|
PR ECMO/ECLS INSJ OF PRPH CANNULA 6 YRS&OLDER PERQ
|
Professional
|
Both
|
$1,875.69
|
|
|
Service Code
|
HCPCS 33952
|
| Min. Negotiated Rate |
$343.97 |
| Max. Negotiated Rate |
$1,105.63 |
| Rate for Payer: Cash Price |
$497.97
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$491.39
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$442.25
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$442.25
|
| Rate for Payer: Fidelis Essential Plan QHP |
$466.82
|
| Rate for Payer: Fidelis Medicare Advantage |
$491.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$466.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$491.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$491.39
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$368.54
|
| Rate for Payer: Healthfirst Commercial |
$491.39
|
| Rate for Payer: Healthfirst Essential Plan |
$1,105.63
|
| Rate for Payer: Healthfirst Medicare Advantage |
$466.82
|
| Rate for Payer: Healthfirst QHP |
$491.39
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$343.97
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$491.39
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$417.68
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$343.97
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$491.39
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$368.54
|
| Rate for Payer: SOMOS Essential |
$368.54
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$491.39
|
|
|
PR ECMO/ECLS INSJ OF PRPH CANNULA BIRTH-5 YRS OPEN
|
Professional
|
Both
|
$2,077.11
|
|
|
Service Code
|
HCPCS 33953
|
| Min. Negotiated Rate |
$381.46 |
| Max. Negotiated Rate |
$1,226.14 |
| Rate for Payer: Cash Price |
$548.90
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$544.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$490.45
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$490.45
|
| Rate for Payer: Fidelis Essential Plan QHP |
$517.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$544.95
|
| Rate for Payer: Fidelis Qualified Health Plan |
$517.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$544.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$544.95
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$408.71
|
| Rate for Payer: Healthfirst Commercial |
$544.95
|
| Rate for Payer: Healthfirst Essential Plan |
$1,226.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$517.70
|
| Rate for Payer: Healthfirst QHP |
$544.95
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$381.46
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$544.95
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$463.21
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$381.46
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$544.95
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$408.71
|
| Rate for Payer: SOMOS Essential |
$408.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$544.95
|
|
|
PR ECMO/ECLS INSJ OF PRPH CANNULA BIRTH-5 YRS PERQ
|
Professional
|
Both
|
$1,864.77
|
|
|
Service Code
|
HCPCS 33951
|
| Min. Negotiated Rate |
$342.17 |
| Max. Negotiated Rate |
$1,099.82 |
| Rate for Payer: Cash Price |
$491.21
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$488.81
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$439.93
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$439.93
|
| Rate for Payer: Fidelis Essential Plan QHP |
$464.37
|
| Rate for Payer: Fidelis Medicare Advantage |
$488.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$464.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$488.81
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$488.81
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$366.61
|
| Rate for Payer: Healthfirst Commercial |
$488.81
|
| Rate for Payer: Healthfirst Essential Plan |
$1,099.82
|
| Rate for Payer: Healthfirst Medicare Advantage |
$464.37
|
| Rate for Payer: Healthfirst QHP |
$488.81
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$342.17
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$488.81
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$415.49
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$342.17
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$488.81
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$366.61
|
| Rate for Payer: SOMOS Essential |
$366.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$488.81
|
|
|
PR ECMO/ECLS REMOVAL OF CENTRAL CANNULA BIRTH-5 YRS
|
Professional
|
Both
|
$2,258.41
|
|
|
Service Code
|
HCPCS 33985
|
| Min. Negotiated Rate |
$412.74 |
| Max. Negotiated Rate |
$1,326.67 |
| Rate for Payer: Cash Price |
$595.61
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$589.63
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$530.67
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$530.67
|
| Rate for Payer: Fidelis Essential Plan QHP |
$560.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$589.63
|
| Rate for Payer: Fidelis Qualified Health Plan |
$560.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$589.63
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$589.63
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$442.22
|
| Rate for Payer: Healthfirst Commercial |
$589.63
|
| Rate for Payer: Healthfirst Essential Plan |
$1,326.67
|
| Rate for Payer: Healthfirst Medicare Advantage |
$560.15
|
| Rate for Payer: Healthfirst QHP |
$589.63
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$412.74
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$589.63
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$501.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$412.74
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$589.63
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$442.22
|
| Rate for Payer: SOMOS Essential |
