|
GLYCOPYRROLATE .2MG/ML ORAL
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
41648044
|
|
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
|
|
|
GLYCOPYRROLATE ORAL .2MG/ML
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
41658044
|
|
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
|
|
|
GLYOCOPYRROLATE 2MG 1ML INJ
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
41647182
|
|
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
|
|
|
GM1 ANTIBODY IGG, IGM
|
Facility
|
OP
|
$28.83
|
|
|
Service Code
|
HCPCS 83516
|
| Hospital Charge Code |
40609889
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.07 |
| Max. Negotiated Rate |
$21.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$15.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.53
|
| Rate for Payer: Aetna Government |
$11.53
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$8.07
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$8.07
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$8.07
|
| Rate for Payer: Brighton Health Commercial |
$21.62
|
| Rate for Payer: Cash Price |
$11.53
|
| Rate for Payer: Cash Price |
$11.53
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$11.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.52
|
| Rate for Payer: Elderplan Medicare Advantage |
$11.53
|
| Rate for Payer: EmblemHealth Commercial |
$11.53
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$9.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$10.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$11.53
|
| Rate for Payer: Fidelis Qualified Health Plan |
$10.26
|
| Rate for Payer: Group Health Inc Commercial |
$11.53
|
| Rate for Payer: Group Health Inc Medicare |
$11.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.53
|
| Rate for Payer: Healthfirst Medicare Advantage |
$11.53
|
| Rate for Payer: Healthfirst QHP |
$11.53
|
| Rate for Payer: Humana Medicare |
$11.76
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$11.53
|
| Rate for Payer: United Healthcare Commercial |
$14.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.53
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.53
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$9.22
|
| Rate for Payer: Wellcare Medicare |
$10.38
|
|
|
GM1 ANTIBODY IGG, IGM
|
Facility
|
IP
|
$28.83
|
|
|
Service Code
|
HCPCS 83516
|
| Hospital Charge Code |
40609889
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$11.53
|
|
|
GNS II CMT TIB SZ2 LEFT
|
Facility
|
IP
|
$3,935.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905245
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,967.62 |
| Max. Negotiated Rate |
$1,967.62 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,967.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,967.62
|
|
|
GNS II CMT TIB SZ2 LEFT
|
Facility
|
OP
|
$3,935.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905245
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$4,132.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,164.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$2,361.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,967.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,262.77
|
| Rate for Payer: EmblemHealth Commercial |
$1,967.62
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,132.01
|
| Rate for Payer: Group Health Inc Commercial |
$1,967.62
|
| Rate for Payer: Group Health Inc Medicare |
$1,377.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,967.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,967.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,557.91
|
|
|
GNS II CMT TIB SZ 3 LEFT
|
Facility
|
OP
|
$3,935.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905341
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$4,132.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,164.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$2,361.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,967.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,262.77
|
| Rate for Payer: EmblemHealth Commercial |
$1,967.62
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,132.01
|
| Rate for Payer: Group Health Inc Commercial |
$1,967.62
|
| Rate for Payer: Group Health Inc Medicare |
$1,377.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,967.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,967.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,557.91
|
|
|
GNS II CMT TIB SZ 3 LEFT
|
Facility
|
IP
|
$3,935.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905341
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,967.62 |
| Max. Negotiated Rate |
$1,967.62 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,967.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,967.62
|
|
|
GNS II CMT TIB SZ 5 LEFT
|
Facility
|
IP
|
$3,935.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,967.62 |
| Max. Negotiated Rate |
$1,967.62 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,967.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,967.62
|
|
|
GNS II CMT TIB SZ 5 LEFT
|
Facility
|
OP
|
$3,935.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905347
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$4,132.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,164.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$2,361.15
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,967.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,262.77
|
| Rate for Payer: EmblemHealth Commercial |
$1,967.62
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,132.01
|
| Rate for Payer: Group Health Inc Commercial |
$1,967.62
|
| Rate for Payer: Group Health Inc Medicare |
$1,377.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,967.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,967.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,557.91
|
|
|
GNS II CON INS SZ5-6 11MM
|
Facility
|
OP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905351
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$4,935.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,585.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$2,820.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,350.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,702.50
|
| Rate for Payer: EmblemHealth Commercial |
$2,350.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,935.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,350.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,645.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,350.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,350.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,055.00
|
|
|
GNS II CON INS SZ5-6 11MM
|
Facility
|
IP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905351
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,350.00 |
| Max. Negotiated Rate |
$2,350.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,350.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,350.00
|
|
|
GOLD FOIL-ONE SURFACE
|
Facility
|
IP
|
$327.44
|
|
|
Service Code
|
HCPCS D2410
|
| Hospital Charge Code |
42300445
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
GOLD FOIL-ONE SURFACE
|
Facility
|
OP
|
$327.44
|
|
|
Service Code
|
HCPCS D2410
|
| Hospital Charge Code |
42300445
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$163.72 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$180.09
|
| 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 |
$245.58
|
| 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 |
$163.72
|
| 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
