|
HCV GENOTYPE REFLEX NS5A
|
Facility
|
OP
|
$643.63
|
|
|
Service Code
|
HCPCS 87902
|
| Hospital Charge Code |
40619905
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$180.22 |
| Max. Negotiated Rate |
$482.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$354.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$257.45
|
| Rate for Payer: Aetna Government |
$257.45
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$180.22
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$180.22
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$180.22
|
| Rate for Payer: Brighton Health Commercial |
$482.72
|
| Rate for Payer: Cash Price |
$257.45
|
| Rate for Payer: Cash Price |
$257.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$257.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$409.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$346.26
|
| Rate for Payer: Elderplan Medicare Advantage |
$257.45
|
| Rate for Payer: EmblemHealth Commercial |
$257.45
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$218.83
|
| Rate for Payer: Fidelis Essential Plan QHP |
$229.13
|
| Rate for Payer: Fidelis Medicare Advantage |
$257.45
|
| Rate for Payer: Fidelis Qualified Health Plan |
$229.13
|
| Rate for Payer: Group Health Inc Commercial |
$257.45
|
| Rate for Payer: Group Health Inc Medicare |
$257.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$321.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$257.45
|
| Rate for Payer: Healthfirst Medicare Advantage |
$257.45
|
| Rate for Payer: Healthfirst QHP |
$257.45
|
| Rate for Payer: Humana Medicare |
$262.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$257.45
|
| Rate for Payer: United Healthcare Commercial |
$326.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$257.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$257.45
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$205.96
|
| Rate for Payer: Wellcare Medicare |
$231.70
|
|
|
HCV GENOTYPE REFLEX NS5A
|
Facility
|
IP
|
$643.63
|
|
|
Service Code
|
HCPCS 87902
|
| Hospital Charge Code |
40619905
|
|
Hospital Revenue Code
|
306
|
| Rate for Payer: Cash Price |
$257.45
|
|
|
HCV GENOTYPING NON REFLEX
|
Facility
|
OP
|
$643.63
|
|
|
Service Code
|
HCPCS 87902
|
| Hospital Charge Code |
40729402
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$180.22 |
| Max. Negotiated Rate |
$482.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$354.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$257.45
|
| Rate for Payer: Aetna Government |
$257.45
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$180.22
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$180.22
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$180.22
|
| Rate for Payer: Brighton Health Commercial |
$482.72
|
| Rate for Payer: Cash Price |
$257.45
|
| Rate for Payer: Cash Price |
$257.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$257.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$409.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$346.26
|
| Rate for Payer: Elderplan Medicare Advantage |
$257.45
|
| Rate for Payer: EmblemHealth Commercial |
$257.45
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$218.83
|
| Rate for Payer: Fidelis Essential Plan QHP |
$229.13
|
| Rate for Payer: Fidelis Medicare Advantage |
$257.45
|
| Rate for Payer: Fidelis Qualified Health Plan |
$229.13
|
| Rate for Payer: Group Health Inc Commercial |
$257.45
|
| Rate for Payer: Group Health Inc Medicare |
$257.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$321.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$257.45
|
| Rate for Payer: Healthfirst Medicare Advantage |
$257.45
|
| Rate for Payer: Healthfirst QHP |
$257.45
|
| Rate for Payer: Humana Medicare |
$262.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$257.45
|
| Rate for Payer: United Healthcare Commercial |
$326.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$257.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$257.45
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$205.96
|
| Rate for Payer: Wellcare Medicare |
$231.70
|
|
|
HCV GENOTYPING NON REFLEX
|
Facility
|
IP
|
$643.63
|
|
|
Service Code
|
HCPCS 87902
|
| Hospital Charge Code |
40729402
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$257.45
|
|
|
HCV NS5A DRUG RESISTANCE ASSAY
|
Facility
|
OP
|
$325.88
|
|
|
Service Code
|
HCPCS 87900
|
| Hospital Charge Code |
40613016
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$91.24 |
| Max. Negotiated Rate |
$244.41 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$179.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$130.35
|
| Rate for Payer: Aetna Government |
$130.35
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$91.24
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$91.24
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$91.24
|
| Rate for Payer: Brighton Health Commercial |
$244.41
|
| Rate for Payer: Cash Price |
$130.35
|
| Rate for Payer: Cash Price |
$130.35
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$130.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$207.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$175.30
|
| Rate for Payer: Elderplan Medicare Advantage |
$130.35
|
| Rate for Payer: EmblemHealth Commercial |
$130.35
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$110.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$116.01
|
| Rate for Payer: Fidelis Medicare Advantage |
$130.35
|
| Rate for Payer: Fidelis Qualified Health Plan |