$442.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$589.63
|
|
|
PR ECMO/ECLS REPOS CENTRAL PERPH CANNULA BIRTH-5YRS
|
Professional
|
Both
|
$2,050.83
|
|
|
Service Code
|
HCPCS 33963
|
| Min. Negotiated Rate |
$376.26 |
| Max. Negotiated Rate |
$1,209.42 |
| Rate for Payer: Cash Price |
$542.63
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$537.52
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$483.77
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$483.77
|
| Rate for Payer: Fidelis Essential Plan QHP |
$510.64
|
| Rate for Payer: Fidelis Medicare Advantage |
$537.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$510.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$537.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$537.52
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$403.14
|
| Rate for Payer: Healthfirst Commercial |
$537.52
|
| Rate for Payer: Healthfirst Essential Plan |
$1,209.42
|
| Rate for Payer: Healthfirst Medicare Advantage |
$510.64
|
| Rate for Payer: Healthfirst QHP |
$537.52
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$376.26
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$537.52
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$456.89
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$376.26
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$537.52
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$403.14
|
| Rate for Payer: SOMOS Essential |
$403.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$537.52
|
|
|
PR ECMO/ECLS REPOS PERIPH CANNULA PERQ BIRTH-5 YRS
|
Professional
|
Both
|
$809.59
|
|
|
Service Code
|
HCPCS 33957
|
| Min. Negotiated Rate |
$149.04 |
| Max. Negotiated Rate |
$479.05 |
| Rate for Payer: Cash Price |
$213.72
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$212.91
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$191.62
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$191.62
|
| Rate for Payer: Fidelis Essential Plan QHP |
$202.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$212.91
|
| Rate for Payer: Fidelis Qualified Health Plan |
$202.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$212.91
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$212.91
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$159.68
|
| Rate for Payer: Healthfirst Commercial |
$212.91
|
| Rate for Payer: Healthfirst Essential Plan |
$479.05
|
| Rate for Payer: Healthfirst Medicare Advantage |
$202.26
|
| Rate for Payer: Healthfirst QHP |
$212.91
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$149.04
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$212.91
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$180.97
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$149.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$212.91
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$159.68
|
| Rate for Payer: SOMOS Essential |
$159.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$212.91
|
|
|
PR ECMO/ECLS REPOS PERPH CANNULA OPEN 6 YRS & OLDER
|
Professional
|
Both
|
$1,024.66
|
|
|
Service Code
|
HCPCS 33962
|
| Min. Negotiated Rate |
$189.04 |
| Max. Negotiated Rate |
$607.63 |
| Rate for Payer: Cash Price |
$273.06
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$270.06
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$243.05
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$243.05
|
| Rate for Payer: Fidelis Essential Plan QHP |
$256.56
|
| Rate for Payer: Fidelis Medicare Advantage |
$270.06
|
| Rate for Payer: Fidelis Qualified Health Plan |
$256.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$270.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$270.06
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$202.54
|
| Rate for Payer: Healthfirst Commercial |
$270.06
|
| Rate for Payer: Healthfirst Essential Plan |
$607.63
|
| Rate for Payer: Healthfirst Medicare Advantage |
$256.56
|
| Rate for Payer: Healthfirst QHP |
$270.06
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$189.04
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$270.06
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$229.55
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$189.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$270.06
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$202.54
|
| Rate for Payer: SOMOS Essential |
$202.54
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$270.06
|
|
|
PR ECMO/ECLS REPOS PERPH CANNULA OPEN BIRTH-5 YRS
|
Professional
|
Both
|
$1,024.66
|
|
|
Service Code
|
HCPCS 33959
|
| Min. Negotiated Rate |
$189.04 |
| Max. Negotiated Rate |
$607.63 |
| Rate for Payer: Cash Price |
$273.06
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$270.06
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$243.05
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$243.05
|
| Rate for Payer: Fidelis Essential Plan QHP |
$256.56
|
| Rate for Payer: Fidelis Medicare Advantage |
$270.06
|
| Rate for Payer: Fidelis Qualified Health Plan |
$256.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$270.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$270.06
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$202.54
|
| Rate for Payer: Healthfirst Commercial |
$270.06
|
| Rate for Payer: Healthfirst Essential Plan |
$607.63
|
| Rate for Payer: Healthfirst Medicare Advantage |
$256.56
|
| Rate for Payer: Healthfirst QHP |
$270.06
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$189.04
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$270.06
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$229.55
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$189.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$270.06
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$202.54
