|
INTRANASAL BIOPSY
|
Facility
|
OP
|
$4,086.83
|
|
|
Service Code
|
HCPCS 30100
|
| Hospital Charge Code |
30304090
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$780.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,763.60
|
| Rate for Payer: Aetna Government |
$1,763.60
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,234.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,234.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,234.52
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,763.60
|
| 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 |
$1,763.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,499.06
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,569.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,763.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,569.60
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,043.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,763.60
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,499.06
|
| Rate for Payer: Healthfirst QHP |
$1,763.60
|
| Rate for Payer: Humana Medicare |
$1,798.87
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,763.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,763.60
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,763.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,763.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,410.88
|
| Rate for Payer: Wellcare Medicare |
$1,675.42
|
|
|
INTRAOCULAR PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$44,984.83
|
|
|
Service Code
|
MSDRG 116
|
| Min. Negotiated Rate |
$15,213.05 |
| Max. Negotiated Rate |
$44,984.83 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26,995.15
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$32,716.24
|
| Rate for Payer: Aetna Government |
$32,716.24
|
| Rate for Payer: Brighton Health Commercial |
$26,546.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$33,370.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$31,616.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$26,090.95
|
| Rate for Payer: Elderplan Medicare Advantage |
$31,080.43
|
| Rate for Payer: EmblemHealth Commercial |
$15,699.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$32,716.24
|
| Rate for Payer: Group Health Inc Commercial |
$32,716.24
|
| Rate for Payer: Group Health Inc Medicare |
$32,716.24
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$32,716.24
|
| Rate for Payer: Healthfirst Medicare Advantage |
$15,213.05
|
| Rate for Payer: Humana Medicare |
$44,984.83
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$32,716.24
|
| Rate for Payer: United Healthcare Commercial |
$36,409.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32,716.24
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$32,716.24
|
| Rate for Payer: Wellcare Medicare |
$31,080.43
|
|
|
INTRAOCULAR PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$32,926.46
|
|
|
Service Code
|
MSDRG 117
|
| Min. Negotiated Rate |
$10,276.30 |
| Max. Negotiated Rate |
$32,926.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$17,670.41
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$23,946.52
|
| Rate for Payer: Aetna Government |
$23,946.52
|
| Rate for Payer: Brighton Health Commercial |
$17,376.80
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$24,425.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$20,695.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17,078.54
|
| Rate for Payer: Elderplan Medicare Advantage |
$22,749.19
|
| Rate for Payer: EmblemHealth Commercial |
$10,276.30
|
| Rate for Payer: Fidelis Medicare Advantage |
$23,946.52
|
| Rate for Payer: Group Health Inc Commercial |
$23,946.52
|
| Rate for Payer: Group Health Inc Medicare |
$23,946.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$23,946.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$11,135.13
|
| Rate for Payer: Humana Medicare |
$32,926.46
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$23,946.52
|
| Rate for Payer: United Healthcare Commercial |
$23,832.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23,946.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$23,946.52
|
| Rate for Payer: Wellcare Medicare |
$22,749.19
|
|
|
INTRAOPERATIVE NEUROMONITORING
|
Facility
|
OP
|
$2,500.00
|
|
| Hospital Charge Code |
64905770
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$2,000.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,375.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,250.00
|
| Rate for Payer: Aetna Government |
$1,250.00
|
| Rate for Payer: Brighton Health Commercial |
$1,875.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,000.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,700.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,250.00
|
| Rate for Payer: Group Health Inc Medicare |
$875.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,250.00
|
|
|
INTRAORAL-COMPLETE SERIES INCLUDI
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
HCPCS D0210
|
| Hospital Charge Code |
42300105
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$62.50 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$68.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$283.37
|
| Rate for Payer: Aetna Government |
$283.37
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$198.36
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$198.36
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$198.36
|
| Rate for Payer: Brighton Health Commercial |
$93.75
|
| Rate for Payer: Cash Price |
$283.37
|
| Rate for Payer: Cash Price |
$283.37
|
| Rate for Payer: Cash Price |
$283.37
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$283.37
|
| 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 |
$283.37
|
| Rate for Payer: EmblemHealth Commercial |
$283.37
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$240.86
|
| Rate for Payer: Fidelis Essential Plan QHP |
$252.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$283.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$252.20
|
| Rate for Payer: Group Health Inc Commercial |
$283.37
|
| Rate for Payer: Group Health Inc Medicare |
$283.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$62.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$283.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$240.86
|
| Rate for Payer: Healthfirst QHP |
$283.37
|
| Rate for Payer: Humana Medicare |
$289.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$283.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$283.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$283.37
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$226.70
|
| Rate for Payer: Wellcare Medicare |
$269.20
|
|
|
INTRAORAL-COMPLETE SERIES INCLUDI
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
HCPCS D0210
|
| Hospital Charge Code |
42300105
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$283.37
|
|
|
INTRA-ORAL INC & DRAIN ABSES CYST
|
Facility
|
IP
|
$4,086.83
|
|
|
Service Code
|
HCPCS 41006
|
| Hospital Charge Code |
30106647
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$1,763.60
|
|
|
INTRA-ORAL INC & DRAIN ABSES CYST
|
Facility
|
OP
|
$4,086.83
|
|
