|
INFLUENZA VACC QUAD 5ML MDV (VFC)
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90688
|
| Hospital Charge Code |
41646648
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
INFLUENZA VACC QUAD 5ML MDV (VFC)
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS 90688
|
| Hospital Charge Code |
41656648
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
INFLUENZA VAC FLUVIRIN .5ML SYR
|
Facility
|
IP
|
$24.90
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
41648016
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$12.45 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.45
|
|
|
INFLUENZA VAC FLUVIRIN .5ML SYR
|
Facility
|
OP
|
$24.90
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
41658016
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$1,267.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.69
|
| Rate for Payer: Aetna Government |
$17.69
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$28.51
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$28.51
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$12.67
|
| Rate for Payer: Amida Care Medicaid |
$12.67
|
| Rate for Payer: Brighton Health Commercial |
$14.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$14.32
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,267.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.67
|
| Rate for Payer: Fidelis Essential Plan QHP |
$12.67
|
| Rate for Payer: Fidelis Qualified Health Plan |
$13.30
|
| Rate for Payer: Group Health Inc Commercial |
$12.45
|
| Rate for Payer: Group Health Inc Medicare |
$8.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.45
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$12.67
|
| Rate for Payer: Healthfirst Essential Plan |
$28.51
|
| Rate for Payer: Healthfirst QHP |
$12.67
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$12.67
|
| Rate for Payer: SOMOS Essential |
$12.67
|
| Rate for Payer: United Healthcare Commercial |
$12.88
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$28.51
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$13.94
|
| Rate for Payer: United Healthcare Medicaid |
$12.67
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$16.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$12.67
|
|
|
INFLUENZA VAC FLUVIRIN .5ML SYR
|
Facility
|
OP
|
$24.90
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
41648016
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$1,267.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.69
|
| Rate for Payer: Aetna Government |
$17.69
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$28.51
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$28.51
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$12.67
|
| Rate for Payer: Amida Care Medicaid |
$12.67
|
| Rate for Payer: Brighton Health Commercial |
$14.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$14.32
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,267.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.67
|
| Rate for Payer: Fidelis Essential Plan QHP |
$12.67
|
| Rate for Payer: Fidelis Qualified Health Plan |
$13.30
|
| Rate for Payer: Group Health Inc Commercial |
$12.45
|
| Rate for Payer: Group Health Inc Medicare |
$8.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.45
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$12.67
|
| Rate for Payer: Healthfirst Essential Plan |
$28.51
|
| Rate for Payer: Healthfirst QHP |
$12.67
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$12.67
|
| Rate for Payer: SOMOS Essential |
$12.67
|
| Rate for Payer: United Healthcare Commercial |
$12.88
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$28.51
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$13.94
|
| Rate for Payer: United Healthcare Medicaid |
$12.67
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$16.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$12.67
|
|
|
INFLUENZA VAC FLUVIRIN .5ML SYR
|
Facility
|
IP
|
$24.90
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
41658016
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$12.45 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.45
|
|
|
INFLUENZA VAC TISS-CULT SUBUNT 0.5 ML IM SUSY [127790]
|
Facility
|
OP
|
$36.22
|
|
|
Service Code
|
HCPCS 90674
|
| Hospital Charge Code |
70461065403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.94 |
| Max. Negotiated Rate |
$36.22 |
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$29.94
|
| Rate for Payer: Aetna Government |
$29.94
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$34.17
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$36.22
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$36.22
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$36.22
|
|
|
INFLUENZA VIRUS VACC (FOR OPA)
|
Facility
|
OP
|
$24.90
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
41646590
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$1,267.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.69
|
| Rate for Payer: Aetna Government |
$17.69
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$28.51
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$28.51
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$12.67
|
