|
F.T.S.G. WITH CLOSURE TRUNK
|
Facility
|
IP
|
$4,914.88
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
40013152
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$2,108.87
|
|
|
F.T.S.G. WITH CLOSURE TRUNK
|
Facility
|
OP
|
$4,914.88
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
40013152
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,409.00 |
| Max. Negotiated Rate |
$3,686.16 |
| 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: Brighton Health Commercial |
$3,686.16
|
| Rate for Payer: Cash Price |
$2,108.87
|
| Rate for Payer: Cash Price |
$2,108.87
|
| Rate for Payer: Cash Price |
$2,108.87
|
| 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 Medicaid |
$2,457.44
|
| 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
|
|
|
FT THER/PROPH/DIAG INJ,SC/IM
|
Facility
|
OP
|
$183.15
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
30303112
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$13.36 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$100.73
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$81.46
|
| Rate for Payer: Aetna Government |
$81.46
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$30.06
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$30.06
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$13.36
|
| Rate for Payer: Amida Care Medicaid |
$13.36
|
| Rate for Payer: Brighton Health Commercial |
$137.36
|
| Rate for Payer: Cash Price |
$81.46
|
| Rate for Payer: Cash Price |
$81.46
|
| Rate for Payer: Cash Price |
$81.46
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$81.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$146.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$124.54
|
| Rate for Payer: Elderplan Medicare Advantage |
$81.46
|
| Rate for Payer: EmblemHealth Commercial |
$81.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,336.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$13.36
|
| Rate for Payer: Fidelis Essential Plan QHP |
$13.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$81.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$14.03
|
| Rate for Payer: Group Health Inc Commercial |
$81.46
|
| Rate for Payer: Group Health Inc Medicare |
$81.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$81.46
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$13.36
|
| Rate for Payer: Healthfirst Essential Plan |
$30.06
|
| Rate for Payer: Healthfirst Medicare Advantage |
$69.24
|
| Rate for Payer: Healthfirst QHP |
$13.36
|
| Rate for Payer: Humana Medicare |
$83.09
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$81.46
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$13.36
|
| Rate for Payer: SOMOS Essential |
$13.36
|
| Rate for Payer: United Healthcare Commercial |
$76.00
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$30.06
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$14.70
|
| Rate for Payer: United Healthcare Medicaid |
$13.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$81.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$81.46
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$65.17
|
| Rate for Payer: Wellcare Medicare |
$77.39
|
|
|
FT THER/PROPH/DIAG INJ,SC/IM
|
Facility
|
IP
|
$183.15
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
30303112
|
|
Hospital Revenue Code
|
260
|
| Rate for Payer: Cash Price |
$81.46
|
|
|
FULGERATION CONDYLOMATA
|
Facility
|
IP
|
$529.93
|
|
|
Service Code
|
HCPCS 17110
|
| Hospital Charge Code |
40123000
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$231.52
|
|
|
FULGERATION CONDYLOMATA
|
Facility
|
OP
|
$529.93
|
|
|
Service Code
|
HCPCS 17110
|
| Hospital Charge Code |
40123000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$162.06 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$231.52
|
| Rate for Payer: Aetna Government |
$231.52
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$162.06
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$162.06
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$162.06
|
| Rate for Payer: Brighton Health Commercial |
$397.45
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$231.52
|
| 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 |
$231.52
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$196.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$206.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$231.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$206.05
|
| Rate for Payer: Group Health Inc Commercial |
$231.52
|
| Rate for Payer: Group Health Inc Medicare |
$231.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$264.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$231.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$196.79
|
| Rate for Payer: Healthfirst QHP |
$231.52
|
| Rate for Payer: Humana Medicare |
$236.15
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$231.52
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$231.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$231.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$185.22
|
| Rate for Payer: Wellcare Medicare |
$219.94
|
|
|
FULLER SHIELD
|
Facility
|
OP
|
$17.01
|
|
| Hospital Charge Code |
40201920
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$13.61 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.50
|
| Rate for Payer: Aetna Government |
$8.50
|
| Rate for Payer: Brighton Health Commercial |
$12.76
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.61
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.57
|
| Rate for Payer: Group Health Inc Commercial |
$8.50
|
