|
SALINE MAMMARY BREST IMPNT 550 CC
|
Facility
OP
|
$2,300.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
40201124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$402.32 |
| Max. Negotiated Rate |
$2,415.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,265.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$402.32
|
| Rate for Payer: Aetna Government |
$402.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,150.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,322.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,415.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,150.00
|
| Rate for Payer: Group Health Inc Medicare |
$805.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,150.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,150.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,495.00
|
|
|
SALINE MAMMARY BREST IMPNT 550 CC
|
Facility
IP
|
$2,300.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
40201124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,150.00 |
| Max. Negotiated Rate |
$1,150.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,150.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,150.00
|
|
|
SALINE MAMMARY BREST IMPNT 650 CC
|
Facility
OP
|
$2,300.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
40201125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$402.32 |
| Max. Negotiated Rate |
$2,415.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,265.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$402.32
|
| Rate for Payer: Aetna Government |
$402.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,150.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,322.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,415.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,150.00
|
| Rate for Payer: Group Health Inc Medicare |
$805.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,150.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,150.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,495.00
|
|
|
SALINE MAMMARY BREST IMPNT 650 CC
|
Facility
IP
|
$2,300.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
40201125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,150.00 |
| Max. Negotiated Rate |
$1,150.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,150.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,150.00
|
|
|
SALINE MAMMARY BRST IMPNT 250 CC
|
Facility
OP
|
$1,150.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
40201120
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$402.32 |
| Max. Negotiated Rate |
$1,207.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$632.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$402.32
|
| Rate for Payer: Aetna Government |
$402.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$575.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$661.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,207.50
|
| Rate for Payer: Group Health Inc Commercial |
$575.00
|
| Rate for Payer: Group Health Inc Medicare |
$402.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$575.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$575.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$747.50
|
|
|
SALINE MAMMARY BRST IMPNT 250 CC
|
Facility
IP
|
$1,150.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
40201120
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$575.00 |
| Max. Negotiated Rate |
$575.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$575.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$575.00
|
|
|
SALIVARY CORTISOL X2
|
Facility
OP
|
$234.65
|
|
|
Service Code
|
HCPCS 82533
|
| Hospital Charge Code |
40601236
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.04 |
| Max. Negotiated Rate |
$129.06 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$129.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.30
|
| Rate for Payer: Aetna Government |
$16.30
|
| Rate for Payer: Cash Price |
$16.30
|
| Rate for Payer: Cash Price |
$16.30
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$16.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$25.92
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$21.93
|
| Rate for Payer: Elderplan Medicare Advantage |
$16.30
|
| Rate for Payer: EmblemHealth Commercial |
$16.30
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$14.67
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$13.86
|
| Rate for Payer: Fidelis Essential Plan QHP |
$14.51
|
| Rate for Payer: Fidelis Medicare Advantage |
$16.30
|
| Rate for Payer: Fidelis Qualified Health Plan |
$14.51
|
| Rate for Payer: Group Health Inc Commercial |
$16.30
|
| Rate for Payer: Group Health Inc Medicare |
$16.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$117.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.30
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$16.30
|
| Rate for Payer: Healthfirst Medicare Advantage |
$16.30
|
| Rate for Payer: Healthfirst QHP |
$16.30
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$16.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$16.30
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$13.04
|
| Rate for Payer: Wellcare Medicare |
$14.67
|
|
|
SALIVARY GLAND PROCEDURES
|
Facility
IP
|
$24,274.09
|
|
|
Service Code
|
MS-DRG 139
|
| Min. Negotiated Rate |
$10,184.50 |
| Max. Negotiated Rate |
$24,274.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$17,512.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$23,798.13
|
| Rate for Payer: Aetna Government |
$23,798.13
|
| Rate for Payer: Brighton Health Commercial |
$17,221.65
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$24,274.09
