|
GRANULOMA SCALP
|
Facility
|
OP
|
$4,157.25
|
|
|
Service Code
|
HCPCS 11423
|
| Hospital Charge Code |
40013243
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,312.42 |
| Max. Negotiated Rate |
$3,117.94 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,874.89
|
| Rate for Payer: Aetna Government |
$1,874.89
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,312.42
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,312.42
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,312.42
|
| Rate for Payer: Brighton Health Commercial |
$3,117.94
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Cash Price |
$1,874.89
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,874.89
|
| 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 |
$1,874.89
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,593.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,668.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,874.89
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,668.65
|
| Rate for Payer: Group Health Inc Commercial |
$1,874.89
|
| Rate for Payer: Group Health Inc Medicare |
$1,874.89
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,078.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,874.89
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,593.66
|
| Rate for Payer: Healthfirst QHP |
$1,874.89
|
| Rate for Payer: Humana Medicare |
$1,912.39
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,874.89
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,874.89
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,874.89
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,499.91
|
| Rate for Payer: Wellcare Medicare |
$1,781.15
|
|
|
GRANULOMA TRUNKS
|
Facility
|
OP
|
$1,847.58
|
|
|
Service Code
|
HCPCS 11403
|
| Hospital Charge Code |
40013242
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$569.54 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$813.63
|
| Rate for Payer: Aetna Government |
$813.63
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$569.54
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$569.54
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$569.54
|
| Rate for Payer: Brighton Health Commercial |
$1,385.68
|
| Rate for Payer: Cash Price |
$813.63
|
| Rate for Payer: Cash Price |
$813.63
|
| Rate for Payer: Cash Price |
$813.63
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$813.63
|
| 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 |
$813.63
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$691.59
|
| Rate for Payer: Fidelis Essential Plan QHP |
$724.13
|
| Rate for Payer: Fidelis Medicare Advantage |
$813.63
|
| Rate for Payer: Fidelis Qualified Health Plan |
$724.13
|
| Rate for Payer: Group Health Inc Commercial |
$813.63
|
| Rate for Payer: Group Health Inc Medicare |
$813.63
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$923.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$813.63
|
| Rate for Payer: Healthfirst Medicare Advantage |
$691.59
|
| Rate for Payer: Healthfirst QHP |
$813.63
|
| Rate for Payer: Humana Medicare |
$829.90
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$813.63
|
| Rate for Payer: United Healthcare Commercial |
$1,188.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$813.63
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$813.63
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$650.90
|
| Rate for Payer: Wellcare Medicare |
$772.95
|
|
|
GRANULOMA TRUNKS
|
Facility
|
IP
|
$1,847.58
|
|
|
Service Code
|
HCPCS 11403
|
| Hospital Charge Code |
40013242
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$813.63
|
|
|
GRAPHIC CASE W/LID FIXATIONSYSTEM
|
Facility
|
OP
|
$3,000.00
|
|
| Hospital Charge Code |
40209532
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,650.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,500.00
|
| Rate for Payer: Aetna Government |
$1,500.00
|
| Rate for Payer: Brighton Health Commercial |
$2,250.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,400.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,040.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,500.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,050.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,500.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,500.00
|
|
|
GRASPER/CLINCH
|
Facility
|
OP
|
$159.33
|
|
| Hospital Charge Code |
64905093
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$55.77 |
| Max. Negotiated Rate |
$127.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$87.63
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$79.66
|
| Rate for Payer: Aetna Government |
$79.66
|
| Rate for Payer: Brighton Health Commercial |
$119.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$127.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$108.34
|
| Rate for Payer: Group Health Inc Commercial |
$79.66
|
| Rate for Payer: Group Health Inc Medicare |
$55.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$79.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$79.66
|
|
|
GRASPER ENDO 5MM W/HANDLE
|
Facility
|
OP
|
$159.32
|
|
| Hospital Charge Code |
64903093
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$55.76 |
| Max. Negotiated Rate |
$127.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$87.63
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$79.66
|
| Rate for Payer: Aetna Government |
$79.66
|
| Rate for Payer: Brighton Health Commercial |
$119.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$127.46
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$108.34
|
| Rate for Payer: Group Health Inc Commercial |
$79.66
|
| Rate for Payer: Group Health Inc Medicare |
$55.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$79.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$79.66
|
|
|
GRASPER ENDO BAB 5MM REPRO
|
Facility
|
OP
|
$65.00
|
|
| Hospital Charge Code |
64905852
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$35.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$32.50
|
| Rate for Payer: Aetna Government |
$32.50
|
| Rate for Payer: Brighton Health Commercial |