$116.01
|
| Rate for Payer: Group Health Inc Commercial |
$130.35
|
| Rate for Payer: Group Health Inc Medicare |
$130.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$162.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$130.35
|
| Rate for Payer: Healthfirst Medicare Advantage |
$130.35
|
| Rate for Payer: Healthfirst QHP |
$130.35
|
| Rate for Payer: Humana Medicare |
$132.96
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$130.35
|
| Rate for Payer: United Healthcare Commercial |
$165.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$130.35
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$104.28
|
| Rate for Payer: Wellcare Medicare |
$117.32
|
|
|
HCV NS5A DRUG RESISTANCE ASSAY
|
Facility
|
IP
|
$325.88
|
|
|
Service Code
|
HCPCS 87900
|
| Hospital Charge Code |
40613016
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$130.35
|
|
|
HCV QUANT GT1A NS5A PROFILE
|
Facility
|
IP
|
$107.10
|
|
|
Service Code
|
HCPCS 87522
|
| Hospital Charge Code |
40619906
|
|
Hospital Revenue Code
|
306
|
| Rate for Payer: Cash Price |
$42.84
|
|
|
HCV QUANT GT1A NS5A PROFILE
|
Facility
|
OP
|
$107.10
|
|
|
Service Code
|
HCPCS 87522
|
| Hospital Charge Code |
40619906
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$29.99 |
| Max. Negotiated Rate |
$80.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$58.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$42.84
|
| Rate for Payer: Aetna Government |
$42.84
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$29.99
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$29.99
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$29.99
|
| Rate for Payer: Brighton Health Commercial |
$80.32
|
| Rate for Payer: Cash Price |
$42.84
|
| Rate for Payer: Cash Price |
$42.84
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$42.84
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$68.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$57.62
|
| Rate for Payer: Elderplan Medicare Advantage |
$42.84
|
| Rate for Payer: EmblemHealth Commercial |
$42.84
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$36.41
|
| Rate for Payer: Fidelis Essential Plan QHP |
$38.13
|
| Rate for Payer: Fidelis Medicare Advantage |
$42.84
|
| Rate for Payer: Fidelis Qualified Health Plan |
$38.13
|
| Rate for Payer: Group Health Inc Commercial |
$42.84
|
| Rate for Payer: Group Health Inc Medicare |
$42.84
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$53.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$42.84
|
| Rate for Payer: Healthfirst Medicare Advantage |
$42.84
|
| Rate for Payer: Healthfirst QHP |
$42.84
|
| Rate for Payer: Humana Medicare |
$43.70
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$42.84
|
| Rate for Payer: United Healthcare Commercial |
$54.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$42.84
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$42.84
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$34.27
|
| Rate for Payer: Wellcare Medicare |
$38.56
|
|
|
HCV RNA GENOTYPE, LIPA
|
Facility
|
IP
|
$643.63
|
|
|
Service Code
|
HCPCS 87902
|
| Hospital Charge Code |
30303357
|
|
Hospital Revenue Code
|
306
|
| Rate for Payer: Cash Price |
$257.45
|
|
|
HCV RNA GENOTYPE, LIPA
|
Facility
|
OP
|
$643.63
|
|
|
Service Code
|
HCPCS 87902
|
| Hospital Charge Code |
30303357
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$180.22 |
| Max. Negotiated Rate |
$482.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$354.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$257.45
|
| Rate for Payer: Aetna Government |
$257.45
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$180.22
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$180.22
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$180.22
|
| Rate for Payer: Brighton Health Commercial |
$482.72
|
| Rate for Payer: Cash Price |
$257.45
|
| Rate for Payer: Cash Price |
$257.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$257.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$409.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$346.26
|
| Rate for Payer: Elderplan Medicare Advantage |
$257.45
|
| Rate for Payer: EmblemHealth Commercial |
$257.45
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$218.83
|
| Rate for Payer: Fidelis Essential Plan QHP |
$229.13
|
| Rate for Payer: Fidelis Medicare Advantage |
$257.45
|
| Rate for Payer: Fidelis Qualified Health Plan |
$229.13
|
| Rate for Payer: Group Health Inc Commercial |
$257.45
|
| Rate for Payer: Group Health Inc Medicare |
$257.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$321.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$257.45
|
| Rate for Payer: Healthfirst Medicare Advantage |
$257.45
|
| Rate for Payer: Healthfirst QHP |
$257.45
|
| Rate for Payer: Humana Medicare |
$262.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$257.45
|
| Rate for Payer: United Healthcare Commercial |
$326.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$257.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$257.45
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$205.96
|
| Rate for Payer: Wellcare Medicare |
$231.70
|
|
|
HCV RNA, PCR
|
Facility
|
IP
|
$107.10
|
|
|
Service Code
|
HCPCS 87522
|
| Hospital Charge Code |
40728200
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$42.84
|
|
|
HCV RNA, PCR
|
Facility
|
OP
|
$107.10
|
|
|
Service Code
|
HCPCS 87522
|
| Hospital Charge Code |
40728200
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.99 |
