|
AMPICILLIN + SULBACTAM 3000 MG INJ PEDIA
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
41640066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.00
|
|
|
AMPICILLIN + SULBACTAM 3000 MG INJ PEDIA
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
41640066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$18.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$15.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.21
|
| Rate for Payer: Aetna Government |
$2.21
|
| Rate for Payer: Brighton Health Commercial |
$16.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$14.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.10
|
| Rate for Payer: Group Health Inc Commercial |
$14.00
|
| Rate for Payer: Group Health Inc Medicare |
$9.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$14.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$14.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$2.25
|
| Rate for Payer: SOMOS Essential |
$2.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.20
|
|
|
AMPICILLIN-SULBACTAM 30MG IN NS
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
41650272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.35
|
|
|
AMPICILLIN-SULBACTAM 30MG IN NS
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
41640272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.35
|
|
|
AMPICILLIN-SULBACTAM 30MG IN NS
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
41640272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.21
|
| Rate for Payer: Aetna Government |
$2.21
|
| Rate for Payer: Brighton Health Commercial |
$0.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.35
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.40
|
| Rate for Payer: Group Health Inc Commercial |
$0.35
|
| Rate for Payer: Group Health Inc Medicare |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.35
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$2.25
|
| Rate for Payer: SOMOS Essential |
$2.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.46
|
|
|
AMPICILLIN-SULBACTAM 30MG IN NS
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
41650272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.21
|
| Rate for Payer: Aetna Government |
$2.21
|
| Rate for Payer: Brighton Health Commercial |
$0.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.35
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.40
|
| Rate for Payer: Group Health Inc Commercial |
$0.35
|
| Rate for Payer: Group Health Inc Medicare |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.35
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$2.25
|
| Rate for Payer: SOMOS Essential |
$2.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.46
|
|
|
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR [9083]
|
Facility
|
OP
|
$9.25
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
00049001381
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$7.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.21
|
| Rate for Payer: Aetna Government |
$2.21
|
| Rate for Payer: Brighton Health Commercial |
$6.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.29
|
| Rate for Payer: Group Health Inc Commercial |
$4.62
|
| Rate for Payer: Group Health Inc Medicare |
$3.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.62
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.01
|
|
|
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR [9083]
|
Facility
|
OP
|
$7.74
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
55150011620
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$6.19 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.21
|
| Rate for Payer: Aetna Government |
$2.21
|
| Rate for Payer: Brighton Health Commercial |
$5.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.19
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.26
|
| Rate for Payer: Group Health Inc Commercial |
$3.87
|
| Rate for Payer: Group Health Inc Medicare |
$2.71
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.87
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.03
|
|
|
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR [9083]
|
Facility
|
OP
|
$9.25
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
00049001383
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$7.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.21
|
| Rate for Payer: Aetna Government |
$2.21
|
| Rate for Payer: Brighton Health Commercial |
$6.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.29
|
| Rate for Payer: Group Health Inc Commercial |
$4.63
|
| Rate for Payer: Group Health Inc Medicare |
$3.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.63
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.63
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.02
|
|
|
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IV SOLR [27282]
|
Facility
|
OP
|
$6.46
|
|
|
Service Code
|
NDC 00409268901
|
| Hospital Charge Code |
00409268901
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$6.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.23
|
| Rate for Payer: Aetna Government |
$3.23
|
| Rate for Payer: Brighton Health Commercial |
$3.87
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.23
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.71
|
| Rate for Payer: EmblemHealth Commercial |
$3.23
|
| Rate for Payer: Fidelis Medicare Advantage |
$6.78
|
| Rate for Payer: Group Health Inc Commercial |
$3.23
|
| Rate for Payer: Group Health Inc Medicare |
$2.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.23
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.20
|
|
|
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IV SOLR [27282]
|
Facility
|
IP
|
$6.46
|
|
|
Service Code
|
NDC 00409268901
|
| Hospital Charge Code |
00409268901
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$3.23 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.23
