|
APPLY LONG ARM CAST
|
Facility
OP
|
$674.00
|
|
|
Service Code
|
HCPCS 29065
|
| Hospital Charge Code |
40029000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$77.28 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$310.57
|
| Rate for Payer: Aetna Government |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$310.57
|
| 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 |
$310.57
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$77.28
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$263.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$276.41
|
| Rate for Payer: Fidelis Medicare Advantage |
$310.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$276.41
|
| Rate for Payer: Group Health Inc Commercial |
$310.57
|
| Rate for Payer: Group Health Inc Medicare |
$310.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$337.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$310.57
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$85.87
|
| Rate for Payer: Healthfirst Medicare Advantage |
$263.98
|
| Rate for Payer: Healthfirst QHP |
$310.57
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$310.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$310.57
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$248.46
|
| Rate for Payer: Wellcare Medicare |
$295.04
|
|
|
APPLY LONG ARM CAST
|
Facility
OP
|
$674.00
|
|
|
Service Code
|
HCPCS 29065
|
| Hospital Charge Code |
30302024
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$77.28 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$310.57
|
| Rate for Payer: Aetna Government |
$310.57
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$310.57
|
| 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 |
$310.57
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$77.28
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$263.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$276.41
|
| Rate for Payer: Fidelis Medicare Advantage |
$310.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$276.41
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$337.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$310.57
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$85.87
|
| Rate for Payer: Healthfirst Medicare Advantage |
$263.98
|
| Rate for Payer: Healthfirst QHP |
$310.57
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$310.57
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$310.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$310.57
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$248.46
|
| Rate for Payer: Wellcare Medicare |
$295.04
|
|
|
APPLY LONG ARM SPLINT
|
Facility
OP
|
$405.08
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
30301504
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$48.45 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$182.22
|
| Rate for Payer: Aetna Government |
$182.22
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$182.22
|
| 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 |
$182.22
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$48.45
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$154.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$162.18
|
| Rate for Payer: Fidelis Medicare Advantage |
$182.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$162.18
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$202.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$182.22
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$53.83
|
| Rate for Payer: Healthfirst Medicare Advantage |
$154.89
|
| Rate for Payer: Healthfirst QHP |
$182.22
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$182.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$182.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$182.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.78
|
| Rate for Payer: Wellcare Medicare |
$173.11
|
|
|
APPLY LONG ARM SPLINT
|
Facility
OP
|
$405.08
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
30101176
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$48.45 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$182.22
|
| Rate for Payer: Aetna Government |
$182.22
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$182.22
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$182.22
|
| 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 |
$182.22
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$48.45
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$154.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$162.18
|
| Rate for Payer: Fidelis Medicare Advantage |
$182.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$162.18
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$202.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$182.22
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$182.22
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$182.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$182.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$182.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.78
|
| Rate for Payer: Wellcare Medicare |
$173.11
|
|
|
APPLY LONG LEG CAST
|
Facility
OP
|
$674.00
|
|
|
Service Code
|
HCPCS 29365
|
| Hospital Charge Code |
30101175
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$98.17 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$310.57
|
| Rate for Payer: Aetna Government |
$310.57
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$310.57
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$310.57
|
| 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 |
$310.57
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$98.17
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$263.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$276.41
|
| Rate for Payer: Fidelis Medicare Advantage |
$310.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$276.41
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$337.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$310.57
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$310.57
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$310.57
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$310.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$310.57
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$248.46
|
