|
POT CL IN D5W LACT RINGERS 20 MEQ/L IV SOLN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0338081104
|
| Hospital Charge Code |
0338081104
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
|
|
POT CL IN D5W LACT RINGERS 20 MEQ/L IV SOLN
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0990711109
|
| Hospital Charge Code |
0990711109
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
|
|
POT CL IN D5W LACT RINGERS 20 MEQ/L IV SOLN
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0338081104
|
| Hospital Charge Code |
0338081104
|
|
Hospital Revenue Code
|
258
|
| 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: EmblemHealth Commercial |
$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
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
POT & SOD CIT-CIT AC 550-500-334 MG/5ML PO SYRP
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 6025800216
|
| Hospital Charge Code |
6025800216
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.08
|
|
|
POT & SOD CIT-CIT AC 550-500-334 MG/5ML PO SYRP
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 6025800216
|
| Hospital Charge Code |
6025800216
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.08
|
| Rate for Payer: Aetna Government |
$0.08
|
| Rate for Payer: Brighton Health Commercial |
$0.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.12
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.10
|
| Rate for Payer: EmblemHealth Commercial |
$0.08
|
| Rate for Payer: Group Health Inc Commercial |
$0.08
|
| Rate for Payer: Group Health Inc Medicare |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.10
|
|
|
POVIDONE-IODINE 10 % EX OINT
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0536127180
|
| Hospital Charge Code |
0536127180
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.03
|
|
|
POVIDONE-IODINE 10 % EX OINT
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0536127180
|
| Hospital Charge Code |
0536127180
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.03
|
| Rate for Payer: Aetna Government |
$0.03
|
| Rate for Payer: Brighton Health Commercial |
$0.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.05
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.04
|
| Rate for Payer: EmblemHealth Commercial |
$0.03
|
| Rate for Payer: Group Health Inc Commercial |
$0.03
|
| Rate for Payer: Group Health Inc Medicare |
$0.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.03
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.04
|
|
|
POVIDONE-IODINE 5 % OP SOLN
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 0065041130
|
| Hospital Charge Code |
0065041130
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.34
|
|
|
POVIDONE-IODINE 5 % OP SOLN
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 0065041130
|
| Hospital Charge Code |
0065041130
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.34
|
| Rate for Payer: Aetna Government |
$0.34
|
| Rate for Payer: Brighton Health Commercial |
$0.51
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.55
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.46
|
| Rate for Payer: EmblemHealth Commercial |
$0.34
|
| Rate for Payer: Group Health Inc Commercial |
$0.34
|
| Rate for Payer: Group Health Inc Medicare |
$0.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.44
|
|
|
PR 1 STAGE DSTL HYPOSPADIAS RPR W/EXTENSIVE DSJ
|
Professional
|
Both
|
$3,913.14
|
|
|
Service Code
|
HCPCS 54328
|
| Min. Negotiated Rate |
$744.88 |
| Max. Negotiated Rate |
$2,394.27 |
| Rate for Payer: Cash Price |
$1,070.36
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,064.12
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$957.71
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$957.71
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,010.91
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,064.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,010.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,064.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,064.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$798.09
|
| Rate for Payer: Healthfirst Commercial |
$1,064.12
|
| Rate for Payer: Healthfirst Essential Plan |
$2,394.27
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,010.91
|
| Rate for Payer: Healthfirst QHP |
$1,064.12
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$744.88
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,064.12
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$904.50
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$744.88
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,064.12
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$798.09
|
| Rate for Payer: SOMOS Essential |
$798.09
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,064.12
|
|
|
PR 1 STAGE PROX PENILE/PENOSCROTAL HYPOSPADIAS RPR
|
Professional
|
Both
|
$4,214.32
|
|
|
Service Code
|
HCPCS 54332
|
| Min. Negotiated Rate |
$803.03 |
| Max. Negotiated Rate |
$2,581.18 |
| Rate for Payer: Cash Price |
$1,153.04
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,147.19
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,032.47
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,032.47
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,089.83
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,147.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,089.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,147.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,147.19
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$860.39
|
| Rate for Payer: Healthfirst Commercial |
$1,147.19
|
| Rate for Payer: Healthfirst Essential Plan |
$2,581.18
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,089.83
|
| Rate for Payer: Healthfirst QHP |
$1,147.19
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$803.03
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,147.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$975.11
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$803.03
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,147.19
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$860.39
|
| Rate for Payer: SOMOS Essential |
$860.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,147.19
|
|
|
PR 1ST CARE PR DAY NML NB XCPT HOSP/BIRTHING CENTER
|
Professional
|
Both
|
$251.30
|
|
|
Service Code
|
HCPCS 99461
|
| Min. Negotiated Rate |