|
| Rate for Payer: SOMOS Essential |
$202.54
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$270.06
|
|
|
PR ECMO/ECLS REPOS PERPH CANNULA PRQ 6 YRS & OLDER
|
Professional
|
Both
|
$809.59
|
|
|
Service Code
|
HCPCS 33958
|
| Min. Negotiated Rate |
$149.04 |
| Max. Negotiated Rate |
$479.05 |
| Rate for Payer: Cash Price |
$213.72
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$212.91
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$191.62
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$191.62
|
| Rate for Payer: Fidelis Essential Plan QHP |
$202.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$212.91
|
| Rate for Payer: Fidelis Qualified Health Plan |
$202.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$212.91
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$212.91
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$159.68
|
| Rate for Payer: Healthfirst Commercial |
$212.91
|
| Rate for Payer: Healthfirst Essential Plan |
$479.05
|
| Rate for Payer: Healthfirst Medicare Advantage |
$202.26
|
| Rate for Payer: Healthfirst QHP |
$212.91
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$149.04
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$212.91
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$180.97
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$149.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$212.91
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$159.68
|
| Rate for Payer: SOMOS Essential |
$159.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$212.91
|
|
|
PR ECMO/ECLS RMVL OF CENTRAL CANNULA 6 YRS & OLDER
|
Professional
|
Both
|
$2,314.20
|
|
|
Service Code
|
HCPCS 33986
|
| Min. Negotiated Rate |
$426.13 |
| Max. Negotiated Rate |
$1,369.71 |
| Rate for Payer: Cash Price |
$613.64
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$608.76
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$547.88
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$547.88
|
| Rate for Payer: Fidelis Essential Plan QHP |
$578.32
|
| Rate for Payer: Fidelis Medicare Advantage |
$608.76
|
| Rate for Payer: Fidelis Qualified Health Plan |
$578.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$608.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$608.76
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$456.57
|
| Rate for Payer: Healthfirst Commercial |
$608.76
|
| Rate for Payer: Healthfirst Essential Plan |
$1,369.71
|
| Rate for Payer: Healthfirst Medicare Advantage |
$578.32
|
| Rate for Payer: Healthfirst QHP |
$608.76
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$426.13
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$608.76
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$517.45
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$426.13
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$608.76
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$456.57
|
| Rate for Payer: SOMOS Essential |
$456.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$608.76
|
|
|
PR ECMO/ECLS RMVL OF PERPH CANNULA OPEN BIRTH-5 YRS
|
Professional
|
Both
|
$1,198.05
|
|
|
Service Code
|
HCPCS 33969
|
| Min. Negotiated Rate |
$218.78 |
| Max. Negotiated Rate |
$703.22 |
| Rate for Payer: Cash Price |
$316.69
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$312.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$281.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$281.29
|
| Rate for Payer: Fidelis Essential Plan QHP |
$296.91
|
| Rate for Payer: Fidelis Medicare Advantage |
$312.54
|
| Rate for Payer: Fidelis Qualified Health Plan |
$296.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$312.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$312.54
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$234.41
|
| Rate for Payer: Healthfirst Commercial |
$312.54
|
| Rate for Payer: Healthfirst Essential Plan |
$703.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$296.91
|
| Rate for Payer: Healthfirst QHP |
$312.54
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$218.78
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$312.54
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$265.66
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$218.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$312.54
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$234.41
|
| Rate for Payer: SOMOS Essential |
$234.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$312.54
|
|
|
PR ECMO/ECLS RMVL OF PERPH CANNULA PERQ BIRTH-5 YRS
|
Professional
|
Both
|
$809.59
|
|
|
Service Code
|
HCPCS 33965
|
| Min. Negotiated Rate |
$149.04 |
| Max. Negotiated Rate |
$479.05 |
| Rate for Payer: Cash Price |
$213.72
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$212.91
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$191.62
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$191.62
|
| Rate for Payer: Fidelis Essential Plan QHP |
$202.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$212.91
|
| Rate for Payer: Fidelis Qualified Health Plan |
$202.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$212.91
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$212.91
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$159.68
|
| Rate for Payer: Healthfirst Commercial |
$212.91
|
| Rate for Payer: Healthfirst Essential Plan |
$479.05
|
| Rate for Payer: Healthfirst Medicare Advantage |
$202.26
|
| Rate for Payer: Healthfirst QHP |
$212.91
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$149.04
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$212.91
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$180.97
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$149.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$212.91
