicare |
$4.66
|
|
|
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML PO SUSP [9009]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 66689006099
|
| Hospital Charge Code |
66689006099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.07
|
| Rate for Payer: Aetna Government |
$0.07
|
| Rate for Payer: Brighton Health Commercial |
$0.10
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.11
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.09
|
| Rate for Payer: Group Health Inc Commercial |
$0.07
|
| Rate for Payer: Group Health Inc Medicare |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.09
|
|
|
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML PO SUSP [9009]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 00121176130
|
| Hospital Charge Code |
00121176130
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.06
|
| Rate for Payer: Aetna Government |
$0.06
|
| Rate for Payer: Brighton Health Commercial |
$0.09
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.09
|
| Rate for Payer: Group Health Inc Commercial |
$0.06
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.08
|
|
|
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML PO SUSP [9009]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 00536129383
|
| Hospital Charge Code |
00536129383
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
ALVELOUS-STABILIZATION, OPEN
|
Facility
|
IP
|
$2,000.00
|
|
|
Service Code
|
HCPCS D7671
|
| Hospital Charge Code |
42303452
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$6,772.21
|
|
|
ALVELOUS-STABILIZATION, OPEN
|
Facility
|
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS D7671
|
| Hospital Charge Code |
42303452
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,000.00 |
| Max. Negotiated Rate |
$6,907.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,100.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,772.21
|
| Rate for Payer: Aetna Government |
$6,772.21
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$4,740.55
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$4,740.55
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$4,740.55
|
| Rate for Payer: Brighton Health Commercial |
$1,500.00
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,772.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$6,772.21
|
| Rate for Payer: EmblemHealth Commercial |
$6,772.21
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,756.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6,027.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,772.21
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6,027.27
|
| Rate for Payer: Group Health Inc Commercial |
$6,772.21
|
| Rate for Payer: Group Health Inc Medicare |
$6,772.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,000.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,772.21
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5,756.38
|
| Rate for Payer: Healthfirst QHP |
$6,772.21
|
| Rate for Payer: Humana Medicare |
$6,907.65
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,772.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,772.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,772.21
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,417.77
|
| Rate for Payer: Wellcare Medicare |
$6,433.60
|
|
|
ALVEOLOPLASTY IN CONJUNC WITH EXT
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS D7310
|
| Hospital Charge Code |
42301735
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,763.60
|
|
|
ALVEOLOPLASTY IN CONJUNC WITH EXT
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS D7310
|
| Hospital Charge Code |
42301735
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$96.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,763.60
|
| Rate for Payer: Aetna Government |
$1,763.60
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,234.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,234.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,234.52
|
| Rate for Payer: Brighton Health Commercial |
$131.25
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,763.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,763.60
|
| Rate for Payer: EmblemHealth Commercial |
$1,763.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,499.06
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,569.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,763.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,569.60
|
| Rate for Payer: Group Health Inc Commercial |
$1,763.60
|
| Rate for Payer: Group Health Inc Medicare |
$1,763.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$87.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,763.60
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,499.06
|
| Rate for Payer: Healthfirst QHP |
$1,763.60
|
| Rate for Payer: Humana Medicare |
$1,798.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,763.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,763.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,763.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,410.88
|
| Rate for Payer: Wellcare Medicare |
$1,675.42
|
|
|
ALVEOLOPLASTY NOT IN CONJUNC WITH
|
Facility
|
OP
|
$287.50
|
|
|
Service Code
|
HCPCS D7320
|
| Hospital Charge Code |
42301740
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$100.62 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$158.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$119.37
|
| Rate for Payer: Aetna Government |
$119.37
|
| Rate for Payer: Brighton Health Commercial |
$215.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Group Health Inc Commercial |
$143.75
|
| Rate for Payer: Group Health Inc Medicare |
$100.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$143.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$143.75
|
|
|
ALVEOLUS-STABILIZE TEETH, CLOSED
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS D7771
|
| Hospital Charge Code |
42303453
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$750.00 |
| Max. Negotiated Rate |
$3,797.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$825.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,723.23
|
| Rate for Payer: Aetna Government |
$3,723.23
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,606.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,606.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,606.26
|
| Rate for Payer: Brighton Health Commercial |
$1,125.00
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,723.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$3,723.23
|
| Rate for Payer: EmblemHealth Commercial |
$3,723.23
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,164.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,313.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,723.23
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,313.67
|