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$20,510.39
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16,926.06
|
| Rate for Payer: Elderplan Medicare Advantage |
$22,608.22
|
| Rate for Payer: EmblemHealth Commercial |
$10,184.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$23,798.13
|
| Rate for Payer: Group Health Inc Commercial |
$23,798.13
|
| Rate for Payer: Group Health Inc Medicare |
$23,798.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$23,798.13
|
| Rate for Payer: Healthfirst Medicare Advantage |
$11,066.13
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$23,798.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$23,798.13
|
| Rate for Payer: Wellcare Medicare |
$22,608.22
|
|
|
SALIVA SUBSTITUTE LIQUID
|
Facility
OP
|
$9.00
|
|
| Hospital Charge Code |
41650269
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.50
|
| Rate for Payer: Aetna Government |
$4.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.12
|
| Rate for Payer: Group Health Inc Commercial |
$4.50
|
| Rate for Payer: Group Health Inc Medicare |
$3.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.85
|
|
|
SALIVA SUBSTITUTE LIQUID
|
Facility
OP
|
$9.00
|
|
| Hospital Charge Code |
41640269
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.50
|
| Rate for Payer: Aetna Government |
$4.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6.12
|
| Rate for Payer: Group Health Inc Commercial |
$4.50
|
| Rate for Payer: Group Health Inc Medicare |
$3.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.85
|
|
|
SALPINGECTOMY
|
Facility
OP
|
$1,845.45
|
|
|
Service Code
|
HCPCS 58700
|
| Hospital Charge Code |
40059989
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$645.91 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,015.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$980.04
|
| Rate for Payer: Aetna Government |
$980.04
|
| 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: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$905.45
|
| Rate for Payer: Group Health Inc Commercial |
$922.72
|
| Rate for Payer: Group Health Inc Medicare |
$645.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$922.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$922.72
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,006.06
|
|
|
SALPINGECTOMY TUBAL PREG
|
Facility
OP
|
$2,209.68
|
|
|
Service Code
|
HCPCS 59120
|
| Hospital Charge Code |
40054335
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$773.39 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,215.32
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$959.36
|
| Rate for Payer: Aetna Government |
$959.36
|
| 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: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$976.01
|
| Rate for Payer: Group Health Inc Commercial |
$1,104.84
|
| Rate for Payer: Group Health Inc Medicare |
$773.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,104.84
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,104.84
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,084.46
|
|
|
SALPINGECTOMY TUBAL PREG LAP
|
Facility
OP
|
$14,640.10
|
|
|
Service Code
|
HCPCS 59151
|
| Hospital Charge Code |
40054334
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$925.79 |
| Max. Negotiated Rate |
$7,320.05 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,065.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,672.53
|
| Rate for Payer: Aetna Government |
$6,672.53
|
| Rate for Payer: Cash Price |
$6,672.53
|
| Rate for Payer: Cash Price |
$6,672.53
|
| Rate for Payer: Cash Price |
$6,672.53
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,672.53
|
| 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 |
$6,672.53
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$925.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,671.65
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5,938.55
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,672.53
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5,938.55
|
| Rate for Payer: Group Health Inc Commercial |
$6,672.53
|
| Rate for Payer: Group Health Inc Medicare |
$6,672.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7,320.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,672.53
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,028.66
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5,671.65
|
| Rate for Payer: Healthfirst QHP |
$6,672.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,672.53
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,672.53
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,338.02
|
| Rate for Payer: Wellcare Medicare |
$6,338.90
|
|
|
SALSALATE 500 MG TAB
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41640696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
SALSALATE 500 MG TAB
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41650696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
SALSALATE 750 MG TAB
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41654580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
SALSALATE 750 MG TAB
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
41644580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna Government |
$0.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
SANI-WIPES
|
Facility
OP
|
$0.06
|
|
| Hospital Charge Code |
40209485
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.03
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.03
|
| Rate for Payer: Aetna Government |
$0.03
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.05
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.04
|
| Rate for Payer: Group Health Inc Commercial |
$0.03
|
| Rate for Payer: Group Health Inc Medicare |