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.23
|
|
|
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR [9084]
|
Facility
|
OP
|
$14.60
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
55150011720
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$11.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.21
|
| Rate for Payer: Aetna Government |
$2.21
|
| Rate for Payer: Brighton Health Commercial |
$10.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.93
|
| Rate for Payer: Group Health Inc Commercial |
$7.30
|
| Rate for Payer: Group Health Inc Medicare |
$5.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.30
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.49
|
|
|
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR [9084]
|
Facility
|
OP
|
$19.14
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
44567021110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$15.31 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.53
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.21
|
| Rate for Payer: Aetna Government |
$2.21
|
| Rate for Payer: Brighton Health Commercial |
$14.36
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15.31
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.02
|
| Rate for Payer: Group Health Inc Commercial |
$9.57
|
| Rate for Payer: Group Health Inc Medicare |
$6.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.57
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.57
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12.44
|
|
|
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR [9084]
|
Facility
|
OP
|
$9.14
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
00641611701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$7.31 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.21
|
| Rate for Payer: Aetna Government |
$2.21
|
| Rate for Payer: Brighton Health Commercial |
$6.86
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.31
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.22
|
| Rate for Payer: Group Health Inc Commercial |
$4.57
|
| Rate for Payer: Group Health Inc Medicare |
$3.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.57
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.57
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.94
|
|
|
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR [9084]
|
Facility
|
OP
|
$14.60
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
55150011710
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$11.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.21
|
| Rate for Payer: Aetna Government |
$2.21
|
| Rate for Payer: Brighton Health Commercial |
$10.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.93
|
| Rate for Payer: Group Health Inc Commercial |
$7.30
|
| Rate for Payer: Group Health Inc Medicare |
$5.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.30
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.49
|
|
|
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR [9084]
|
Facility
|
OP
|
$17.47
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
00049001483
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$13.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.21
|
| Rate for Payer: Aetna Government |
$2.21
|
| Rate for Payer: Brighton Health Commercial |
$13.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.98
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.88
|
| Rate for Payer: Group Health Inc Commercial |
$8.74
|
| Rate for Payer: Group Health Inc Medicare |
$6.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8.74
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$2.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$2.25
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$2.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.36
|
|
|
AMPLATZ GRADUATED DILTOR KIT
|
Facility
|
OP
|
$582.90
|
|
| Hospital Charge Code |
64905384
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$204.02 |
| Max. Negotiated Rate |
$466.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$320.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$291.45
|
| Rate for Payer: Aetna Government |
$291.45
|
| Rate for Payer: Brighton Health Commercial |
$437.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$466.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$396.37
|
| Rate for Payer: Group Health Inc Commercial |
$291.45
|
| Rate for Payer: Group Health Inc Medicare |
$204.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$291.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$291.45
|
|
|
AMPLATZ J TIP WIRE
|
Facility
|
OP
|
$78.30
|
|
| Hospital Charge Code |
64905376
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$27.40 |
| Max. Negotiated Rate |
$62.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$43.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$39.15
|
| Rate for Payer: Aetna Government |
$39.15
|
| Rate for Payer: Brighton Health Commercial |
$58.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$62.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$53.24
|
| Rate for Payer: Group Health Inc Commercial |
$39.15
|
| Rate for Payer: Group Health Inc Medicare |
$27.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$39.15
|
|
|
AMPLATZ SUPER STIFF .035/180
|
Facility
|
OP
|
$420.00
|
|
| Hospital Charge Code |
40200264
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$147.00 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$231.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$210.00
|
| Rate for Payer: Aetna Government |
$210.00
|
| Rate for Payer: Brighton Health Commercial |
$315.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$336.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$285.60
|
| Rate for Payer: Group Health Inc Commercial |
$210.00
|
| Rate for Payer: Group Health Inc Medicare |