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$159.68
|
| Rate for Payer: SOMOS Essential |
$159.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$212.91
|
|
|
PR ECMO/ECLS RMVL OF PRPH CANNULA PRQ 6 YRS & OLDER
|
Professional
|
Both
|
$1,033.17
|
|
|
Service Code
|
HCPCS 33966
|
| Min. Negotiated Rate |
$191.34 |
| Max. Negotiated Rate |
$615.04 |
| Rate for Payer: Cash Price |
$277.01
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$273.35
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$246.01
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$246.01
|
| Rate for Payer: Fidelis Essential Plan QHP |
$259.68
|
| Rate for Payer: Fidelis Medicare Advantage |
$273.35
|
| Rate for Payer: Fidelis Qualified Health Plan |
$259.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$273.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$273.35
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$205.01
|
| Rate for Payer: Healthfirst Commercial |
$273.35
|
| Rate for Payer: Healthfirst Essential Plan |
$615.04
|
| Rate for Payer: Healthfirst Medicare Advantage |
$259.68
|
| Rate for Payer: Healthfirst QHP |
$273.35
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$191.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$273.35
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$232.35
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$191.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$273.35
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$205.01
|
| Rate for Payer: SOMOS Essential |
$205.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$273.35
|
|
|
PR ECMO/ECLS RMVL PRPH CANNULA OPEN 6 YRS & OLDER
|
Professional
|
Both
|
$1,256.89
|
|
|
Service Code
|
HCPCS 33984
|
| Min. Negotiated Rate |
$230.57 |
| Max. Negotiated Rate |
$741.13 |
| Rate for Payer: Cash Price |
$332.49
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$329.39
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$296.45
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$296.45
|
| Rate for Payer: Fidelis Essential Plan QHP |
$312.92
|
| Rate for Payer: Fidelis Medicare Advantage |
$329.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$312.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$329.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$329.39
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$247.04
|
| Rate for Payer: Healthfirst Commercial |
$329.39
|
| Rate for Payer: Healthfirst Essential Plan |
$741.13
|
| Rate for Payer: Healthfirst Medicare Advantage |
$312.92
|
| Rate for Payer: Healthfirst QHP |
$329.39
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$230.57
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$329.39
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$279.98
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$230.57
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$329.39
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$247.04
|
| Rate for Payer: SOMOS Essential |
$247.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$329.39
|
|
|
PR ECOG IMPLANTED BRAIN NPGT W/REC I&R <30 DAYS
|
Professional
|
Both
|
$435.23
|
|
|
Service Code
|
HCPCS 95836
|
| Min. Negotiated Rate |
$82.11 |
| Max. Negotiated Rate |
$263.93 |
| Rate for Payer: Cash Price |
$117.96
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$117.30
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$105.57
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$105.57
|
| Rate for Payer: Fidelis Essential Plan QHP |
$111.44
|
| Rate for Payer: Fidelis Medicare Advantage |
$117.30
|
| Rate for Payer: Fidelis Qualified Health Plan |
$111.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$117.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$117.30
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$87.97
|
| Rate for Payer: Healthfirst Commercial |
$117.30
|
| Rate for Payer: Healthfirst Essential Plan |
$263.93
|
| Rate for Payer: Healthfirst Medicare Advantage |
$111.44
|
| Rate for Payer: Healthfirst QHP |
$117.30
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$82.11
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$117.30
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$99.70
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$82.11
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$117.30
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$87.97
|
| Rate for Payer: SOMOS Essential |
$87.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$117.30
|
|
|
PR ECP CILIARY BODY DSTRJ W/O RMVL CRYSTALLINE LENS
|
Professional
|
Both
|
$2,095.17
|
|
|
Service Code
|
HCPCS 66711
|
| Min. Negotiated Rate |
$399.37 |
| Max. Negotiated Rate |
$1,283.69 |
| Rate for Payer: Cash Price |
$578.49
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$570.53
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$513.48
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$513.48
|
| Rate for Payer: Fidelis Essential Plan QHP |
$542.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$570.53
|
| Rate for Payer: Fidelis Qualified Health Plan |
$542.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$570.53
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$570.53
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$427.90
|
| Rate for Payer: Healthfirst Commercial |
$570.53
|
| Rate for Payer: Healthfirst Essential Plan |
$1,283.69
|
| Rate for Payer: Healthfirst Medicare Advantage |
$542.00
|
| Rate for Payer: Healthfirst QHP |
$570.53
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$399.37
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$570.53
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$484.95
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$399.37