|
Service Code
|
HCPCS 41006
|
| Hospital Charge Code |
30106647
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,763.60
|
| Rate for Payer: Aetna Government |
$1,763.60
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,234.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,234.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,234.52
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$1,763.60
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Cash Price |
$1,763.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,763.60
|
| 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 |
$1,763.60
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,499.06
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,569.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,763.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,569.60
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,043.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,763.60
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$1,763.60
|
| Rate for Payer: Humana Medicare |
$1,798.87
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,763.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,763.60
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,763.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,763.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,410.88
|
| Rate for Payer: Wellcare Medicare |
$1,675.42
|
|
|
INTRAORAL-OCCLUSAL FILM
|
Facility
|
IP
|
$37.50
|
|
|
Service Code
|
HCPCS D0240
|
| Hospital Charge Code |
42300125
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$105.08
|
|
|
INTRAORAL-OCCLUSAL FILM
|
Facility
|
OP
|
$37.50
|
|
|
Service Code
|
HCPCS D0240
|
| Hospital Charge Code |
42300125
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$18.75 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$105.08
|
| Rate for Payer: Aetna Government |
$105.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$73.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$73.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$73.56
|
| Rate for Payer: Brighton Health Commercial |
$28.12
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$105.08
|
| 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 |
$105.08
|
| Rate for Payer: EmblemHealth Commercial |
$105.08
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$89.32
|
| Rate for Payer: Fidelis Essential Plan QHP |
$93.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$105.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$93.52
|
| Rate for Payer: Group Health Inc Commercial |
$105.08
|
| Rate for Payer: Group Health Inc Medicare |
$105.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$105.08
|
| Rate for Payer: Healthfirst Medicare Advantage |
$89.32
|
| Rate for Payer: Healthfirst QHP |
$105.08
|
| Rate for Payer: Humana Medicare |
$107.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$105.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$105.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$105.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$84.06
|
| Rate for Payer: Wellcare Medicare |
$99.83
|
|
|
INTRAORAL-PERIAPICAL-EACH ADDITIO
|
Facility
|
OP
|
$12.50
|
|
|
Service Code
|
HCPCS D0230
|
| Hospital Charge Code |
42300120
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.34
|
| Rate for Payer: Aetna Government |
$6.34
|
| Rate for Payer: Brighton Health Commercial |
$9.38
|
| 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 |
$6.25
|
| Rate for Payer: Group Health Inc Medicare |
$4.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.25
|
|
|
INTRAORAL-PERIAPICAL-FIRST FILM
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS D0220
|
| Hospital Charge Code |
42300115
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$105.08
|
| Rate for Payer: Aetna Government |
$105.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$73.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$73.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$73.56
|
| Rate for Payer: Brighton Health Commercial |
$15.00
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$105.08
|
| 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 |
$105.08
|
| Rate for Payer: EmblemHealth Commercial |
$105.08
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$89.32
|
| Rate for Payer: Fidelis Essential Plan QHP |
$93.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$105.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$93.52
|
| Rate for Payer: Group Health Inc Commercial |
$105.08
|
| Rate for Payer: Group Health Inc Medicare |
$105.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$105.08
|
| Rate for Payer: Healthfirst Medicare Advantage |
$89.32
|
| Rate for Payer: Healthfirst QHP |
$105.08
|
| Rate for Payer: Humana Medicare |
$107.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$105.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$105.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$105.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$84.06
|
| Rate for Payer: Wellcare Medicare |
$99.83
|
|
|
INTRAORAL-PERIAPICAL-FIRST FILM
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS D0220
|
| Hospital Charge Code |
42300115
|
|
Hospital Revenue Code
|
361
|
| Rate for Payer: Cash Price |
$105.08
|
|
|
INTRAORAL PLACE OF FIX DEV
|
Facility
|
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS D7998
|
| Hospital Charge Code |
42303430
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$367.24 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,100.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$367.24
|
| Rate for Payer: Aetna Government |
$367.24
|
| Rate for Payer: Brighton Health Commercial |
$1,500.00
|
| 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 |
$1,000.00
|
| Rate for Payer: Group Health Inc Medicare |
$700.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,000.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,000.00
|
|
|
Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; initial vessel (List separately in addition to code for primary procedure)
|
Facility
|
OP
|
$6,937.00
|
|
|
Service Code
|
CPT 93571
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$255.78 |
| Max. Negotiated Rate |
$6,937.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$255.78
|
| Rate for Payer: Aetna Government |
$255.78
|
| Rate for Payer: Brighton Health Commercial |
$6,937.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,959.74
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4,215.78
|
| Rate for Payer: United Healthcare Commercial |
$1,113.00
|
|
|
INTRAVENOUS INFUSION THER ADD/HR
|
Facility
|
OP
|
$40.00
|
|
| Hospital Charge Code |
40509864
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$644.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$22.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.00
|
| Rate for Payer: Aetna Government |
$20.00
|
| Rate for Payer: Brighton Health Commercial |
$30.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$644.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$547.94
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$20.00
|