$48.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$52.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$44.20
|
| Rate for Payer: Group Health Inc Commercial |
$32.50
|
| Rate for Payer: Group Health Inc Medicare |
$22.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$32.50
|
|
|
GRASPER ENDO BABCOCK 5MM DISP 5BB
|
Facility
|
OP
|
$184.40
|
|
| Hospital Charge Code |
64903053
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$64.54 |
| Max. Negotiated Rate |
$147.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$101.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$92.20
|
| Rate for Payer: Aetna Government |
$92.20
|
| Rate for Payer: Brighton Health Commercial |
$138.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$147.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$125.39
|
| Rate for Payer: Group Health Inc Commercial |
$92.20
|
| Rate for Payer: Group Health Inc Medicare |
$64.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$92.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$92.20
|
|
|
GRASPER ENDO-CLINCH II 5MM
|
Facility
|
OP
|
$164.00
|
|
| Hospital Charge Code |
40206032
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$131.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$90.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$82.00
|
| Rate for Payer: Aetna Government |
$82.00
|
| Rate for Payer: Brighton Health Commercial |
$123.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$131.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$111.52
|
| Rate for Payer: Group Health Inc Commercial |
$82.00
|
| Rate for Payer: Group Health Inc Medicare |
$57.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$82.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$82.00
|
|
|
GRASPER STONE RET 2.6FR
|
Facility
|
OP
|
$360.00
|
|
| Hospital Charge Code |
40200813
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$198.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$180.00
|
| Rate for Payer: Aetna Government |
$180.00
|
| Rate for Payer: Brighton Health Commercial |
$270.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$288.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$244.80
|
| Rate for Payer: Group Health Inc Commercial |
$180.00
|
| Rate for Payer: Group Health Inc Medicare |
$126.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$180.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$180.00
|
|
|
GRAVIFEED LID
|
Facility
|
OP
|
$35.00
|
|
| Hospital Charge Code |
64903728
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.50
|
| Rate for Payer: Aetna Government |
$17.50
|
| Rate for Payer: Brighton Health Commercial |
$26.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$23.80
|
| Rate for Payer: Group Health Inc Commercial |
$17.50
|
| Rate for Payer: Group Health Inc Medicare |
$12.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.50
|
|
|
GREATER OCCIPITAL NERVE
|
Facility
|
IP
|
$792.83
|
|
|
Service Code
|
HCPCS 64405
|
| Hospital Charge Code |
30305022
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$342.51
|
|
|
GREATER OCCIPITAL NERVE
|
Facility
|
OP
|
$792.83
|
|
|
Service Code
|
HCPCS 64405
|
| Hospital Charge Code |
30305022
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$342.51
|
| Rate for Payer: Aetna Government |
$342.51
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$239.76
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$239.76
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$239.76
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Cash Price |
$342.51
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$342.51
|
| 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 |
$342.51
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$291.13
|
| Rate for Payer: Fidelis Essential Plan QHP |
$304.83
|
| Rate for Payer: Fidelis Medicare Advantage |
$342.51
|
| Rate for Payer: Fidelis Qualified Health Plan |
$304.83
|
| 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 |
$396.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$342.51
|
| Rate for Payer: Healthfirst Medicare Advantage |
$291.13
|
| Rate for Payer: Healthfirst QHP |
$342.51
|
| Rate for Payer: Humana Medicare |
$349.36
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$342.51
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$342.51
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$342.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$342.51
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$274.01
|
| Rate for Payer: Wellcare Medicare |
$325.38
|
|
|
GREAT TOE M-P JNT SM 17MM POROUS
|
Facility
|
IP
|
$1,600.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40209956
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$800.00 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$800.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$800.00
|
|
|
GREAT TOE M-P JNT SM 17MM POROUS
|
Facility
|
OP
|
$1,600.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40209956
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$880.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$960.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$800.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$920.00
|
| Rate for Payer: EmblemHealth Commercial |
$800.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,680.00
|
| Rate for Payer: Group Health Inc Commercial |
$800.00
|
| Rate for Payer: Group Health Inc Medicare |
$560.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$800.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$800.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,040.00
|
|
|
GREEN DIALYZERS
|
Facility
|
OP
|
$52.45
|
|
| Hospital Charge Code |
42905310
|
|
Hospital Revenue Code
|
801
|
| Min. Negotiated Rate |
$18.36 |
| Max. Negotiated Rate |
$41.96 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$28.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.22
|
| Rate for Payer: Aetna Government |
$26.22
|
| Rate for Payer: Brighton Health Commercial |
$39.34
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$41.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$35.67