$0.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.03
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.03
|
|
|
SA (NOT TOB) SCREENING/INTER
|
Facility
OP
|
$100.00
|
|
|
Service Code
|
HCPCS 99408
|
| Hospital Charge Code |
30301261
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.76 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$55.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.76
|
| Rate for Payer: Aetna Government |
$24.76
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$50.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$50.00
|
|
|
S ANTIGEN
|
Facility
OP
|
$858.38
|
|
|
Service Code
|
HCPCS 86905
|
| Hospital Charge Code |
40701262
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$472.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$472.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$415.67
|
| Rate for Payer: Aetna Government |
$415.67
|
| Rate for Payer: Cash Price |
$415.67
|
| Rate for Payer: Cash Price |
$415.67
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$415.67
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.15
|
| Rate for Payer: Elderplan Medicare Advantage |
$415.67
|
| Rate for Payer: EmblemHealth Commercial |
$415.67
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3.45
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$353.32
|
| Rate for Payer: Fidelis Essential Plan QHP |
$369.95
|
| Rate for Payer: Fidelis Medicare Advantage |
$415.67
|
| Rate for Payer: Fidelis Qualified Health Plan |
$369.95
|
| Rate for Payer: Group Health Inc Commercial |
$415.67
|
| Rate for Payer: Group Health Inc Medicare |
$415.67
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$429.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$415.67
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3.83
|
| Rate for Payer: Healthfirst Medicare Advantage |
$415.67
|
| Rate for Payer: Healthfirst QHP |
$415.67
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$415.67
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$415.67
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$332.54
|
| Rate for Payer: Wellcare Medicare |
$374.10
|
|
|
SAQUINAVIR 200 MG CAP
|
Facility
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
41640966
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.50
|
|
|
SAQUINAVIR 200 MG CAP
|
Facility
OP
|
$7.00
|
|
| Hospital Charge Code |
41650966
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.50
|
| Rate for Payer: Aetna Government |
$3.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.76
|
| Rate for Payer: Group Health Inc Commercial |
$3.50
|
| Rate for Payer: Group Health Inc Medicare |
$2.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.55
|
|
|
SAQUINAVIR 200 MG CAP
|
Facility
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
41640966
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$9.37 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.57
|
| Rate for Payer: Aetna Government |
$8.57
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.02
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$4.06
|
| Rate for Payer: Group Health Inc Commercial |
$3.50
|
| Rate for Payer: Group Health Inc Medicare |
$2.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$4.51
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$9.37
|
| Rate for Payer: SOMOS Essential |
$9.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.55
|
|
|
SARS COV-2 ANTIBODY IGG (SBH)
|
Facility
OP
|
$45.00
|
|
|
Service Code
|
HCPCS 86769
|
| Hospital Charge Code |
40724489
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$42.13 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$24.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$42.13
|
| Rate for Payer: Aetna Government |
$42.13
|
| Rate for Payer: Cash Price |
$42.13
|
| Rate for Payer: Cash Price |
$42.13
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$42.13
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$36.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$30.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$42.13
|
| Rate for Payer: EmblemHealth Commercial |
$42.13
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$37.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$35.81
|
| Rate for Payer: Fidelis Essential Plan QHP |
$37.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$42.13
|
| Rate for Payer: Fidelis Qualified Health Plan |
$37.50
|
| Rate for Payer: Group Health Inc Commercial |
$42.13
|
| Rate for Payer: Group Health Inc Medicare |
$42.13
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$22.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$42.13
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$42.13
|
| Rate for Payer: Healthfirst Medicare Advantage |
$42.13
|
| Rate for Payer: Healthfirst QHP |
$42.13
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$42.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$42.13
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$33.70
|
| Rate for Payer: Wellcare Medicare |
$37.92
|
|
|
SARS-COV-2 COVID-19 AMP PRB
|
Facility
OP
|
$130.00
|
|
|
Service Code
|
HCPCS U0003
|
| Hospital Charge Code |
40611998
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$71.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$75.00
|
| Rate for Payer: Aetna Government |
$75.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$104.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$88.40
|
| Rate for Payer: Group Health Inc Commercial |
$65.00
|
| Rate for Payer: Group Health Inc Medicare |
$45.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$65.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$65.00
|
|