$46.35 |
| Max. Negotiated Rate |
$148.97 |
| Rate for Payer: Cash Price |
$67.65
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$66.21
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$59.59
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$59.59
|
| Rate for Payer: Fidelis Essential Plan QHP |
$62.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$66.21
|
| Rate for Payer: Fidelis Qualified Health Plan |
$62.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$66.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$66.21
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$49.66
|
| Rate for Payer: Healthfirst Commercial |
$66.21
|
| Rate for Payer: Healthfirst Essential Plan |
$148.97
|
| Rate for Payer: Healthfirst Medicare Advantage |
$62.90
|
| Rate for Payer: Healthfirst QHP |
$66.21
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$46.35
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$66.21
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$56.28
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$46.35
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$66.21
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$49.66
|
| Rate for Payer: SOMOS Essential |
$49.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$66.21
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR URTP SKN FLAPS
|
Professional
|
Both
|
$3,937.92
|
|
|
Service Code
|
HCPCS 54326
|
| Min. Negotiated Rate |
$749.53 |
| Max. Negotiated Rate |
$2,409.21 |
| Rate for Payer: Cash Price |
$1,077.32
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,070.76
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$963.68
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$963.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,017.22
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,070.76
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,017.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,070.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,070.76
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$803.07
|
| Rate for Payer: Healthfirst Commercial |
$1,070.76
|
| Rate for Payer: Healthfirst Essential Plan |
$2,409.21
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,017.22
|
| Rate for Payer: Healthfirst QHP |
$1,070.76
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$749.53
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,070.76
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$910.15
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$749.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,070.76
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$803.07
|
| Rate for Payer: SOMOS Essential |
$803.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,070.76
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR W/SMPL MEATAL ADVMNT
|
Professional
|
Both
|
$3,271.66
|
|
|
Service Code
|
HCPCS 54322
|
| Min. Negotiated Rate |
$622.61 |
| Max. Negotiated Rate |
$2,001.24 |
| Rate for Payer: Cash Price |
$894.09
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$889.44
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$800.50
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$800.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$844.97
|
| Rate for Payer: Fidelis Medicare Advantage |
$889.44
|
| Rate for Payer: Fidelis Qualified Health Plan |
$844.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$889.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$889.44
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$667.08
|
| Rate for Payer: Healthfirst Commercial |
$889.44
|
| Rate for Payer: Healthfirst Essential Plan |
$2,001.24
|
| Rate for Payer: Healthfirst Medicare Advantage |
$844.97
|
| Rate for Payer: Healthfirst QHP |
$889.44
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$622.61
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$889.44
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$756.02
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$622.61
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$889.44
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$667.08
|
| Rate for Payer: SOMOS Essential |
$667.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$889.44
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR W/URTP SKIN FLAPS
|
Professional
|
Both
|
$4,043.73
|
|
|
Service Code
|
HCPCS 54324
|
| Min. Negotiated Rate |
$769.97 |
| Max. Negotiated Rate |
$2,474.89 |
| Rate for Payer: Cash Price |
$1,106.24
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,099.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$989.96
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$989.96
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,044.95
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,099.95
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,044.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,099.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,099.95
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$824.96
|
| Rate for Payer: Healthfirst Commercial |
$1,099.95
|
| Rate for Payer: Healthfirst Essential Plan |
$2,474.89
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,044.95
|
| Rate for Payer: Healthfirst QHP |
$1,099.95
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$769.97
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,099.95
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$934.96
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$769.97
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,099.95
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$824.96
|
| Rate for Payer: SOMOS Essential |
$824.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,099.95
|
|
|
PR 1 STG PERINEAL HYPOSPADIAS RPR W/GRF&/FLAP
|
Professional
|
Both
|
$4,956.49
|
|
|
Service Code
|
HCPCS 54336
|
| Min. Negotiated Rate |
$943.11 |
| Max. Negotiated Rate |
$3,031.43 |
| Rate for Payer: Cash Price |
$1,355.69
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,347.30
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,212.57
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,212.57
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,279.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,347.30
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,279.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,347.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,347.30