| Rate for Payer: Group Health Inc Commercial |
$3,723.23
|
| Rate for Payer: Group Health Inc Medicare |
$3,723.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,723.23
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,164.75
|
| Rate for Payer: Healthfirst QHP |
$3,723.23
|
| Rate for Payer: Humana Medicare |
$3,797.69
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,723.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,723.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,723.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,978.58
|
| Rate for Payer: Wellcare Medicare |
$3,537.07
|
|
|
ALVEOLUS-STABILIZE TEETH, CLOSED
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS D7771
|
| Hospital Charge Code |
42303453
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$3,723.23
|
|
|
ALVEOLUS-STABIL TEETH, OPEN RED/1
|
Facility
|
IP
|
$2,729.00
|
|
|
Service Code
|
HCPCS D7770
|
| Hospital Charge Code |
42301930
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$6,772.21
|
|
|
ALVEOLUS-STABIL TEETH, OPEN RED/1
|
Facility
|
OP
|
$2,729.00
|
|
|
Service Code
|
HCPCS D7770
|
| Hospital Charge Code |
42301930
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,364.50 |
| Max. Negotiated Rate |
$6,907.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,500.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,772.21
|
| Rate for Payer: Aetna Government |
$6,772.21
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$4,740.55
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$4,740.55
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$4,740.55
|
| Rate for Payer: Brighton Health Commercial |
$2,046.75
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Cash Price |
$6,772.21
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,772.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$6,772.21
|
| Rate for Payer: EmblemHealth Commercial |
$6,772.21
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,756.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6,027.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,772.21
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6,027.27
|
| Rate for Payer: Group Health Inc Commercial |
$6,772.21
|
| Rate for Payer: Group Health Inc Medicare |
$6,772.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,364.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,772.21
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5,756.38
|
| Rate for Payer: Healthfirst QHP |
$6,772.21
|
| Rate for Payer: Humana Medicare |
$6,907.65
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,772.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,772.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,772.21
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,417.77
|
| Rate for Payer: Wellcare Medicare |
$6,433.60
|
|
|
ALVEOLUS-STABIL TEETH, OPEN REDUC
|
Facility
|
IP
|
$507.50
|
|
|
Service Code
|
HCPCS D7670
|
| Hospital Charge Code |
42301890
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$3,723.23
|
|
|
ALVEOLUS-STABIL TEETH, OPEN REDUC
|
Facility
|
OP
|
$507.50
|
|
|
Service Code
|
HCPCS D7670
|
| Hospital Charge Code |
42301890
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$253.75 |
| Max. Negotiated Rate |
$3,797.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$279.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,723.23
|
| Rate for Payer: Aetna Government |
$3,723.23
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,606.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,606.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,606.26
|
| Rate for Payer: Brighton Health Commercial |
$380.62
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Cash Price |
$3,723.23
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,723.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$3,723.23
|
| Rate for Payer: EmblemHealth Commercial |
$3,723.23
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,164.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,313.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,723.23
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,313.67
|
| Rate for Payer: Group Health Inc Commercial |
$3,723.23
|
| Rate for Payer: Group Health Inc Medicare |
$3,723.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$253.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,723.23
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,164.75
|
| Rate for Payer: Healthfirst QHP |
$3,723.23
|
| Rate for Payer: Humana Medicare |
$3,797.69
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,723.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,723.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,723.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,978.58
|
| Rate for Payer: Wellcare Medicare |
$3,537.07
|
|
|
AMALGAM-FOUR OR MORE SURFACES, PE
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
HCPCS D2161
|
| Hospital Charge Code |
42300360
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
AMALGAM-FOUR OR MORE SURFACES, PE
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
HCPCS D2161
|
| Hospital Charge Code |
42300360
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$134.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: 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 |
$183.75
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: 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
|
|
|
AMALGAM-ONE SURFACE,PERMANENT
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
HCPCS D2140
|
| Hospital Charge Code |
42300340
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
AMALGAM-ONE SURFACE,PERMANENT
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
HCPCS D2140
|
| Hospital Charge Code |
42300340
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$62.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$68.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: 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 |
$93.75
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$62.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: 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
|
|
|
AMALGAM-THREE SURFACES, PERMANENT
|
Facility
|
IP
|
$205.00
|
|
|
Service Code
|
HCPCS D2160
|
| Hospital Charge Code |
42300355
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
AMALGAM-THREE SURFACES, PERMANENT
|
Facility
|
OP
|
$205.00
|
|
|
Service Code
|
HCPCS D2160
|
| Hospital Charge Code |
42300355
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$102.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$112.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: 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 |
$153.75
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$102.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: 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
|
|