| Max. Negotiated Rate |
$80.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$58.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$42.84
|
| Rate for Payer: Aetna Government |
$42.84
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$29.99
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$29.99
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$29.99
|
| Rate for Payer: Brighton Health Commercial |
$80.32
|
| Rate for Payer: Cash Price |
$42.84
|
| Rate for Payer: Cash Price |
$42.84
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$42.84
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$68.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$57.62
|
| Rate for Payer: Elderplan Medicare Advantage |
$42.84
|
| Rate for Payer: EmblemHealth Commercial |
$42.84
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$36.41
|
| Rate for Payer: Fidelis Essential Plan QHP |
$38.13
|
| Rate for Payer: Fidelis Medicare Advantage |
$42.84
|
| Rate for Payer: Fidelis Qualified Health Plan |
$38.13
|
| Rate for Payer: Group Health Inc Commercial |
$42.84
|
| Rate for Payer: Group Health Inc Medicare |
$42.84
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$53.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$42.84
|
| Rate for Payer: Healthfirst Medicare Advantage |
$42.84
|
| Rate for Payer: Healthfirst QHP |
$42.84
|
| Rate for Payer: Humana Medicare |
$43.70
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$42.84
|
| Rate for Payer: United Healthcare Commercial |
$54.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$42.84
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$42.84
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$34.27
|
| Rate for Payer: Wellcare Medicare |
$38.56
|
|
|
HCV RT-PCR, QUANT (NON-GRAPH_
|
Facility
|
OP
|
$107.10
|
|
|
Service Code
|
HCPCS 87522
|
| Hospital Charge Code |
40729394
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.99 |
| Max. Negotiated Rate |
$80.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$58.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$42.84
|
| Rate for Payer: Aetna Government |
$42.84
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$29.99
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$29.99
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$29.99
|
| Rate for Payer: Brighton Health Commercial |
$80.32
|
| Rate for Payer: Cash Price |
$42.84
|
| Rate for Payer: Cash Price |
$42.84
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$42.84
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$68.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$57.62
|
| Rate for Payer: Elderplan Medicare Advantage |
$42.84
|
| Rate for Payer: EmblemHealth Commercial |
$42.84
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$36.41
|
| Rate for Payer: Fidelis Essential Plan QHP |
$38.13
|
| Rate for Payer: Fidelis Medicare Advantage |
$42.84
|
| Rate for Payer: Fidelis Qualified Health Plan |
$38.13
|
| Rate for Payer: Group Health Inc Commercial |
$42.84
|
| Rate for Payer: Group Health Inc Medicare |
$42.84
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$53.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$42.84
|
| Rate for Payer: Healthfirst Medicare Advantage |
$42.84
|
| Rate for Payer: Healthfirst QHP |
$42.84
|
| Rate for Payer: Humana Medicare |
$43.70
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$42.84
|
| Rate for Payer: United Healthcare Commercial |
$54.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$42.84
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$42.84
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$34.27
|
| Rate for Payer: Wellcare Medicare |
$38.56
|
|
|
HCV RT-PCR, QUANT (NON-GRAPH_
|
Facility
|
IP
|
$107.10
|
|
|
Service Code
|
HCPCS 87522
|
| Hospital Charge Code |
40729394
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$42.84
|
|
|
HEA CARE PRACT TX IN PLACE
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS G2021
|
| Hospital Charge Code |
30300133
|
|
Hospital Revenue Code
|
969
|
| Max. Negotiated Rate |
$0.01 |
| 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: Brighton Health Commercial |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| 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 |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
HEAD 12/14 COCR FEMORAL 40MM+10.5
|
Facility
|
OP
|
$2,544.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40204616
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$2,671.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,399.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$1,526.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,272.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,462.80
|
| Rate for Payer: EmblemHealth Commercial |
$1,272.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,671.20
|
| Rate for Payer: Group Health Inc Commercial |
$1,272.00
|
| Rate for Payer: Group Health Inc Medicare |
$890.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,272.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,272.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,653.60
|
|
|
HEAD 12/14 COCR FEMORAL 40MM+10.5
|
Facility
|
IP
|
$2,544.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40204616
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,272.00 |
| Max. Negotiated Rate |
$1,272.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,272.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,272.00
|
|
|