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,010.48
|
| Rate for Payer: Healthfirst Commercial |
$1,347.30
|
| Rate for Payer: Healthfirst Essential Plan |
$3,031.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,279.93
|
| Rate for Payer: Healthfirst QHP |
$1,347.30
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$943.11
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,347.30
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,145.20
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$943.11
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,347.30
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,010.48
|
| Rate for Payer: SOMOS Essential |
$1,010.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,347.30
|
|
|
PR 1ST HOSP/BIRTHING CENTER CARE PER DAY NML NB
|
Professional
|
Both
|
$373.94
|
|
|
Service Code
|
HCPCS 99460
|
| Min. Negotiated Rate |
$23.22 |
| Max. Negotiated Rate |
$227.16 |
| Rate for Payer: Amida Care Medicaid |
$23.22
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$100.96
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$90.86
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$90.86
|
| Rate for Payer: Fidelis Essential Plan QHP |
$95.91
|
| Rate for Payer: Fidelis Medicare Advantage |
$100.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$95.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$100.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$100.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$75.72
|
| Rate for Payer: Healthfirst Commercial |
$100.96
|
| Rate for Payer: Healthfirst Essential Plan |
$227.16
|
| Rate for Payer: Healthfirst Medicare Advantage |
$95.91
|
| Rate for Payer: Healthfirst QHP |
$100.96
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$70.67
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$100.96
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$85.82
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$70.67
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$100.96
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$75.72
|
| Rate for Payer: SOMOS Essential |
$75.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$100.96
|
|
|
PR 1ST HOSP/BIRTHING CENTER NB ADMIT & DSCHG SM DAT
|
Professional
|
Both
|
$445.55
|
|
|
Service Code
|
HCPCS 99463
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$267.70 |
| Rate for Payer: Amida Care Medicaid |
$31.20
|
| Rate for Payer: Cash Price |
$120.21
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$118.98
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$107.08
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$107.08
|
| Rate for Payer: Fidelis Essential Plan QHP |
$113.03
|
| Rate for Payer: Fidelis Medicare Advantage |
$118.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$113.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$118.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$118.98
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$89.23
|
| Rate for Payer: Healthfirst Commercial |
$118.98
|
| Rate for Payer: Healthfirst Essential Plan |
$267.70
|
| Rate for Payer: Healthfirst Medicare Advantage |
$113.03
|
| Rate for Payer: Healthfirst QHP |
$118.98
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$83.29
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$118.98
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$101.13
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$83.29
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$118.98
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$89.23
|
| Rate for Payer: SOMOS Essential |
$89.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$118.98
|
|
|
PR 1ST HOSPITAL IP/OBS CARE HIGH MDM 75 MINUTES
|
Professional
|
Both
|
$706.44
|
|
|
Service Code
|
HCPCS 99223
|
| Min. Negotiated Rate |
$71.33 |
| Max. Negotiated Rate |
$431.62 |
| Rate for Payer: Amida Care Medicaid |
$71.33
|
| Rate for Payer: Cash Price |
$192.55
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$191.83
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$172.65
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$172.65
|
| Rate for Payer: Fidelis Essential Plan QHP |
$182.24
|
| Rate for Payer: Fidelis Medicare Advantage |
$191.83
|
| Rate for Payer: Fidelis Qualified Health Plan |
$182.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$191.83
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$191.83
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$143.87
|
| Rate for Payer: Healthfirst Commercial |
$191.83
|
| Rate for Payer: Healthfirst Essential Plan |
$431.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$182.24
|
| Rate for Payer: Healthfirst QHP |
$191.83
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$134.28
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$191.83
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$163.06
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$134.28
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$191.83
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$143.87
|
| Rate for Payer: SOMOS Essential |
$143.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$191.83
|
|
|
PR 1ST HOSPITAL IP/OBS CARE MODERATE MDM 55 MINUTES
|
Professional
|
Both
|
$533.89
|
|
|
Service Code
|
HCPCS 99222
|
| Min. Negotiated Rate |
$48.55 |
| Max. Negotiated Rate |
$324.70 |
| Rate for Payer: Amida Care Medicaid |
$48.55
|
| Rate for Payer: Cash Price |
$146.32
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$144.31
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$129.88
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$129.88
|
| Rate for Payer: Fidelis Essential Plan QHP |
$137.09
|
| Rate for Payer: Fidelis Medicare Advantage |
$144.31
|
| Rate for Payer: Fidelis Qualified Health Plan |
$137.09
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$144.31
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$144.31
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$108.23
|
| Rate for Payer: Healthfirst Commercial |
$144.31
|
| Rate for Payer: Healthfirst Essential Plan |
$324.70
|
| Rate for Payer: Healthfirst Medicare Advantage |
$137.09
|
| Rate for Payer: Healthfirst QHP |
$144.31
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$101.02
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$144.31