| Rate for Payer: Wellcare Medicare |
$295.04
|
|
|
APPLY LONG LEG CAST BRACE
|
Facility
OP
|
$696.08
|
|
|
Service Code
|
HCPCS 29358
|
| Hospital Charge Code |
30301171
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$116.36 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$310.57
|
| Rate for Payer: Aetna Government |
$310.57
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$310.57
|
| 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 |
$310.57
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$116.36
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$263.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$276.41
|
| Rate for Payer: Fidelis Medicare Advantage |
$310.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$276.41
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$348.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$310.57
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$129.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$263.98
|
| Rate for Payer: Healthfirst QHP |
$310.57
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$310.57
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$310.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$310.57
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$248.46
|
| Rate for Payer: Wellcare Medicare |
$295.04
|
|
|
APPLY LONG LEG SPLINT
|
Facility
OP
|
$405.08
|
|
|
Service Code
|
HCPCS 29505
|
| Hospital Charge Code |
30103031
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$58.02 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$182.22
|
| Rate for Payer: Aetna Government |
$182.22
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$182.22
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Cash Price |
$182.22
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$182.22
|
| 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 |
$182.22
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$58.02
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$154.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$162.18
|
| Rate for Payer: Fidelis Medicare Advantage |
$182.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$162.18
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$202.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$182.22
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$182.22
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$182.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$182.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$182.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.78
|
| Rate for Payer: Wellcare Medicare |
$173.11
|
|
|
APPLY SHORT LEG CAST
|
Facility
OP
|
$674.00
|
|
|
Service Code
|
HCPCS 29405
|
| Hospital Charge Code |
30301050
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$64.52 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$310.57
|
| Rate for Payer: Aetna Government |
$310.57
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$310.57
|
| 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 |
$310.57
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$64.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$263.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$276.41
|
| Rate for Payer: Fidelis Medicare Advantage |
$310.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$276.41
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$337.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$310.57
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$71.69
|
| Rate for Payer: Healthfirst Medicare Advantage |
$263.98
|
| Rate for Payer: Healthfirst QHP |
$310.57
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$310.57
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$310.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$310.57
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$248.46
|
| Rate for Payer: Wellcare Medicare |
$295.04
|
|
|
APPLY SHORT LEG CAST - WALKER
|
Facility
OP
|
$674.00
|
|
|
Service Code
|
HCPCS 29425
|
| Hospital Charge Code |
40029936
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$59.05 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$310.57
|
| Rate for Payer: Aetna Government |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$310.57
|
| 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 |
$310.57
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$59.05
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$263.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$276.41
|
| Rate for Payer: Fidelis Medicare Advantage |
$310.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$276.41
|
| Rate for Payer: Group Health Inc Commercial |
$310.57
|
| Rate for Payer: Group Health Inc Medicare |
$310.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$337.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$310.57
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$65.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$263.98
|
| Rate for Payer: Healthfirst QHP |
$310.57
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$310.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$310.57
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$248.46
|
| Rate for Payer: Wellcare Medicare |
$295.04
|
|
|
APPLY SHORT LEG CAST - WALKER
|
Facility
OP
|
$674.00
|
|
|
Service Code
|
HCPCS 29425
|
| Hospital Charge Code |
30302490
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$59.05 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$310.57
|
| Rate for Payer: Aetna Government |
$310.57
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$310.57
|
| 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 |
$310.57
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$59.05
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$263.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$276.41
|
| Rate for Payer: Fidelis Medicare Advantage |
$310.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$276.41
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$337.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$310.57
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$65.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$263.98
|
| Rate for Payer: Healthfirst QHP |
$310.57
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$310.57