| Rate for Payer: Group Health Inc Medicare |
$5.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.50
|
|
|
FULL MOUTH DEBRIDEMENT
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
HCPCS D4355
|
| Hospital Charge Code |
42303313
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$88.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$97.35
|
| 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 |
$132.75
|
| 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 |
$88.50
|
| 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
|
|
|
FULL MOUTH DEBRIDEMENT
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
HCPCS D4355
|
| Hospital Charge Code |
42303313
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
FULL MOUTH X-RAY OF TEETH
|
Facility
|
OP
|
$705.83
|
|
|
Service Code
|
HCPCS 70320 TC
|
| Hospital Charge Code |
41109863
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$51.62 |
| Max. Negotiated Rate |
$388.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$388.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$283.37
|
| Rate for Payer: Aetna Government |
$283.37
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$198.36
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$198.36
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$198.36
|
| Rate for Payer: Brighton Health Commercial |
$283.37
|
| Rate for Payer: Cash Price |
$283.37
|
| Rate for Payer: Cash Price |
$283.37
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$283.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$61.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$51.62
|
| Rate for Payer: Elderplan Medicare Advantage |
$283.37
|
| Rate for Payer: EmblemHealth Commercial |
$198.36
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$240.86
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$240.86
|
| Rate for Payer: Fidelis Essential Plan QHP |
$252.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$283.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$252.20
|
| Rate for Payer: Group Health Inc Commercial |
$255.03
|
| Rate for Payer: Group Health Inc Medicare |
$255.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$352.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$283.37
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$255.03
|
| Rate for Payer: Healthfirst Medicare Advantage |
$283.37
|
| Rate for Payer: Healthfirst QHP |
$283.37
|
| Rate for Payer: Humana Medicare |
$289.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$283.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$283.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$283.37
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$226.70
|
| Rate for Payer: Wellcare Medicare |
$269.20
|
|
|
FULL MOUTH X-RAY OF TEETH
|
Facility
|
IP
|
$705.83
|
|
|
Service Code
|
HCPCS 70320 TC
|
| Hospital Charge Code |
41109863
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$283.37
|
|
|
FULL TERM NEONATE WITH MAJOR PROBLEMS
|
Facility
|
IP
|
$90,337.25
|
|
|
Service Code
|
MSDRG 793
|
| Min. Negotiated Rate |
$3,163.00 |
| Max. Negotiated Rate |
$90,337.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$62,066.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$65,699.82
|
| Rate for Payer: Aetna Government |
$65,699.82
|
| Rate for Payer: Brighton Health Commercial |
$61,034.85
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$67,013.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$72,690.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$59,987.24
|
| Rate for Payer: Elderplan Medicare Advantage |
$62,414.83
|
| Rate for Payer: EmblemHealth Commercial |
$36,094.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$65,699.82
|
| Rate for Payer: Group Health Inc Commercial |
$65,699.82
|
| Rate for Payer: Group Health Inc Medicare |
$65,699.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$65,699.82
|
| Rate for Payer: Healthfirst Medicare Advantage |
$30,550.42
|
| Rate for Payer: Humana Medicare |
$90,337.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$65,699.82
|
| Rate for Payer: United Healthcare Commercial |
$3,163.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$65,699.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$65,699.82
|
| Rate for Payer: Wellcare Medicare |
$62,414.83
|
|
|
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY
|
Facility
|
IP
|
$49,974.86
|
|
|
Service Code
|
MSDRG 934
|
| Min. Negotiated Rate |
$16,900.59 |
| Max. Negotiated Rate |
$49,974.86 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$30,853.91
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$36,345.35
|
| Rate for Payer: Aetna Government |
$36,345.35
|
| Rate for Payer: Brighton Health Commercial |
$30,341.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$37,072.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$36,135.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$29,820.47
|
| Rate for Payer: Elderplan Medicare Advantage |
$34,528.08
|
| Rate for Payer: EmblemHealth Commercial |
$17,943.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$36,345.35
|
| Rate for Payer: Group Health Inc Commercial |
$36,345.35
|
| Rate for Payer: Group Health Inc Medicare |
$36,345.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$36,345.35
|
| Rate for Payer: Healthfirst Medicare Advantage |
$16,900.59
|
| Rate for Payer: Humana Medicare |
$49,974.86
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$36,345.35
|
| Rate for Payer: United Healthcare Commercial |
$41,613.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36,345.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$36,345.35