| Rate for Payer: Group Health Inc Medicare |
$14.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.00
|
| Rate for Payer: United Healthcare Commercial |
$316.00
|
|
|
INTRAVENOUS INFUSION THERAPEUTIC
|
Facility
|
OP
|
$556.50
|
|
|
Service Code
|
HCPCS 96360
|
| Hospital Charge Code |
30103250
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$874.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$694.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$247.87
|
| Rate for Payer: Aetna Government |
$247.87
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$173.51
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$173.51
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$173.51
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$247.87
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$247.87
|
| Rate for Payer: Cash Price |
$247.87
|
| Rate for Payer: Cash Price |
$247.87
|
| Rate for Payer: Cash Price |
$247.87
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$247.87
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$747.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$635.21
|
| Rate for Payer: Elderplan Medicare Advantage |
$247.87
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$210.69
|
| Rate for Payer: Fidelis Essential Plan QHP |
$220.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$247.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$220.60
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$278.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$247.87
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$247.87
|
| Rate for Payer: Humana Medicare |
$252.83
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$247.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$247.87
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$247.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$247.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$198.30
|
| Rate for Payer: Wellcare Medicare |
$235.48
|
|
|
INTRAVENOUS INFUSION THERAPEUTIC
|
Facility
|
IP
|
$556.50
|
|
|
Service Code
|
HCPCS 96360
|
| Hospital Charge Code |
30103250
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$247.87
|
|
|
INT. REPAIR OF WOUND 2.6 - 5.0 CM
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 12052
|
| Hospital Charge Code |
30100180
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$461.12
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$461.12
|
| 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 |
$461.12
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$461.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
INT. REPAIR OF WOUND 2.6 - 5.0 CM
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 12052
|
| Hospital Charge Code |
30100180
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
INT REPAIR OF WOUND 2.6-5.0CM
|
Facility
|
IP
|
$967.73
|
|
|
Service Code
|
HCPCS 12052
|
| Hospital Charge Code |
30306415
|
|
Hospital Revenue Code
|
510
|
| Rate for Payer: Cash Price |
$461.12
|
|
|
INT REPAIR OF WOUND 2.6-5.0CM
|
Facility
|
OP
|
$967.73
|
|
|
Service Code
|
HCPCS 12052
|
| Hospital Charge Code |
30306415
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$222.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$461.12
|
| Rate for Payer: Aetna Government |
$461.12
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$322.78
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$322.78
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$322.78
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Cash Price |
$461.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$461.12
|
| 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 |
$461.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$391.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$461.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.40
|
| Rate for Payer: Group Health Inc Commercial |
$250.00
|
| Rate for Payer: Group Health Inc Medicare |
$250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$483.86
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$461.12
|
| Rate for Payer: Healthfirst Medicare Advantage |
$391.95
|
| Rate for Payer: Healthfirst QHP |
$461.12
|
| Rate for Payer: Humana Medicare |
$470.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$461.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$461.12
|
| Rate for Payer: United Healthcare Commercial |
$222.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$461.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$461.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$368.90
|
| Rate for Payer: Wellcare Medicare |
$438.06
|
|
|
INTRINSIC FACTOR ABS, SERUM
|
Facility
|
IP
|
$37.70
|
|
|
Service Code
|
HCPCS 86340
|
| Hospital Charge Code |
40609147
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$15.08
|
|
|
INTRINSIC FACTOR ABS, SERUM
|
Facility
|
OP
|
$37.70
|
|
|
Service Code
|
HCPCS 86340
|
| Hospital Charge Code |
40609147
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$28.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$15.08
|
| Rate for Payer: Aetna Government |
$15.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$10.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$10.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$10.56
|
| Rate for Payer: Brighton Health Commercial |
$28.28
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$15.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$23.97
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$20.28
|
| Rate for Payer: Elderplan Medicare Advantage |
$15.08
|
| Rate for Payer: EmblemHealth Commercial |
$15.08
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$13.42
|
| Rate for Payer: Fidelis Medicare Advantage |
$15.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$13.42
|
| Rate for Payer: Group Health Inc Commercial |
$15.08
|
| Rate for Payer: Group Health Inc Medicare |
$15.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.08
|
| Rate for Payer: Healthfirst Medicare Advantage |
$15.08
|
| Rate for Payer: Healthfirst QHP |
$15.08
|
| Rate for Payer: Humana Medicare |
$15.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$15.08
|
| Rate for Payer: United Healthcare Commercial |
$19.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$12.06
|
| Rate for Payer: Wellcare Medicare |
$13.57
|
|
|
INTRLOK 75MM FXD CRUCIATE TIB PLT
|
Facility
|
OP
|
$3,178.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40200875
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$3,336.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,747.90
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$1,906.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,589.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,827.35
|
| Rate for Payer: EmblemHealth Commercial |
$1,589.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,336.90
|
| Rate for Payer: Group Health Inc Commercial |
$1,589.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,112.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,589.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,589.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,065.70
|
|
