|
INLAY-COMPOSITE/RESIN-THREE SURF.
|
Facility
|
IP
|
$1,240.31
|
|
|
Service Code
|
HCPCS D2652
|
| Hospital Charge Code |
42300510
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
INLAY-COMPOSITE/RESIN-TWO SURF. (
|
Facility
|
IP
|
$1,240.31
|
|
|
Service Code
|
HCPCS D2651
|
| Hospital Charge Code |
42300505
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
INLAY-COMPOSITE/RESIN-TWO SURF. (
|
Facility
|
OP
|
$1,240.31
|
|
|
Service Code
|
HCPCS D2651
|
| Hospital Charge Code |
42300505
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$620.16 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$682.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$930.23
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$620.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
INLAY-METALLIC-ONE SURFACE
|
Facility
|
OP
|
$1,240.31
|
|
|
Service Code
|
HCPCS D2510
|
| Hospital Charge Code |
42300460
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$620.16 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$682.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$930.23
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$620.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
INLAY-METALLIC-ONE SURFACE
|
Facility
|
IP
|
$1,240.31
|
|
|
Service Code
|
HCPCS D2510
|
| Hospital Charge Code |
42300460
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
INLAY-METALLIC-THREE SURFACES
|
Facility
|
OP
|
$1,240.31
|
|
|
Service Code
|
HCPCS D2530
|
| Hospital Charge Code |
42300470
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$620.16 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$682.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$930.23
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$620.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
INLAY-METALLIC-THREE SURFACES
|
Facility
|
IP
|
$1,240.31
|
|
|
Service Code
|
HCPCS D2530
|
| Hospital Charge Code |
42300470
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
INLAY-METALLIC-TWO SURFACES
|
Facility
|
OP
|
$1,240.31
|
|
|
Service Code
|
HCPCS D2520
|
| Hospital Charge Code |
42300465
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$620.16 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$682.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$930.23
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$620.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
INLAY-METALLIC-TWO SURFACES
|
Facility
|
IP
|
$1,240.31
|
|
|
Service Code
|
HCPCS D2520
|
| Hospital Charge Code |
42300465
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
INLAY PORCELAIN/CERAMIC, 2 SURF
|
Facility
|
OP
|
$1,240.00
|
|
|
Service Code
|
HCPCS D6600
|
| Hospital Charge Code |
42303444
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$240.63 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$682.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$240.63
|
| Rate for Payer: Aetna Government |
$240.63
|
| Rate for Payer: Brighton Health Commercial |
$930.00
|
| 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: Group Health Inc Commercial |
$620.00
|
| Rate for Payer: Group Health Inc Medicare |
$434.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$620.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$620.00
|
|
|
INLAY-PORCELAIN/CERAMIC-ONE SURFA
|
Facility
|
IP
|
$1,270.08
|
|
|
Service Code
|
HCPCS D2610
|
| Hospital Charge Code |
42300480
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
INLAY-PORCELAIN/CERAMIC-ONE SURFA
|
Facility
|
OP
|
$1,270.08
|
|
|
Service Code
|
HCPCS D2610
|
| Hospital Charge Code |
42300480
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$635.04 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$698.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$952.56
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$635.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
INLAY-PORCELAIN/CERAMIC-THREE SUR
|
Facility
|
IP
|
$1,240.31
|
|
|
Service Code
|
HCPCS D2630
|
| Hospital Charge Code |
42300490
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
INLAY-PORCELAIN/CERAMIC-THREE SUR
|
Facility
|
OP
|
$1,240.31
|
|
|
Service Code
|
HCPCS D2630
|
| Hospital Charge Code |
42300490
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$620.16 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$682.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$930.23
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$620.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
INLAY-PORCELAIN/CERAMIC-TWO SURFA
|
Facility
|
IP
|
$1,240.31
|
|
|
Service Code
|
HCPCS D2620
|
| Hospital Charge Code |
42300485
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$1,018.19
|
|
|
INLAY-PORCELAIN/CERAMIC-TWO SURFA
|
Facility
|
OP
|
$1,240.31
|
|
|
Service Code
|
HCPCS D2620
|
| Hospital Charge Code |
42300485
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$620.16 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$682.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,018.19
|
| Rate for Payer: Aetna Government |
$1,018.19
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$712.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$712.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$712.73
|
| Rate for Payer: Brighton Health Commercial |
$930.23
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Cash Price |
$1,018.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,018.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,018.19
|
| Rate for Payer: EmblemHealth Commercial |
$1,018.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$865.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$906.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,018.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$906.19
|
| Rate for Payer: Group Health Inc Commercial |
$1,018.19
|
| Rate for Payer: Group Health Inc Medicare |
$1,018.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$620.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,018.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$865.46
