|
GII QUICK ANCHOR PLUS SZ 2 GREEN
|
Facility
|
OP
|
$1,212.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$1,273.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$666.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$727.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$606.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$697.19
|
| Rate for Payer: EmblemHealth Commercial |
$606.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,273.12
|
| Rate for Payer: Group Health Inc Commercial |
$606.25
|
| Rate for Payer: Group Health Inc Medicare |
$424.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$606.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$606.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$788.12
|
|
|
GII QUICK ANCHOR PLUS SZ 2 GREEN
|
Facility
|
IP
|
$1,212.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$606.25 |
| Max. Negotiated Rate |
$606.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$606.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$606.25
|
|
|
GINGER ALE
|
Facility
|
OP
|
$6.03
|
|
| Hospital Charge Code |
40202220
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$4.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.02
|
| Rate for Payer: Aetna Government |
$3.02
|
| Rate for Payer: Brighton Health Commercial |
$4.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.82
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.10
|
| Rate for Payer: Group Health Inc Commercial |
$3.02
|
| Rate for Payer: Group Health Inc Medicare |
$2.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.02
|
|
|
GINGIVAL FLAP PROCEDURE INC ROOT
|
Facility
|
OP
|
$728.60
|
|
|
Service Code
|
HCPCS D4240
|
| Hospital Charge Code |
42300855
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$364.30 |
| Max. Negotiated Rate |
$3,797.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$400.73
|
| 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 |
$546.45
|
| 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 |
$364.30
|
| 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
|
|
|
GINGIVAL FLAP PROCEDURE INC ROOT
|
Facility
|
IP
|
$728.60
|
|
|
Service Code
|
HCPCS D4240
|
| Hospital Charge Code |
42300855
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$3,723.23
|
|
|
GINGIVECTOMY
|
Facility
|
OP
|
$7,933.18
|
|
|
Service Code
|
HCPCS 41820
|
| Hospital Charge Code |
40011290
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$780.00 |
| Max. Negotiated Rate |
$5,949.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| 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 |
$5,949.88
|
| 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 |
$1,505.00
|
| 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 |
$3,966.59
|
| 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 Commercial |
$1,468.00
|
| 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
|
|
|
GINGIVECTOMY
|
Facility
|
IP
|
$7,933.18
|
|
|
Service Code
|
HCPCS 41820
|
| Hospital Charge Code |
40011290
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$3,723.23
|
|
|
GINGIVECTOMY OR GINGIVOPLASTY-P/1
|
Facility
|
OP
|
$162.50
|
|
|
Service Code
|
HCPCS D4211
|
| Hospital Charge Code |
42300840
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$81.25 |
| Max. Negotiated Rate |
$3,797.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$89.38
|
| 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 |
$121.88
|
| 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 |
$81.25
|
| 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
|
|
|
GINGIVECTOMY OR GINGIVOPLASTY-P/1
|
Facility
|
IP
|
$162.50
|
|
|
Service Code
|
HCPCS D4211
|
| Hospital Charge Code |
42300840
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$3,723.23
|
|
|
GINGIVECTOMY OR GINGIVOPLASTY-PER
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
HCPCS D4210
|
| Hospital Charge Code |
42300835
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$125.00 |
| Max. Negotiated Rate |
$3,797.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$137.50
|
| 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 |
$187.50
|
| 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 |
$125.00
|
| 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
|
|
|
GINGIVECTOMY OR GINGIVOPLASTY-PER
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
HCPCS D4210
|
| Hospital Charge Code |
42300835
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$3,723.23
|
|
|
GIZA CAGE 18-22MM
|
Facility
|
OP
|
$28,374.85
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64905416
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$29,793.59 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$15,606.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$17,024.91
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14,187.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16,315.54
|
| Rate for Payer: EmblemHealth Commercial |
$14,187.42
|
| Rate for Payer: Fidelis Medicare Advantage |
$29,793.59
|
| Rate for Payer: Group Health Inc Commercial |
$14,187.42
|
| Rate for Payer: Group Health Inc Medicare |
$9,931.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14,187.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14,187.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18,443.65
|
|
|
GIZA CAGE 18-22MM
|
Facility
|
IP
|
$28,374.85
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64905416
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$14,187.42 |
| Max. Negotiated Rate |
$14,187.42 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14,187.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14,187.42
|
|
|
GL1 QUICK ANCHOR +SZ2GREEN
|
Facility
|
OP
|
$684.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40209994
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$718.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$376.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$410.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$342.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$393.30
|
| Rate for Payer: EmblemHealth Commercial |
$342.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$718.20
|
| Rate for Payer: Group Health Inc Commercial |
$342.00
|
| Rate for Payer: Group Health Inc Medicare |
$239.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$342.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$342.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$444.60
|
|
|
GL1 QUICK ANCHOR +SZ2GREEN
|
Facility
|
IP
|
$684.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40209994
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$342.00 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$342.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$342.00
|
|
|
GLATIRAMER 20MG 1ML
|
Facility
|
IP
|
$9.25
|
|
|
Service Code
|
HCPCS J1595
|
| Hospital Charge Code |
41658444
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Cash Price |
$155.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.62
|
|
|
GLATIRAMER 20MG 1ML
|
Facility
|
IP
|
$9.25
|
|
|
Service Code
|
HCPCS J1595
|
| Hospital Charge Code |
41648444
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Cash Price |
$155.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.62
|
|
|
GLATIRAMER 20MG 1ML
|
Facility
|
OP
|
$9.25
|
|
|
Service Code
|
HCPCS J1595
|
| Hospital Charge Code |
41648444
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$163.77 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$155.98
|
| Rate for Payer: Aetna Government |
$155.98
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$109.18
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$109.18