|
|
|
GOLD FOIL-THREE SURFACES
|
Facility
|
IP
|
$695.99
|
|
|
Service Code
|
HCPCS D2430
|
| Hospital Charge Code |
42300455
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
GOLD FOIL-THREE SURFACES
|
Facility
|
OP
|
$695.99
|
|
|
Service Code
|
HCPCS D2430
|
| Hospital Charge Code |
42300455
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$348.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$382.79
|
| 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 |
$521.99
|
| 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 |
$348.00
|
| 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
|
|
|
GOLD FOIL-TWO SURFACES
|
Facility
|
OP
|
$511.72
|
|
|
Service Code
|
HCPCS D2420
|
| Hospital Charge Code |
42300450
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$255.86 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$281.45
|
| 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 |
$383.79
|
| 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 |
$255.86
|
| 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
|
|
|
GOLD FOIL-TWO SURFACES
|
Facility
|
IP
|
$511.72
|
|
|
Service Code
|
HCPCS D2420
|
| Hospital Charge Code |
42300450
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
GONADOTROPIN,CHORIONIC,QUALITA
|
Facility
|
OP
|
$18.80
|
|
|
Service Code
|
HCPCS 84703
|
| Hospital Charge Code |
40602190
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.26 |
| Max. Negotiated Rate |
$14.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.34
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.52
|
| Rate for Payer: Aetna Government |
$7.52
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$5.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$5.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5.26
|
| Rate for Payer: Brighton Health Commercial |
$14.10
|
| Rate for Payer: Cash Price |
$7.52
|
| Rate for Payer: Cash Price |
$7.52
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$7.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.93
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.10
|
| Rate for Payer: Elderplan Medicare Advantage |
$7.52
|
| Rate for Payer: EmblemHealth Commercial |
$7.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$6.39
|
| Rate for Payer: Fidelis Essential Plan QHP |
$6.69
|
| Rate for Payer: Fidelis Medicare Advantage |
$7.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$6.69
|
| Rate for Payer: Group Health Inc Commercial |
$7.52
|
| Rate for Payer: Group Health Inc Medicare |
$7.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7.52
|
| Rate for Payer: Healthfirst QHP |
$7.52
|
| Rate for Payer: Humana Medicare |
$7.67
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$7.52
|
| Rate for Payer: United Healthcare Commercial |
$9.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6.02
|
| Rate for Payer: Wellcare Medicare |
$6.77
|
|
|
GONADOTROPIN,CHORIONIC,QUALITA
|
Facility
|
IP
|
$18.80
|
|
|
Service Code
|
HCPCS 84703
|
| Hospital Charge Code |
40602190
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$7.52
|
|
|
GONIOSCOPY
|
Facility
|
IP
|
$330.23
|
|
|
Service Code
|
HCPCS 92020
|
| Hospital Charge Code |
42101800
|
|
Hospital Revenue Code
|
920
|
| Rate for Payer: Cash Price |
$147.72
|
|
|
GONIOSCOPY
|
Facility
|
OP
|
$330.23
|
|
|
Service Code
|
HCPCS 92020
|
| Hospital Charge Code |
42101800
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$94.00 |
| Max. Negotiated Rate |
$264.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$181.63
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$147.72
|
| Rate for Payer: Aetna Government |
$147.72
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$103.40
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$103.40
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$103.40
|
| Rate for Payer: Brighton Health Commercial |
$247.67
|
| Rate for Payer: Cash Price |
$147.72
|
| Rate for Payer: Cash Price |
$147.72
|
| Rate for Payer: Cash Price |
$147.72
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$147.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$264.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$224.56
|
| Rate for Payer: Elderplan Medicare Advantage |
$147.72
|
| Rate for Payer: EmblemHealth Commercial |
$147.72
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$125.56
|
| Rate for Payer: Fidelis Essential Plan QHP |
$131.47
|
| Rate for Payer: Fidelis Medicare Advantage |
$147.72
|
| Rate for Payer: Fidelis Qualified Health Plan |
$131.47
|
| Rate for Payer: Group Health Inc Commercial |
$147.72
|
| Rate for Payer: Group Health Inc Medicare |
$147.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$165.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$147.72
|
| Rate for Payer: Healthfirst Medicare Advantage |
$125.56
|
| Rate for Payer: Healthfirst QHP |
$147.72
|
| Rate for Payer: Humana Medicare |
$150.67
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$147.72
|
| Rate for Payer: United Healthcare Commercial |
$94.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$147.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$147.72
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$118.18
|
| Rate for Payer: Wellcare Medicare |
$140.33
|
|
|
Goniotomy
|
Facility
|
OP
|
$4,795.87
|
|
|
Service Code
|
CPT 65820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,412.00 |
| Max. Negotiated Rate |
$4,795.87 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,701.83
|
| Rate for Payer: Aetna Government |
$4,701.83
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,291.28
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,291.28
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,291.28
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4,701.83
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$4,701.83
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,996.56
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4,184.63
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,701.83
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4,184.63
|
| Rate for Payer: Group Health Inc Commercial |
$4,701.83
|
| Rate for Payer: Group Health Inc Medicare |
$4,701.83
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,701.83
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,996.56
|
| Rate for Payer: Healthfirst QHP |
$4,701.83
|
| Rate for Payer: Humana Medicare |
$4,795.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4,701.83
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,701.83
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4,701.83
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3,761.46
|
| Rate for Payer: Wellcare Medicare |
$4,466.74
|
|
|
GOODE T-TUBE VENTLTION SHEP1.14MM
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
40201148
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$117.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$61.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$56.00
|
| Rate for Payer: Aetna Government |
$56.00
|
| Rate for Payer: Brighton Health Commercial |
$67.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$56.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$64.40
|
| Rate for Payer: EmblemHealth Commercial |
$56.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$117.60
|
| Rate for Payer: Group Health Inc Commercial |
$56.00
|
| Rate for Payer: Group Health Inc Medicare |
$39.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$56.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$72.80
|
|
