|
RX90 CENTRAL SLEEVE FEMOR13X1.5MM
|
Facility
IP
|
$640.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40209996
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$320.00 |
| Max. Negotiated Rate |
$320.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$320.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$320.00
|
|
|
RX CL ELBOW DISLOC W/O ANESTHESIA
|
Facility
OP
|
$653.13
|
|
|
Service Code
|
HCPCS 24600
|
| Hospital Charge Code |
30103304
|
|
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 |
$272.71
|
| Rate for Payer: Aetna Government |
$272.71
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$272.71
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Cash Price |
$272.71
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$272.71
|
| 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 |
$272.71
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$397.42
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$231.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$242.71
|
| Rate for Payer: Fidelis Medicare Advantage |
$272.71
|
| Rate for Payer: Fidelis Qualified Health Plan |
$242.71
|
| 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 |
$326.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$272.71
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$272.71
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$272.71
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$272.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$272.71
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$218.17
|
| Rate for Payer: Wellcare Medicare |
$259.07
|
|
|
RX CONTACT LENS APHKIA 2 EYE
|
Facility
OP
|
$166.60
|
|
|
Service Code
|
HCPCS 92316
|
| Hospital Charge Code |
30306403
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.47 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$91.63
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$147.72
|
| Rate for Payer: Aetna Government |
$147.72
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cash Price |
$147.72
|
| Rate for Payer: Cash Price |
$147.72
|
| Rate for Payer: Cash Price |
$147.72
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$147.72
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| Rate for Payer: Elderplan Medicare Advantage |
$147.72
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$31.47
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$125.56
|
| Rate for Payer: Fidelis Essential Plan QHP |
$131.47
|
| Rate for Payer: Fidelis Medicare Advantage |
$147.72
|
| Rate for Payer: Fidelis Qualified Health Plan |
$131.47
|
| 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 |
$83.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$147.72
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$34.97
|
| Rate for Payer: Healthfirst Medicare Advantage |
$125.56
|
| Rate for Payer: Healthfirst QHP |
$147.72
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$147.72
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$147.72
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$147.72
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$118.18
|
| Rate for Payer: Wellcare Medicare |
$140.33
|
|
|
RX STANDARD ERCP CANNULA
|
Facility
OP
|
$154.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40209676
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$53.90 |
| Max. Negotiated Rate |
$339.17 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$84.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$77.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$88.55
|
| Rate for Payer: Fidelis Medicare Advantage |
$161.70
|
| Rate for Payer: Group Health Inc Commercial |
$77.00
|
| Rate for Payer: Group Health Inc Medicare |
$53.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$77.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$77.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$100.10
|
|
|
RX STANDARD ERCP CANNULA
|
Facility
IP
|
$154.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40209676
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$77.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$77.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$77.00
|
|
|
RX TAPERED ERCP CANNULA
|
Facility
OP
|
$154.00
|
|
| Hospital Charge Code |
40200897
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$53.90 |
| Max. Negotiated Rate |
$123.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$84.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$77.00
|
| Rate for Payer: Aetna Government |
$77.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$123.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$104.72
|
| Rate for Payer: Group Health Inc Commercial |
$77.00
|
| Rate for Payer: Group Health Inc Medicare |
$53.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$77.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$77.00
|
|
|
S7845 AUTOCHECK 6< LEVEL 2
|
Facility
OP
|
$8.32
|
|
| Hospital Charge Code |
64903515
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$6.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.16
|
| Rate for Payer: Aetna Government |
$4.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.66
|
| Rate for Payer: Group Health Inc Commercial |
$4.16
|
| Rate for Payer: Group Health Inc Medicare |
$2.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.16
|
|
|
SACCHAROMYCES BOULARDII 250 MG CAP - NF
|
Facility
OP
|
$1.38
|
|
| Hospital Charge Code |
41643773
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.76
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.69
|
| Rate for Payer: Aetna Government |
$0.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.94
|
| Rate for Payer: Group Health Inc Commercial |
$0.69
|
| Rate for Payer: Group Health Inc Medicare |
$0.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.90
|
|
|
SACCHAROMYCES BOULARDII 250 MG CAP - NF
|
Facility
OP
|
$1.38
|
|
| Hospital Charge Code |
41653773
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.76
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.69
|
| Rate for Payer: Aetna Government |
$0.69
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.94
|
| Rate for Payer: Group Health Inc Commercial |
$0.69
|
| Rate for Payer: Group Health Inc Medicare |
$0.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.90
|
|
|
SACCHAROMYCES CEREVISIAE PANEL
|
Facility
OP
|
$30.63
|
|
|
Service Code
|
HCPCS 86671