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$122.66
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$101.02
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$144.31
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$108.23
|
| Rate for Payer: SOMOS Essential |
$108.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$144.31
|
|
|
PR 1ST HOSPITAL IP/OBS CARE SF/LOW MDM 40 MINUTES
|
Professional
|
Both
|
$346.85
|
|
|
Service Code
|
HCPCS 99221
|
| Min. Negotiated Rate |
$35.25 |
| Max. Negotiated Rate |
$207.63 |
| Rate for Payer: Amida Care Medicaid |
$35.25
|
| Rate for Payer: Cash Price |
$93.65
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$92.28
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$83.05
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$83.05
|
| Rate for Payer: Fidelis Essential Plan QHP |
$87.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$92.28
|
| Rate for Payer: Fidelis Qualified Health Plan |
$87.67
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$92.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$92.28
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$69.21
|
| Rate for Payer: Healthfirst Commercial |
$92.28
|
| Rate for Payer: Healthfirst Essential Plan |
$207.63
|
| Rate for Payer: Healthfirst Medicare Advantage |
$87.67
|
| Rate for Payer: Healthfirst QHP |
$92.28
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$64.60
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$92.28
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$78.44
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$64.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$92.28
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$69.21
|
| Rate for Payer: SOMOS Essential |
$69.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$92.28
|
|
|
PR 1ST INPATIENT CRITICAL CARE PR DAY AGE 28 DAYS/<
|
Professional
|
Both
|
$3,615.92
|
|
|
Service Code
|
HCPCS 99468
|
| Min. Negotiated Rate |
$357.57 |
| Max. Negotiated Rate |
$2,186.86 |
| Rate for Payer: Amida Care Medicaid |
$357.57
|
| Rate for Payer: Cash Price |
$988.21
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$971.94
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$874.75
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$874.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$923.34
|
| Rate for Payer: Fidelis Medicare Advantage |
$971.94
|
| Rate for Payer: Fidelis Qualified Health Plan |
$923.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$971.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$971.94
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$728.96
|
| Rate for Payer: Healthfirst Commercial |
$971.94
|
| Rate for Payer: Healthfirst Essential Plan |
$2,186.86
|
| Rate for Payer: Healthfirst Medicare Advantage |
$923.34
|
| Rate for Payer: Healthfirst QHP |
$971.94
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$680.36
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$971.94
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$826.15
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$680.36
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$971.94
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$728.96
|
| Rate for Payer: SOMOS Essential |
$728.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$971.94
|
|
|
PR 1ST PSYCHIATRIC COLLAB CARE MGMT 1ST 70 MINS
|
Professional
|
Both
|
$374.68
|
|
|
Service Code
|
HCPCS 99492
|
| Min. Negotiated Rate |
$72.69 |
| Max. Negotiated Rate |
$233.66 |
| Rate for Payer: Cash Price |
$104.11
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$103.85
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$93.47
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$93.47
|
| Rate for Payer: Fidelis Essential Plan QHP |
$98.66
|
| Rate for Payer: Fidelis Medicare Advantage |
$103.85
|
| Rate for Payer: Fidelis Qualified Health Plan |
$98.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$103.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$103.85
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$77.89
|
| Rate for Payer: Healthfirst Commercial |
$103.85
|
| Rate for Payer: Healthfirst Essential Plan |
$233.66
|
| Rate for Payer: Healthfirst Medicare Advantage |
$98.66
|
| Rate for Payer: Healthfirst QHP |
$103.85
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$72.69
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$103.85
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$88.27
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$72.69
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$103.85
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$77.89
|
| Rate for Payer: SOMOS Essential |
$77.89
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$103.85
|
|
|
PR 1ST/SBSQ PSYCH COLLAB CARE MGMT EA ADDL 30 MINS
|
Professional
|
Both
|
$165.13
|
|
|
Service Code
|
HCPCS 99494
|
| Min. Negotiated Rate |
$30.74 |
| Max. Negotiated Rate |
$98.82 |
| Rate for Payer: Cash Price |
$45.48
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$43.92
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$39.53
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.53
|
| Rate for Payer: Fidelis Essential Plan QHP |
$41.72
|
| Rate for Payer: Fidelis Medicare Advantage |
$43.92
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$43.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$43.92
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$32.94
|
| Rate for Payer: Healthfirst Commercial |
$43.92
|
| Rate for Payer: Healthfirst Essential Plan |
$98.82
|
| Rate for Payer: Healthfirst Medicare Advantage |
$41.72
|
| Rate for Payer: Healthfirst QHP |
$43.92
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$30.74
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$43.92
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$37.33
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$30.74
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$43.92
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$32.94
|
| Rate for Payer: SOMOS Essential |
$32.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$43.92
|
|
|
PR 1ST SET-UP & PRGRMG PHYS/QHP OF WEARABLE CVDFB
|
Professional
|
Both
|
$216.30
|
|
|
Service Code
|
HCPCS 93745 26
|
| Min. Negotiated Rate |
$61.53 |
| Max. Negotiated Rate |
$61.53 |
| Rate for Payer: Amida Care Medicaid |
$61.53
|
|