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$109.18
|
| Rate for Payer: Brighton Health Commercial |
$5.55
|
| Rate for Payer: Cash Price |
$155.98
|
| Rate for Payer: Cash Price |
$155.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$155.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.32
|
| Rate for Payer: Elderplan Medicare Advantage |
$155.98
|
| Rate for Payer: EmblemHealth Commercial |
$155.98
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$155.98
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$155.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$163.77
|
| Rate for Payer: Fidelis Medicare Advantage |
$155.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$163.77
|
| Rate for Payer: Group Health Inc Commercial |
$155.98
|
| Rate for Payer: Group Health Inc Medicare |
$155.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$132.58
|
| Rate for Payer: Healthfirst QHP |
$155.98
|
| Rate for Payer: Humana Medicare |
$159.10
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$155.98
|
| Rate for Payer: United Healthcare Commercial |
$141.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$155.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.01
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$124.78
|
| Rate for Payer: Wellcare Medicare |
$148.18
|
|
|
GLATIRAMER 20MG 1ML
|
Facility
|
OP
|
$9.25
|
|
|
Service Code
|
HCPCS J1595
|
| Hospital Charge Code |
41658444
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$163.77 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$155.98
|
| Rate for Payer: Aetna Government |
$155.98
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$109.18
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$109.18
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$109.18
|
| Rate for Payer: Brighton Health Commercial |
$5.55
|
| Rate for Payer: Cash Price |
$155.98
|
| Rate for Payer: Cash Price |
$155.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$155.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.32
|
| Rate for Payer: Elderplan Medicare Advantage |
$155.98
|
| Rate for Payer: EmblemHealth Commercial |
$155.98
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$155.98
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$155.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$163.77
|
| Rate for Payer: Fidelis Medicare Advantage |
$155.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$163.77
|
| Rate for Payer: Group Health Inc Commercial |
$155.98
|
| Rate for Payer: Group Health Inc Medicare |
$155.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$132.58
|
| Rate for Payer: Healthfirst QHP |
$155.98
|
| Rate for Payer: Humana Medicare |
$159.10
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$155.98
|
| Rate for Payer: United Healthcare Commercial |
$141.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$155.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.01
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$124.78
|
| Rate for Payer: Wellcare Medicare |
$148.18
|
|
|
GLATIRAMER ACETATE 20 MG/ML SC SOSY [127661]
|
Facility
|
OP
|
$284.56
|
|
|
Service Code
|
HCPCS J1595
|
| Hospital Charge Code |
68546031730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$109.18 |
| Max. Negotiated Rate |
$227.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$156.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$155.98
|
| Rate for Payer: Aetna Government |
$155.98
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$109.18
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$109.18
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$109.18
|
| Rate for Payer: Brighton Health Commercial |
$213.42
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$155.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$227.65
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$193.50
|
| Rate for Payer: Elderplan Medicare Advantage |
$155.98
|
| Rate for Payer: EmblemHealth Commercial |
$155.98
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$132.58
|
| Rate for Payer: Fidelis Essential Plan QHP |
$138.82
|
| Rate for Payer: Fidelis Medicare Advantage |
$155.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$138.82
|
| Rate for Payer: Group Health Inc Commercial |
$155.98
|
| Rate for Payer: Group Health Inc Medicare |
$155.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$142.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$155.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$132.58
|
| Rate for Payer: Healthfirst QHP |
$155.98
|
| Rate for Payer: Humana Medicare |
$159.10
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$155.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$155.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$184.96
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$124.78
|
| Rate for Payer: Wellcare Medicare |
$148.18
|
|
|
GLENOID REUNION TSA SZ48
|
Facility
|
OP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
64907487
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,093.75 |
| Max. Negotiated Rate |
$3,281.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,718.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,562.50
|
| Rate for Payer: Aetna Government |
$1,562.50
|
| Rate for Payer: Brighton Health Commercial |
$1,875.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,562.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,796.88
|
| Rate for Payer: EmblemHealth Commercial |
$1,562.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,281.25
|
| Rate for Payer: Group Health Inc Commercial |
$1,562.50
|
| Rate for Payer: Group Health Inc Medicare |
$1,093.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,562.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,562.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,031.25
|
|
|
GLENOID REUNION TSA SZ48
|
Facility
|
IP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
64907487
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,562.50 |
| Max. Negotiated Rate |
$1,562.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,562.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,562.50
|
|
|
GLENOSPHERE RVSR SHOULDER 36MM
|
Facility
|
OP
|
$4,462.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64906973
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$4,685.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,454.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$2,677.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,231.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,565.94
|
| Rate for Payer: EmblemHealth Commercial |
$2,231.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,685.62
|
| Rate for Payer: Group Health Inc Commercial |
$2,231.25
|
| Rate for Payer: Group Health Inc Medicare |
$1,561.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,231.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,231.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,900.62
|
|
|
GLENOSPHERE RVSR SHOULDER 36MM
|
Facility
|
IP
|
$4,462.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64906973
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,231.25 |
| Max. Negotiated Rate |
$2,231.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,231.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,231.25
|
|
|
GLENOSPHERE W/BASEPLTE 25MM
|
Facility
|
IP
|
$6,500.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64906969
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,250.00 |
| Max. Negotiated Rate |
$3,250.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,250.00
|
|