|
| Hospital Charge Code |
40729363
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$19.47 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.25
|
| Rate for Payer: Aetna Government |
$12.25
|
| Rate for Payer: Cash Price |
$12.25
|
| Rate for Payer: Cash Price |
$12.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$12.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.48
|
| Rate for Payer: Elderplan Medicare Advantage |
$12.25
|
| Rate for Payer: EmblemHealth Commercial |
$12.25
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$11.02
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$10.41
|
| Rate for Payer: Fidelis Essential Plan QHP |
$10.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$12.25
|
| Rate for Payer: Fidelis Qualified Health Plan |
$10.90
|
| Rate for Payer: Group Health Inc Commercial |
$12.25
|
| Rate for Payer: Group Health Inc Medicare |
$12.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.25
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$12.25
|
| Rate for Payer: Healthfirst Medicare Advantage |
$12.25
|
| Rate for Payer: Healthfirst QHP |
$12.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$12.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12.25
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$9.80
|
| Rate for Payer: Wellcare Medicare |
$11.02
|
|
|
SACITUZUMAB GOVITECAN-HZIY
|
Facility
OP
|
$64.47
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
41640242
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.26 |
| Max. Negotiated Rate |
$41.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$35.46
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$34.08
|
| Rate for Payer: Aetna Government |
$34.08
|
| Rate for Payer: Cash Price |
$34.08
|
| Rate for Payer: Cash Price |
$34.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$34.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$32.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$37.07
|
| Rate for Payer: Elderplan Medicare Advantage |
$34.08
|
| Rate for Payer: EmblemHealth Commercial |
$34.08
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$34.08
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$34.08
|
| Rate for Payer: Fidelis Essential Plan QHP |
$35.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$34.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$35.78
|
| Rate for Payer: Group Health Inc Commercial |
$34.08
|
| Rate for Payer: Group Health Inc Medicare |
$34.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32.24
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$32.24
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$33.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.97
|
| Rate for Payer: Healthfirst QHP |
$34.08
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$34.08
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$36.15
|
| Rate for Payer: SOMOS Essential |
$36.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$41.91
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$27.26
|
| Rate for Payer: Wellcare Medicare |
$32.37
|
|
|
SACITUZUMAB GOVITECAN-HZIY
|
Facility
IP
|
$64.47
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
41650242
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.24 |
| Max. Negotiated Rate |
$32.24 |
| Rate for Payer: Cash Price |
$34.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32.24
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$32.24
|
|
|
SACITUZUMAB GOVITECAN-HZIY
|
Facility
IP
|
$64.47
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
41640242
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.24 |
| Max. Negotiated Rate |
$32.24 |
| Rate for Payer: Cash Price |
$34.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32.24
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$32.24
|
|
|
SACITUZUMAB GOVITECAN-HZIY
|
Facility
OP
|
$64.47
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
41650242
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.26 |
| Max. Negotiated Rate |
$41.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$35.46
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$34.08
|
| Rate for Payer: Aetna Government |
$34.08
|
| Rate for Payer: Cash Price |
$34.08
|
| Rate for Payer: Cash Price |
$34.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$34.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$32.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$37.07
|
| Rate for Payer: Elderplan Medicare Advantage |
$34.08
|
| Rate for Payer: EmblemHealth Commercial |
$34.08
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$34.08
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$34.08
|
| Rate for Payer: Fidelis Essential Plan QHP |
$35.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$34.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$35.78
|
| Rate for Payer: Group Health Inc Commercial |
$34.08
|
| Rate for Payer: Group Health Inc Medicare |
$34.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$32.24
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$32.24
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$33.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.97
|
| Rate for Payer: Healthfirst QHP |
$34.08
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$34.08
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$36.15
|
| Rate for Payer: SOMOS Essential |
$36.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$41.91
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$27.26
|
| Rate for Payer: Wellcare Medicare |
$32.37
|
|
|
SACKS-VINE GASTROSTOMY KIT
|
Facility
OP
|
$166.91
|
|
| Hospital Charge Code |
40202200
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$58.42 |
| Max. Negotiated Rate |
$133.53 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$91.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$83.46
|
| Rate for Payer: Aetna Government |
$83.46
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$133.53
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$113.50
|
| Rate for Payer: Group Health Inc Commercial |
$83.46
|
| Rate for Payer: Group Health Inc Medicare |
$58.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$83.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$83.46
|
|
|
SACRAL LAMINECTOMY
|
Facility
OP
|
$18,117.83
|
|
|
Service Code
|
HCPCS 63011
|
| Hospital Charge Code |
40000495