$147.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$210.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$210.00
|
|
|
AMPLATZ SUPER STIFF .035/260
|
Facility
|
OP
|
$440.00
|
|
| Hospital Charge Code |
40200263
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$154.00 |
| Max. Negotiated Rate |
$352.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$242.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$220.00
|
| Rate for Payer: Aetna Government |
$220.00
|
| Rate for Payer: Brighton Health Commercial |
$330.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$352.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$299.20
|
| Rate for Payer: Group Health Inc Commercial |
$220.00
|
| Rate for Payer: Group Health Inc Medicare |
$154.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$220.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$220.00
|
|
|
AMPUTATE TOE
|
Facility
|
IP
|
$8,291.05
|
|
|
Service Code
|
HCPCS 28820
|
| Hospital Charge Code |
42500138
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$3,743.15
|
|
|
AMPUTATE TOE
|
Facility
|
OP
|
$8,291.05
|
|
|
Service Code
|
HCPCS 28820
|
| Hospital Charge Code |
42500138
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,468.00 |
| Max. Negotiated Rate |
$6,218.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,743.15
|
| Rate for Payer: Aetna Government |
$3,743.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,620.20
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,620.20
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,620.20
|
| Rate for Payer: Brighton Health Commercial |
$6,218.29
|
| Rate for Payer: Cash Price |
$3,743.15
|
| Rate for Payer: Cash Price |
$3,743.15
|
| Rate for Payer: Cash Price |
$3,743.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,743.15
|
| 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 |
$3,743.15
|
| Rate for Payer: EmblemHealth Commercial |
$3,743.15
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,181.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,331.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,743.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,331.40
|
| Rate for Payer: Group Health Inc Commercial |
$3,743.15
|
| Rate for Payer: Group Health Inc Medicare |
$3,743.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,145.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,743.15
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,181.68
|
| Rate for Payer: Healthfirst QHP |
$3,743.15
|
| Rate for Payer: Humana Medicare |
$3,818.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,743.15
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,743.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,743.15
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,994.52
|
| Rate for Payer: Wellcare Medicare |
$3,555.99
|
|
|
AMPUTATION - ABOVE KNEE
|
Facility
|
OP
|
$3,338.36
|
|
|
Service Code
|
HCPCS 27590
|
| Hospital Charge Code |
40031810
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$846.02 |
| Max. Negotiated Rate |
$3,190.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,836.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$846.02
|
| Rate for Payer: Aetna Government |
$846.02
|
| Rate for Payer: Brighton Health Commercial |
$2,503.77
|
| 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: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,669.18
|
| Rate for Payer: Group Health Inc Medicare |
$1,168.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,669.18
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,669.18
|
| Rate for Payer: United Healthcare Commercial |
$3,190.00
|
|
|
AMPUTATION -BELOW KNEE
|
Facility
|
OP
|
$3,015.25
|
|
|
Service Code
|
HCPCS 27598
|
| Hospital Charge Code |
40031820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$757.33 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,658.39
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$757.33
|
| Rate for Payer: Aetna Government |
$757.33
|
| Rate for Payer: Brighton Health Commercial |
$2,261.44
|
| 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: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,507.62
|
| Rate for Payer: Group Health Inc Medicare |
$1,055.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,507.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,507.62
|
| Rate for Payer: United Healthcare Commercial |
$2,546.00
|
|
|
Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure
|
Facility
|
OP
|
$3,818.01
|
|
|
Service Code
|
CPT 26951
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,409.00 |
| Max. Negotiated Rate |
$3,818.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,743.15
|
| Rate for Payer: Aetna Government |
$3,743.15
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,620.20
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,620.20
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,620.20
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,743.15
|
| 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 |
$3,743.15
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,181.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,331.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,743.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,331.40
|
| Rate for Payer: Group Health Inc Commercial |
$3,743.15
|
| Rate for Payer: Group Health Inc Medicare |
$3,743.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,743.15
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,181.68
|
| Rate for Payer: Healthfirst QHP |
$3,743.15
|
| Rate for Payer: Humana Medicare |
$3,818.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,743.15
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,743.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,743.15
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,994.52
|
| Rate for Payer: Wellcare Medicare |
$3,555.99
|
|