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$310.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$310.57
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$248.46
|
| Rate for Payer: Wellcare Medicare |
$295.04
|
|
|
APP OF CAST & STRAP HAND FINGER
|
Facility
OP
|
$101.25
|
|
|
Service Code
|
HCPCS 29280
|
| Hospital Charge Code |
30106502
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$21.28 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$70.74
|
| Rate for Payer: Aetna Government |
$70.74
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$70.74
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$70.74
|
| Rate for Payer: Cash Price |
$70.74
|
| Rate for Payer: Cash Price |
$70.74
|
| Rate for Payer: Cash Price |
$70.74
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$70.74
|
| 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 |
$70.74
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$21.28
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$60.13
|
| Rate for Payer: Fidelis Essential Plan QHP |
$62.96
|
| Rate for Payer: Fidelis Medicare Advantage |
$70.74
|
| Rate for Payer: Fidelis Qualified Health Plan |
$62.96
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$50.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$70.74
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$70.74
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$70.74
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$70.74
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$70.74
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$56.59
|
| Rate for Payer: Wellcare Medicare |
$67.20
|
|
|
APP OF LONG LEG CAST (THIGH-TOE)
|
Facility
OP
|
$696.08
|
|
|
Service Code
|
HCPCS 29345
|
| Hospital Charge Code |
30105375
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$112.14 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$310.57
|
| Rate for Payer: Aetna Government |
$310.57
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$310.57
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Cash Price |
$310.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$310.57
|
| 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 |
$310.57
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$112.14
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$263.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$276.41
|
| Rate for Payer: Fidelis Medicare Advantage |
$310.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$276.41
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$348.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$310.57
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$310.57
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$310.57
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$310.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$310.57
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$248.46
|
| Rate for Payer: Wellcare Medicare |
$295.04
|
|
|
APRACLONIDINE 0.5% OPHTHALMIC SOLN
|
Facility
OP
|
$0.02
|
|
| Hospital Charge Code |
41651914
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| 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: Cigna HMO/Network Benefit Plan/Open Access |
$0.02
|
| 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 |
$0.01
|
| 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
|
|
|
APRACLONIDINE 0.5% OPHTHALMIC SOLN
|
Facility
OP
|
$0.02
|
|
| Hospital Charge Code |
41641914
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| 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: Cigna HMO/Network Benefit Plan/Open Access |
$0.02
|
| 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 |
$0.01
|
| 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
|
|
|
APRACLONIDINE 1% OPHTHALMIC SOLN
|
Facility
OP
|
$46.00
|
|
| Hospital Charge Code |
41652100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$36.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$23.00
|
| Rate for Payer: Aetna Government |
$23.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$36.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$31.28
|
| Rate for Payer: Group Health Inc Commercial |
$23.00
|
| Rate for Payer: Group Health Inc Medicare |
$16.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$23.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$29.90
|
|
|
APRACLONIDINE 1% OPHTHALMIC SOLN
|
Facility
OP
|
$46.00
|
|
| Hospital Charge Code |
41642100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$36.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$25.30
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$23.00
|
| Rate for Payer: Aetna Government |
$23.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$36.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$31.28
|
| Rate for Payer: Group Health Inc Commercial |
$23.00
|
| Rate for Payer: Group Health Inc Medicare |
$16.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$23.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$29.90
|
|
|
APR-DRG 0011: Liver transplant &/or intestinal transplant
|
Facility
IP
|
$267,391.00
|
|
|
Service Code
|
APR-DRG 0011
|
| Min. Negotiated Rate |
$61,351.08 |
| Max. Negotiated Rate |
$267,391.00 |
| Rate for Payer: Amida Care Medicaid |
$61,351.08
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$61,351.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$73,621.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$61,351.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$61,351.08
|
| Rate for Payer: Healthfirst Commercial |
$267,391.00
|
| Rate for Payer: Healthfirst Essential Plan |
$138,039.93
|
| Rate for Payer: Healthfirst QHP |
$119,641.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$61,351.08
|
| Rate for Payer: SOMOS Essential |
$138,039.93
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$61,351.08
|
|
|
APR-DRG 0012: Liver transplant &/or intestinal transplant
|
Facility
IP
|
$272,466.00
|
|
|
Service Code
|
APR-DRG 0012
|
| Min. Negotiated Rate |
$61,351.08 |
| Max. Negotiated Rate |
$272,466.00 |
| Rate for Payer: Amida Care Medicaid |
$61,351.08
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$61,351.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$73,621.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$61,351.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$61,351.08