HEAD 12/14 COCR FEMRL 40MM +10.5
|
Facility
|
OP
|
$2,544.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40007535
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$2,671.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,399.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$1,526.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,272.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,462.80
|
| Rate for Payer: EmblemHealth Commercial |
$1,272.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,671.20
|
| Rate for Payer: Group Health Inc Commercial |
$1,272.00
|
| Rate for Payer: Group Health Inc Medicare |
$890.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,272.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,272.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,653.60
|
|
|
HEAD 12/14 COCR FEMRL 40MM +10.5
|
Facility
|
IP
|
$2,544.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40007535
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,272.00 |
| Max. Negotiated Rate |
$1,272.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,272.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,272.00
|
|
|
HEAD 26MM 7MM
|
Facility
|
OP
|
$1,963.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901790
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$2,061.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,079.92
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$1,178.10
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$981.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,129.01
|
| Rate for Payer: EmblemHealth Commercial |
$981.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,061.68
|
| Rate for Payer: Group Health Inc Commercial |
$981.75
|
| Rate for Payer: Group Health Inc Medicare |
$687.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$981.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$981.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,276.28
|
|
|
HEAD 26MM 7MM
|
Facility
|
IP
|
$1,963.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901790
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$981.75 |
| Max. Negotiated Rate |
$981.75 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$981.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$981.75
|
|
|
HEAD 36MM COCR MOD HD +9MM
|
Facility
|
OP
|
$1,908.00
|
|
| Hospital Charge Code |
64906711
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$667.80 |
| Max. Negotiated Rate |
$1,526.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,049.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$954.00
|
| Rate for Payer: Aetna Government |
$954.00
|
| Rate for Payer: Brighton Health Commercial |
$1,431.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,526.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,297.44
|
| Rate for Payer: Group Health Inc Commercial |
$954.00
|
| Rate for Payer: Group Health Inc Medicare |
$667.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$954.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$954.00
|
|
|
HEAD 5
|
Facility
|
OP
|
$5,193.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64904696
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$5,452.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,856.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$3,115.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,596.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,985.98
|
| Rate for Payer: EmblemHealth Commercial |
$2,596.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$5,452.65
|
| Rate for Payer: Group Health Inc Commercial |
$2,596.50
|
| Rate for Payer: Group Health Inc Medicare |
$1,817.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,596.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,596.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,375.45
|
|
|
HEAD 5
|
Facility
|
IP
|
$5,193.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64904696
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,596.50 |
| Max. Negotiated Rate |
$2,596.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,596.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,596.50
|
|
|
HEADACHES WITH MCC
|
Facility
|
IP
|
$33,082.80
|
|
|
Service Code
|
MSDRG 102
|
| Min. Negotiated Rate |
$10,346.60 |
| Max. Negotiated Rate |
$33,082.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$17,791.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24,060.22
|
| Rate for Payer: Aetna Government |
$24,060.22
|
| Rate for Payer: Brighton Health Commercial |
$17,495.70
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$24,541.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$20,836.78
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17,195.40
|
| Rate for Payer: Elderplan Medicare Advantage |
$22,857.21
|
| Rate for Payer: EmblemHealth Commercial |
$10,346.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$24,060.22
|
| Rate for Payer: Group Health Inc Commercial |
$24,060.22
|
| Rate for Payer: Group Health Inc Medicare |
$24,060.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24,060.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$11,188.00
|
| Rate for Payer: Humana Medicare |
$33,082.80
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$24,060.22
|
| Rate for Payer: United Healthcare Commercial |
$23,995.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24,060.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24,060.22
|
| Rate for Payer: Wellcare Medicare |
$22,857.21
|
|