|
| Rate for Payer: Healthfirst QHP |
$1,018.19
|
| Rate for Payer: Humana Medicare |
$1,038.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,018.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,018.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,018.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$814.55
|
| Rate for Payer: Wellcare Medicare |
$967.28
|
|
|
INLAY UPPERFACE FXTN MODULE
|
Facility
|
OP
|
$484.00
|
|
| Hospital Charge Code |
40200520
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$169.40 |
| Max. Negotiated Rate |
$387.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$266.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$242.00
|
| Rate for Payer: Aetna Government |
$242.00
|
| Rate for Payer: Brighton Health Commercial |
$363.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$387.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$329.12
|
| Rate for Payer: Group Health Inc Commercial |
$242.00
|
| Rate for Payer: Group Health Inc Medicare |
$169.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$242.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$242.00
|
|
|
IN-LINE-FILTER W PRESS. PUMP
|
Facility
|
OP
|
$5.31
|
|
| Hospital Charge Code |
40509816
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.92
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.66
|
| Rate for Payer: Aetna Government |
$2.66
|
| Rate for Payer: Brighton Health Commercial |
$3.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.61
|
| Rate for Payer: Group Health Inc Commercial |
$2.66
|
| Rate for Payer: Group Health Inc Medicare |
$1.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.66
|
| Rate for Payer: United Healthcare Commercial |
$76.00
|
|
|
INNER SCREW
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40200946
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$472.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$247.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$270.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$225.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$258.75
|
| Rate for Payer: EmblemHealth Commercial |
$225.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$472.50
|
| Rate for Payer: Group Health Inc Commercial |
$225.00
|
| Rate for Payer: Group Health Inc Medicare |
$157.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$225.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$225.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$292.50
|
|
|
INNER SCREW
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40200946
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$225.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$225.00
|
|
|
INOGEN EL ICD MODEL- D140
|
Facility
|
OP
|
$39,500.00
|
|
|
Service Code
|
HCPCS C1722
|
| Hospital Charge Code |
66572897
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$3,988.80 |
| Max. Negotiated Rate |
$41,475.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$21,725.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,988.80
|
| Rate for Payer: Aetna Government |
$3,988.80
|
| Rate for Payer: Brighton Health Commercial |
$23,700.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19,750.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$22,712.50
|
| Rate for Payer: EmblemHealth Commercial |
$19,750.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$41,475.00
|
| Rate for Payer: Group Health Inc Commercial |
$19,750.00
|
| Rate for Payer: Group Health Inc Medicare |
$13,825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19,750.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19,750.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$25,675.00
|
|
|
INSERET TIB FINNED 75MM COBLT CHR
|
Facility
|
OP
|
$4,337.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64901621
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$4,554.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,385.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$2,602.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,168.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,494.06
|
| Rate for Payer: EmblemHealth Commercial |
$2,168.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,554.38
|
| Rate for Payer: Group Health Inc Commercial |
$2,168.75
|
| Rate for Payer: Group Health Inc Medicare |
$1,518.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,168.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,168.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,819.38
|
|
|
INSERET TIB FINNED 75MM COBLT CHR
|
Facility
|
IP
|
$4,337.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64901621
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,168.75 |
| Max. Negotiated Rate |
$2,168.75 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,168.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,168.75
|
|
|
INSERT 0D 36MM TRIDENT POLY
|
Facility
|
OP
|
$6,086.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64902224
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$6,390.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3,347.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$3,651.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,043.12
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,499.59
|
| Rate for Payer: EmblemHealth Commercial |
$3,043.12
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,390.56
|
| Rate for Payer: Group Health Inc Commercial |
$3,043.12
|
| Rate for Payer: Group Health Inc Medicare |
$2,130.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,043.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,043.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,956.06
|
|
|
INSERT 0D 36MM TRIDENT POLY
|
Facility
|
IP
|
$6,086.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64902224
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,043.12 |
| Max. Negotiated Rate |
$3,043.12 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,043.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,043.12
|
|