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,279.28 |
| Max. Negotiated Rate |
$9,058.92 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,065.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8,273.12
|
| Rate for Payer: Aetna Government |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Cash Price |
$8,273.12
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$8,273.12
|
| 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 |
$8,273.12
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,279.28
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$7,032.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$7,363.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$8,273.12
|
| Rate for Payer: Fidelis Qualified Health Plan |
$7,363.08
|
| Rate for Payer: Group Health Inc Commercial |
$8,273.12
|
| Rate for Payer: Group Health Inc Medicare |
$8,273.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9,058.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,273.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,421.42
|
| Rate for Payer: Healthfirst Medicare Advantage |
$7,032.15
|
| Rate for Payer: Healthfirst QHP |
$8,273.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$8,273.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,273.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$6,618.50
|
| Rate for Payer: Wellcare Medicare |
$7,859.46
|
|
|
SACUBITRIL/VALSARTAN 24MG-26MG
|
Facility
OP
|
$52.70
|
|
| Hospital Charge Code |
41650210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.44 |
| Max. Negotiated Rate |
$42.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$28.98
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.35
|
| Rate for Payer: Aetna Government |
$26.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$42.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$35.84
|
| Rate for Payer: Group Health Inc Commercial |
$26.35
|
| Rate for Payer: Group Health Inc Medicare |
$18.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34.26
|
|
|
SACUBITRIL/VALSARTAN 24MG-26MG
|
Facility
OP
|
$52.70
|
|
| Hospital Charge Code |
41640210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.44 |
| Max. Negotiated Rate |
$42.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$28.98
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.35
|
| Rate for Payer: Aetna Government |
$26.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$42.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$35.84
|
| Rate for Payer: Group Health Inc Commercial |
$26.35
|
| Rate for Payer: Group Health Inc Medicare |
$18.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34.26
|
|
|
SACUBITRIL/VALSARTAN 49MG-51MG
|
Facility
OP
|
$52.70
|
|
| Hospital Charge Code |
41650209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.44 |
| Max. Negotiated Rate |
$42.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$28.98
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.35
|
| Rate for Payer: Aetna Government |
$26.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$42.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$35.84
|
| Rate for Payer: Group Health Inc Commercial |
$26.35
|
| Rate for Payer: Group Health Inc Medicare |
$18.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34.26
|
|
|
SACUBITRIL/VALSARTAN 49MG-51MG
|
Facility
OP
|
$52.70
|
|
| Hospital Charge Code |
41640209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.44 |
| Max. Negotiated Rate |
$42.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$28.98
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.35
|
| Rate for Payer: Aetna Government |
$26.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$42.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$35.84
|
| Rate for Payer: Group Health Inc Commercial |
$26.35
|
| Rate for Payer: Group Health Inc Medicare |
$18.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34.26
|
|
|
SACUBITRIL/VALSARTAN 97MG-103MG
|
Facility
OP
|
$52.70
|
|
| Hospital Charge Code |
41650208
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.44 |
| Max. Negotiated Rate |
$42.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$28.98
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.35
|
| Rate for Payer: Aetna Government |
$26.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$42.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$35.84
|
| Rate for Payer: Group Health Inc Commercial |
$26.35
|
| Rate for Payer: Group Health Inc Medicare |
$18.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34.26
|
|
|
SACUBITRIL/VALSARTAN 97MG-103MG
|
Facility
OP
|
$52.70
|
|
| Hospital Charge Code |
41640208
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.44 |
| Max. Negotiated Rate |
$42.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$28.98
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$26.35
|
| Rate for Payer: Aetna Government |
$26.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$42.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$35.84
|
| Rate for Payer: Group Health Inc Commercial |
$26.35
|
| Rate for Payer: Group Health Inc Medicare |
$18.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34.26
|
|
|
SAFEPICO 22G X 1 1/4 0.7-1.5
|
Facility
OP
|
$2.38
|
|
| Hospital Charge Code |
64902056
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.19
|
| Rate for Payer: Aetna Government |
$1.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.62
|
| Rate for Payer: Group Health Inc Commercial |
$1.19
|
| Rate for Payer: Group Health Inc Medicare |
$0.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.19
|
|
|
SAFEPICO 23G X 1 0.7-1.5
|
Facility
OP
|
$2.38
|
|
| Hospital Charge Code |
64902058
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.19
|
| Rate for Payer: Aetna Government |
$1.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.62
|
| Rate for Payer: Group Health Inc Commercial |
$1.19
|
| Rate for Payer: Group Health Inc Medicare |
$0.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.19
|
|
|
SAFEPICO 25G X 5/8 0.7-1.5
|
Facility
OP
|
$2.38
|
|
| Hospital Charge Code |
64902060
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.19
|
| Rate for Payer: Aetna Government |
$1.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.62
|
| Rate for Payer: Group Health Inc Commercial |
$1.19
|
| Rate for Payer: Group Health Inc Medicare |
$0.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.19
|
|