|
| Rate for Payer: Healthfirst Commercial |
$272,466.00
|
| Rate for Payer: Healthfirst Essential Plan |
$138,039.93
|
| Rate for Payer: Healthfirst QHP |
$119,641.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$61,351.08
|
| Rate for Payer: SOMOS Essential |
$138,039.93
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$61,351.08
|
|
|
APR-DRG 0013: Liver transplant &/or intestinal transplant
|
Facility
IP
|
$274,887.00
|
|
|
Service Code
|
APR-DRG 0013
|
| Min. Negotiated Rate |
$78,572.72 |
| Max. Negotiated Rate |
$274,887.00 |
| Rate for Payer: Amida Care Medicaid |
$78,572.72
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$78,572.72
|
| Rate for Payer: Fidelis Qualified Health Plan |
$94,287.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$78,572.72
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$78,572.72
|
| Rate for Payer: Healthfirst Commercial |
$274,887.00
|
| Rate for Payer: Healthfirst Essential Plan |
$176,788.62
|
| Rate for Payer: Healthfirst QHP |
$140,641.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$78,572.72
|
| Rate for Payer: SOMOS Essential |
$176,788.62
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$78,572.72
|
|
|
APR-DRG 0014: Liver transplant &/or intestinal transplant
|
Facility
IP
|
$543,815.00
|
|
|
Service Code
|
APR-DRG 0014
|
| Min. Negotiated Rate |
$150,008.30 |
| Max. Negotiated Rate |
$543,815.00 |
| Rate for Payer: Amida Care Medicaid |
$150,008.30
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$150,008.30
|
| Rate for Payer: Fidelis Qualified Health Plan |
$180,009.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$150,008.30
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$150,008.30
|
| Rate for Payer: Healthfirst Commercial |
$543,815.00
|
| Rate for Payer: Healthfirst Essential Plan |
$337,518.68
|
| Rate for Payer: Healthfirst QHP |
$290,943.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$150,008.30
|
| Rate for Payer: SOMOS Essential |
$337,518.68
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$150,008.30
|
|
|
APR-DRG 0021: Heart &/or lung transplant
|
Facility
IP
|
$251,740.00
|
|
|
Service Code
|
APR-DRG 0021
|
| Min. Negotiated Rate |
$107,756.97 |
| Max. Negotiated Rate |
$251,740.00 |
| Rate for Payer: Amida Care Medicaid |
$107,756.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$107,756.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$129,308.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$107,756.97
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$107,756.97
|
| Rate for Payer: Healthfirst Commercial |
$251,740.00
|
| Rate for Payer: Healthfirst Essential Plan |
$242,453.18
|
| Rate for Payer: Healthfirst QHP |
$181,134.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$107,756.97
|
| Rate for Payer: SOMOS Essential |
$242,453.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$107,756.97
|
|
|
APR-DRG 0022: Heart &/or lung transplant
|
Facility
IP
|
$263,266.00
|
|
|
Service Code
|
APR-DRG 0022
|
| Min. Negotiated Rate |
$113,585.84 |
| Max. Negotiated Rate |
$263,266.00 |
| Rate for Payer: Amida Care Medicaid |
$113,585.84
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$113,585.84
|
| Rate for Payer: Fidelis Qualified Health Plan |
$136,303.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$113,585.84
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$113,585.84
|
| Rate for Payer: Healthfirst Commercial |
$263,266.00
|
| Rate for Payer: Healthfirst Essential Plan |
$255,568.14
|
| Rate for Payer: Healthfirst QHP |
$197,251.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$113,585.84
|
| Rate for Payer: SOMOS Essential |
$255,568.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$113,585.84
|
|
|
APR-DRG 0023: Heart &/or lung transplant
|
Facility
IP
|
$431,334.00
|
|
|
Service Code
|
APR-DRG 0023
|
| Min. Negotiated Rate |
$130,962.26 |
| Max. Negotiated Rate |
$431,334.00 |
| Rate for Payer: Amida Care Medicaid |
$130,962.26
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$130,962.26
|
| Rate for Payer: Fidelis Qualified Health Plan |
$157,154.71
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$130,962.26
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$130,962.26
|
| Rate for Payer: Healthfirst Commercial |
$431,334.00
|
| Rate for Payer: Healthfirst Essential Plan |
$294,665.08
|
| Rate for Payer: Healthfirst QHP |
$268,219.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$130,962.26
|
| Rate for Payer: SOMOS Essential |
$294,665.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$130,962.26
|
|
|
APR-DRG 0024: Heart &/or lung transplant
|
Facility
IP
|
$696,293.00
|
|
|
Service Code
|
APR-DRG 0024
|
| Min. Negotiated Rate |
$285,924.22 |
| Max. Negotiated Rate |
$696,293.00 |
| Rate for Payer: Amida Care Medicaid |
$285,924.22
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$285,924.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$343,109.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$285,924.22
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$285,924.22
|
| Rate for Payer: Healthfirst Commercial |
$696,293.00
|
| Rate for Payer: Healthfirst Essential Plan |
$643,329.50
|
| Rate for Payer: Healthfirst QHP |
$440,499.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$285,924.22
|
| Rate for Payer: SOMOS Essential |
$643,329.50
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$285,924.22
|
|
|
APR-DRG 0031: Bone marrow transplant
|
Facility
IP
|
$213,921.00
|
|
|
Service Code
|
APR-DRG 0031
|
| Min. Negotiated Rate |
$64,964.72 |
| Max. Negotiated Rate |
$213,921.00 |
| Rate for Payer: Amida Care Medicaid |
$64,964.72
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$64,964.72
|
| Rate for Payer: Fidelis Qualified Health Plan |
$77,957.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$64,964.72
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$64,964.72
|
| Rate for Payer: Healthfirst Commercial |
$213,921.00
|
| Rate for Payer: Healthfirst Essential Plan |
$146,170.62
|
| Rate for Payer: Healthfirst QHP |
$100,009.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$64,964.72
|
| Rate for Payer: SOMOS Essential |
$146,170.62
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$64,964.72
|
|