|
| Rate for Payer: Wellcare Medicare |
$34,528.08
|
|
|
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC
|
Facility
|
IP
|
$142,018.25
|
|
|
Service Code
|
MSDRG 928
|
| Min. Negotiated Rate |
$48,027.99 |
| Max. Negotiated Rate |
$142,018.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$102,030.98
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$103,286.00
|
| Rate for Payer: Aetna Government |
$103,286.00
|
| Rate for Payer: Brighton Health Commercial |
$100,335.65
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$105,351.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$119,496.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$98,613.48
|
| Rate for Payer: Elderplan Medicare Advantage |
$98,121.70
|
| Rate for Payer: EmblemHealth Commercial |
$59,336.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$103,286.00
|
| Rate for Payer: Group Health Inc Commercial |
$103,286.00
|
| Rate for Payer: Group Health Inc Medicare |
$103,286.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$103,286.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$48,027.99
|
| Rate for Payer: Humana Medicare |
$142,018.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$103,286.00
|
| Rate for Payer: United Healthcare Commercial |
$137,612.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$103,286.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$103,286.00
|
| Rate for Payer: Wellcare Medicare |
$98,121.70
|
|
|
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC
|
Facility
|
IP
|
$71,387.86
|
|
|
Service Code
|
MSDRG 929
|
| Min. Negotiated Rate |
$24,142.07 |
| Max. Negotiated Rate |
$71,387.86 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$47,412.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$51,918.44
|
| Rate for Payer: Aetna Government |
$51,918.44
|
| Rate for Payer: Brighton Health Commercial |
$46,624.75
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$52,956.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$55,528.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$45,824.48
|
| Rate for Payer: Elderplan Medicare Advantage |
$49,322.52
|
| Rate for Payer: EmblemHealth Commercial |
$27,572.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$51,918.44
|
| Rate for Payer: Group Health Inc Commercial |
$51,918.44
|
| Rate for Payer: Group Health Inc Medicare |
$51,918.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$51,918.44
|
| Rate for Payer: Healthfirst Medicare Advantage |
$24,142.07
|
| Rate for Payer: Humana Medicare |
$71,387.86
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$51,918.44
|
| Rate for Payer: United Healthcare Commercial |
$63,946.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$51,918.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$51,918.44
|
| Rate for Payer: Wellcare Medicare |
$49,322.52
|
|
|
FULVESTRANT 250 MG/5ML IM SOSY [188010]
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
NDC 63323071505
|
| Hospital Charge Code |
63323071505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$66.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$60.00
|
| Rate for Payer: Aetna Government |
$60.00
|
| Rate for Payer: Brighton Health Commercial |
$90.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$96.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$81.60
|
| Rate for Payer: Group Health Inc Commercial |
$60.00
|
| Rate for Payer: Group Health Inc Medicare |
$42.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$60.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$60.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$78.00
|
|
|
FULVESTRANT 250 MG/5ML IM SOSY [188010]
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
NDC 70860021174
|
| Hospital Charge Code |
70860021174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$56.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$51.00
|
| Rate for Payer: Aetna Government |
$51.00
|
| Rate for Payer: Brighton Health Commercial |
$76.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$81.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$69.36
|
| Rate for Payer: Group Health Inc Commercial |
$51.00
|
| Rate for Payer: Group Health Inc Medicare |
$35.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$51.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$51.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$66.30
|
|
|
FULVESTRANT 250 MG/5ML IM SOSY [188010]
|
Facility
|
OP
|
$209.42
|
|
|
Service Code
|
NDC 00591501902
|
| Hospital Charge Code |
00591501902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.30 |
| Max. Negotiated Rate |
$167.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$115.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$104.71
|
| Rate for Payer: Aetna Government |
$104.71
|
| Rate for Payer: Brighton Health Commercial |
$157.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$167.54
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$142.40
|
| Rate for Payer: Group Health Inc Commercial |
$104.71
|
| Rate for Payer: Group Health Inc Medicare |
$73.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$104.71
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$104.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$136.12
|
|
|
FULVESTRANT 250 MG/5ML IM SOSY [188010]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00143902202
|
| Hospital Charge Code |
00143902202
|
|
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
|
|
|
FULVESTRANT 250 MG/5ML IM SOSY [188010]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