|
| Rate for Payer: Group Health Inc Commercial |
$26.22
|
| Rate for Payer: Group Health Inc Medicare |
$18.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.22
|
|
|
GREENFIELD FILTER
|
Facility
|
OP
|
$1,823.62
|
|
| Hospital Charge Code |
40207005
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$638.27 |
| Max. Negotiated Rate |
$1,458.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,002.99
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$911.81
|
| Rate for Payer: Aetna Government |
$911.81
|
| Rate for Payer: Brighton Health Commercial |
$1,367.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,458.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,240.06
|
| Rate for Payer: Group Health Inc Commercial |
$911.81
|
| Rate for Payer: Group Health Inc Medicare |
$638.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$911.81
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$911.81
|
|
|
GREENLIGHT XPS 1
|
Facility
|
OP
|
$4,250.00
|
|
| Hospital Charge Code |
64905804
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,487.50 |
| Max. Negotiated Rate |
$3,400.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,337.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,125.00
|
| Rate for Payer: Aetna Government |
$2,125.00
|
| Rate for Payer: Brighton Health Commercial |
$3,187.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,400.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,890.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,125.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,487.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,125.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,125.00
|
|
|
GREENLIGHT XPS 2
|
Facility
|
OP
|
$4,250.00
|
|
| Hospital Charge Code |
64905806
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,487.50 |
| Max. Negotiated Rate |
$3,400.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,337.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,125.00
|
| Rate for Payer: Aetna Government |
$2,125.00
|
| Rate for Payer: Brighton Health Commercial |
$3,187.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,400.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,890.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,125.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,487.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,125.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,125.00
|
|
|
GREEN RELOAD 45MM
|
Facility
|
OP
|
$330.31
|
|
| Hospital Charge Code |
64905159
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$115.61 |
| Max. Negotiated Rate |
$264.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$181.67
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$165.16
|
| Rate for Payer: Aetna Government |
$165.16
|
| Rate for Payer: Brighton Health Commercial |
$247.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$264.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$224.61
|
| Rate for Payer: Group Health Inc Commercial |
$165.16
|
| Rate for Payer: Group Health Inc Medicare |
$115.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$165.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$165.16
|
|
|
GRFT BIFURCATED HEMASHIELD
|
Facility
|
IP
|
$1,382.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
40209674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$691.00 |
| Max. Negotiated Rate |
$691.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$691.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$691.00
|
|
|
GRFT BIFURCATED HEMASHIELD
|
Facility
|
OP
|
$1,382.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
40209674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$322.77 |
| Max. Negotiated Rate |
$1,451.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$760.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$322.77
|
| Rate for Payer: Aetna Government |
$322.77
|
| Rate for Payer: Brighton Health Commercial |
$829.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$691.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$794.65
|
| Rate for Payer: EmblemHealth Commercial |
$691.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,451.10
|
| Rate for Payer: Group Health Inc Commercial |
$691.00
|
| Rate for Payer: Group Health Inc Medicare |
$483.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$691.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$691.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$898.30
|
|
|
GRFT JCKT TISSUE REGEN 4X4CM
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
40200245
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$90.65 |
| Max. Negotiated Rate |
$1,879.82 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$142.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,879.82
|
| Rate for Payer: Aetna Government |
$1,879.82
|
| Rate for Payer: Brighton Health Commercial |
$155.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$129.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$148.92
|
| Rate for Payer: EmblemHealth Commercial |
$129.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$271.95
|
| Rate for Payer: Group Health Inc Commercial |
$129.50
|
| Rate for Payer: Group Health Inc Medicare |
$90.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$129.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$129.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$168.35
|
|
|
GRFT JCKT TISSUE REGEN 4X4CM
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
40200245
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$129.50 |
| Max. Negotiated Rate |
$129.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$129.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$129.50
|
|
|
GRFT STRAIGHT HEMASHIELD
|
Facility
|
IP
|
$850.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
40209675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$425.00 |
| Max. Negotiated Rate |
$425.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$425.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$425.00
|
|