| Rate for Payer: Amida Care Medicaid |
$12.67
|
| Rate for Payer: Brighton Health Commercial |
$14.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$14.32
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,267.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.67
|
| Rate for Payer: Fidelis Essential Plan QHP |
$12.67
|
| Rate for Payer: Fidelis Qualified Health Plan |
$13.30
|
| Rate for Payer: Group Health Inc Commercial |
$12.45
|
| Rate for Payer: Group Health Inc Medicare |
$8.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.45
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$12.67
|
| Rate for Payer: Healthfirst Essential Plan |
$28.51
|
| Rate for Payer: Healthfirst QHP |
$12.67
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$12.67
|
| Rate for Payer: SOMOS Essential |
$12.67
|
| Rate for Payer: United Healthcare Commercial |
$12.88
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$28.51
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$13.94
|
| Rate for Payer: United Healthcare Medicaid |
$12.67
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$16.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$12.67
|
|
|
INFLUENZA VIRUS VACC (FOR OPA)
|
Facility
|
IP
|
$24.90
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
41646590
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$12.45 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.45
|
|
|
INFLUENZA VIRUS VACC (FOR OPA)
|
Facility
|
IP
|
$24.90
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
41656590
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$12.45 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.45
|
|
|
INFLUENZA VIRUS VACC (FOR OPA)
|
Facility
|
OP
|
$24.90
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
41656590
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$1,267.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.69
|
| Rate for Payer: Aetna Government |
$17.69
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$28.51
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$28.51
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$12.67
|
| Rate for Payer: Amida Care Medicaid |
$12.67
|
| Rate for Payer: Brighton Health Commercial |
$14.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$14.32
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,267.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.67
|
| Rate for Payer: Fidelis Essential Plan QHP |
$12.67
|
| Rate for Payer: Fidelis Qualified Health Plan |
$13.30
|
| Rate for Payer: Group Health Inc Commercial |
$12.45
|
| Rate for Payer: Group Health Inc Medicare |
$8.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.67
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.45
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$12.67
|
| Rate for Payer: Healthfirst Essential Plan |
$28.51
|
| Rate for Payer: Healthfirst QHP |
$12.67
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$12.67
|
| Rate for Payer: SOMOS Essential |
$12.67
|
| Rate for Payer: United Healthcare Commercial |
$12.88
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$28.51
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$13.94
|
| Rate for Payer: United Healthcare Medicaid |
$12.67
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$16.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$12.67
|
|
|
INFLUENZA VIRUS VACCINE
|
Facility
|
IP
|
$38.52
|
|
|
Service Code
|
HCPCS 90668
|
| Hospital Charge Code |
30103360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.26 |
| Max. Negotiated Rate |
$19.26 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.26
|
|
|
INFLUENZA VIRUS VACCINE
|
Facility
|
OP
|
$38.52
|
|
|
Service Code
|
HCPCS 90668
|
| Hospital Charge Code |
30103360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.48 |
| Max. Negotiated Rate |
$25.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$21.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.26
|
| Rate for Payer: Aetna Government |
$19.26
|
| Rate for Payer: Brighton Health Commercial |
$23.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$22.15
|
| Rate for Payer: Group Health Inc Commercial |
$19.26
|
| Rate for Payer: Group Health Inc Medicare |
$13.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$25.04
|
|
|
INFLUENZA VIRUS VACCINE (FLUARIX) INJ 0.
|
Facility
|
IP
|
$19.00
|
|
| Hospital Charge Code |
41645577
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.50
|
|
|
INFLUENZA VIRUS VACCINE (FLUARIX) INJ 0.
|
Facility
|
IP
|
$19.00
|
|
| Hospital Charge Code |
41655577
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.50
|
|
|
INFLUENZA VIRUS VACCINE (FLUARIX) INJ 0.
|
Facility
|
OP
|
$19.00
|
|
| Hospital Charge Code |
41655577
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.65 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.50
|
| Rate for Payer: Aetna Government |
$9.50
|
| Rate for Payer: Brighton Health Commercial |
$11.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.92
|
| Rate for Payer: Group Health Inc Commercial |
$9.50
|
| Rate for Payer: Group Health Inc Medicare |
$6.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12.35
|
|
|
INFLUENZA VIRUS VACCINE (FLUARIX) INJ 0.