NDC 43598026202
|
| Hospital Charge Code |
43598026202
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.00
|
| Rate for Payer: Aetna Government |
$12.00
|
| Rate for Payer: Brighton Health Commercial |
$18.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.32
|
| Rate for Payer: Group Health Inc Commercial |
$12.00
|
| Rate for Payer: Group Health Inc Medicare |
$8.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.60
|
|
|
FULVESTRANT 250MG/5ML INJ
|
Facility
|
OP
|
$259.23
|
|
|
Service Code
|
HCPCS J9395
|
| Hospital Charge Code |
41653255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.91 |
| Max. Negotiated Rate |
$168.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$142.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.44
|
| Rate for Payer: Aetna Government |
$8.44
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5.91
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5.91
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5.91
|
| Rate for Payer: Brighton Health Commercial |
$155.54
|
| Rate for Payer: Cash Price |
$8.45
|
| Rate for Payer: Cash Price |
$8.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$8.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$129.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$149.06
|
| Rate for Payer: Elderplan Medicare Advantage |
$8.44
|
| Rate for Payer: EmblemHealth Commercial |
$8.44
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$8.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$8.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$8.87
|
| Rate for Payer: Fidelis Medicare Advantage |
$8.44
|
| Rate for Payer: Fidelis Qualified Health Plan |
$8.87
|
| Rate for Payer: Group Health Inc Commercial |
$8.44
|
| Rate for Payer: Group Health Inc Medicare |
$8.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$129.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$129.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7.18
|
| Rate for Payer: Healthfirst QHP |
$8.44
|
| Rate for Payer: Humana Medicare |
$8.61
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$8.44
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$8.66
|
| Rate for Payer: SOMOS Essential |
$8.66
|
| Rate for Payer: United Healthcare Commercial |
$12.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$168.50
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6.76
|
| Rate for Payer: Wellcare Medicare |
$8.02
|
|
|
FULVESTRANT 250MG/5ML INJ
|
Facility
|
IP
|
$259.23
|
|
|
Service Code
|
HCPCS J9395
|
| Hospital Charge Code |
41653255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.62 |
| Max. Negotiated Rate |
$129.62 |
| Rate for Payer: Cash Price |
$8.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$129.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$129.62
|
|
|
FULVETRANT 250MG/5ML INJ
|
Facility
|
IP
|
$259.23
|
|
|
Service Code
|
HCPCS J9395
|
| Hospital Charge Code |
41643255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.62 |
| Max. Negotiated Rate |
$129.62 |
| Rate for Payer: Cash Price |
$8.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$129.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$129.62
|
|
|
FULVETRANT 250MG/5ML INJ
|
Facility
|
OP
|
$259.23
|
|
|
Service Code
|
HCPCS J9395
|
| Hospital Charge Code |
41643255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.91 |
| Max. Negotiated Rate |
$168.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$142.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.44
|
| Rate for Payer: Aetna Government |
$8.44
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5.91
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5.91
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5.91
|
| Rate for Payer: Brighton Health Commercial |
$155.54
|
| Rate for Payer: Cash Price |
$8.45
|
| Rate for Payer: Cash Price |
$8.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$8.44
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$129.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$149.06
|
| Rate for Payer: Elderplan Medicare Advantage |
$8.44
|
| Rate for Payer: EmblemHealth Commercial |
$8.44
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$8.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$8.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$8.87
|
| Rate for Payer: Fidelis Medicare Advantage |
$8.44
|
| Rate for Payer: Fidelis Qualified Health Plan |
$8.87
|
| Rate for Payer: Group Health Inc Commercial |
$8.44
|
| Rate for Payer: Group Health Inc Medicare |
$8.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$129.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$129.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7.18
|
| Rate for Payer: Healthfirst QHP |
$8.44
|
| Rate for Payer: Humana Medicare |
$8.61
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$8.44
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$8.66
|
| Rate for Payer: SOMOS Essential |
$8.66
|
| Rate for Payer: United Healthcare Commercial |
$12.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$168.50
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6.76
|
| Rate for Payer: Wellcare Medicare |
$8.02
|
|
|
FUNCTIONAL STATUS ASSESSED
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
HCPCS 1170F
|
| Hospital Charge Code |
30305812
|
|
Hospital Revenue Code
|
969
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$7.50
|
| 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 |
$5.00
|
| Rate for Payer: Group Health Inc Medicare |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.00
|
|