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$570.53
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$427.90
|
| Rate for Payer: SOMOS Essential |
$427.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$570.53
|
|
|
PR EDG US EXAM SURGICAL ALTER STOM DUODENUM/JEJUNUM
|
Professional
|
Both
|
$931.14
|
|
|
Service Code
|
HCPCS 43259
|
| Min. Negotiated Rate |
$177.16 |
| Max. Negotiated Rate |
$569.43 |
| Rate for Payer: Cash Price |
$254.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$253.08
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$227.77
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$227.77
|
| Rate for Payer: Fidelis Essential Plan QHP |
$240.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$253.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$240.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$253.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$253.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$189.81
|
| Rate for Payer: Healthfirst Commercial |
$253.08
|
| Rate for Payer: Healthfirst Essential Plan |
$569.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$240.43
|
| Rate for Payer: Healthfirst QHP |
$253.08
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$177.16
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$253.08
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$215.12
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$177.16
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$253.08
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$189.81
|
| Rate for Payer: SOMOS Essential |
$189.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$253.08
|
|
|
PREDNISOLONE ACETATE 1 % OP SUSP
|
Facility
|
IP
|
$38.50
|
|
|
Service Code
|
NDC 1198018005
|
| Hospital Charge Code |
1198018005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.25 |
| Max. Negotiated Rate |
$19.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.25
|
|
|
PREDNISOLONE ACETATE 1 % OP SUSP
|
Facility
|
IP
|
$10.64
|
|
|
Service Code
|
NDC 6131463715
|
| Hospital Charge Code |
6131463715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.32 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.32
|
|
|
PREDNISOLONE ACETATE 1 % OP SUSP
|
Facility
|
OP
|
$38.50
|
|
|
Service Code
|
NDC 1198018005
|
| Hospital Charge Code |
1198018005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.47 |
| Max. Negotiated Rate |
$30.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$21.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.25
|
| Rate for Payer: Aetna Government |
$19.25
|
| Rate for Payer: Brighton Health Commercial |
$28.87
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$30.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$26.18
|
| Rate for Payer: EmblemHealth Commercial |
$19.25
|
| Rate for Payer: Group Health Inc Commercial |
$19.25
|
| Rate for Payer: Group Health Inc Medicare |
$13.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$25.02
|
|
|
PREDNISOLONE ACETATE 1 % OP SUSP
|
Facility
|
OP
|
$10.64
|
|
|
Service Code
|
NDC 6131463715
|
| Hospital Charge Code |
6131463715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$8.51 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.32
|
| Rate for Payer: Aetna Government |
$5.32
|
| Rate for Payer: Brighton Health Commercial |
$7.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.51
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.24
|
| Rate for Payer: EmblemHealth Commercial |
$5.32
|
| Rate for Payer: Group Health Inc Commercial |
$5.32
|
| Rate for Payer: Group Health Inc Medicare |
$3.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6.92
|
|
|
PREDNISOLONE ACETATE 1 % OP SUSP
|
Facility
|
OP
|
$11.05
|
|
|
Service Code
|
NDC 6131463710
|
| Hospital Charge Code |
6131463710
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.87 |
| Max. Negotiated Rate |
$8.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.53
|
| Rate for Payer: Aetna Government |
$5.53
|
| Rate for Payer: Brighton Health Commercial |
$8.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.52
|
| Rate for Payer: EmblemHealth Commercial |
$5.53
|
| Rate for Payer: Group Health Inc Commercial |
$5.53
|
| Rate for Payer: Group Health Inc Medicare |
$3.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.53
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.53
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.19
|
|
|
PREDNISOLONE ACETATE 1 % OP SUSP
|
Facility
|
IP
|
$11.06
|
|
|
Service Code
|
NDC 6131463705
|
| Hospital Charge Code |
6131463705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$5.53 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.53
|
|
|
PREDNISOLONE ACETATE 1 % OP SUSP
|
Facility
|
IP
|
$11.05
|
|
|
Service Code
|
NDC 6131463710
|
| Hospital Charge Code |
6131463710
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$5.53 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.53
|
|
|
PREDNISOLONE ACETATE 1 % OP SUSP
|
Facility
|
OP
|
$11.06
|
|
|
Service Code
|
NDC 6131463705
|
| Hospital Charge Code |
6131463705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.87 |
| Max. Negotiated Rate |
$8.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.53
|
| Rate for Payer: Aetna Government |
$5.53
|
| Rate for Payer: Brighton Health Commercial |
$8.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8.85
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7.52
|
| Rate for Payer: EmblemHealth Commercial |
$5.53
|
| Rate for Payer: Group Health Inc Commercial |
$5.53
|
| Rate for Payer: Group Health Inc Medicare |
$3.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.53
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.53
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.19
|
|