|
Facility
|
OP
|
$19.00
|
|
| Hospital Charge Code |
41645577
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.65 |
| Max. Negotiated Rate |
$12.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$9.50
|
| Rate for Payer: Aetna Government |
$9.50
|
| Rate for Payer: Brighton Health Commercial |
$11.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.92
|
| Rate for Payer: Group Health Inc Commercial |
$9.50
|
| Rate for Payer: Group Health Inc Medicare |
$6.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12.35
|
|
|
INFLUENZA VIRUS VACCINE (FLUZONE) INJ 5
|
Facility
|
OP
|
$7.35
|
|
| Hospital Charge Code |
41645562
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.68
|
| Rate for Payer: Aetna Government |
$3.68
|
| Rate for Payer: Brighton Health Commercial |
$4.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.23
|
| Rate for Payer: Group Health Inc Commercial |
$3.68
|
| Rate for Payer: Group Health Inc Medicare |
$2.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.78
|
|
|
INFLUENZA VIRUS VACCINE (FLUZONE) INJ 5
|
Facility
|
IP
|
$7.35
|
|
| Hospital Charge Code |
41655562
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.68 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.68
|
|
|
INFLUENZA VIRUS VACCINE (FLUZONE) INJ 5
|
Facility
|
IP
|
$7.35
|
|
| Hospital Charge Code |
41645562
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.68 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.68
|
|
|
INFLUENZA VIRUS VACCINE (FLUZONE) INJ 5
|
Facility
|
OP
|
$7.35
|
|
| Hospital Charge Code |
41655562
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.68
|
| Rate for Payer: Aetna Government |
$3.68
|
| Rate for Payer: Brighton Health Commercial |
$4.41
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.23
|
| Rate for Payer: Group Health Inc Commercial |
$3.68
|
| Rate for Payer: Group Health Inc Medicare |
$2.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.78
|
|
|
INFORMASEQ(SM)WITH XY ANALYSIS
|
Facility
|
OP
|
$1,897.63
|
|
|
Service Code
|
HCPCS 81420
|
| Hospital Charge Code |
40729234
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$531.34 |
| Max. Negotiated Rate |
$1,518.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,043.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$759.05
|
| Rate for Payer: Aetna Government |
$759.05
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$531.34
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$531.34
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$531.34
|
| Rate for Payer: Brighton Health Commercial |
$759.05
|
| Rate for Payer: Cash Price |
$759.05
|
| Rate for Payer: Cash Price |
$759.05
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$759.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,518.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,290.39
|
| Rate for Payer: Elderplan Medicare Advantage |
$759.05
|
| Rate for Payer: EmblemHealth Commercial |
$759.05
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$645.19
|
| Rate for Payer: Fidelis Essential Plan QHP |
$675.55
|
| Rate for Payer: Fidelis Medicare Advantage |
$759.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$675.55
|
| Rate for Payer: Group Health Inc Commercial |
$759.05
|
| Rate for Payer: Group Health Inc Medicare |
$759.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$948.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$759.05
|
| Rate for Payer: Healthfirst Medicare Advantage |
$759.05
|
| Rate for Payer: Healthfirst QHP |
$759.05
|
| Rate for Payer: Humana Medicare |
$774.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$759.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$759.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$759.05
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$607.24
|
| Rate for Payer: Wellcare Medicare |
$683.14
|
|
|
INFORMASEQ(SM)WITH XY ANALYSIS
|
Facility
|
IP
|
$1,897.63
|
|
|
Service Code
|
HCPCS 81420
|
| Hospital Charge Code |
40729234
|
|
Hospital Revenue Code
|
310
|
| Rate for Payer: Cash Price |
$759.05
|
|
|
INFUSE BONE GRAFT
|
Facility
|
OP
|
$10,816.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40205944
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$11,356.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,948.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$6,489.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5,408.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6,219.20
|
| Rate for Payer: EmblemHealth Commercial |
$5,408.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$11,356.80
|
| Rate for Payer: Group Health Inc Commercial |
$5,408.00
|
| Rate for Payer: Group Health Inc Medicare |
$3,785.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5,408.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5,408.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7,030.40
|
|
|
INFUSE BONE GRAFT
|
Facility
|
IP
|
$10,816.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40205944
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,408.00 |
| Max. Negotiated Rate |
$5,408.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5,408.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5,408.00
|
|
