|
SODIUM HYPOCHLORITE 0.25% SOLUTION
|
Facility
OP
|
$20.12
|
|
| Hospital Charge Code |
41652014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.04 |
| Max. Negotiated Rate |
$16.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.06
|
| Rate for Payer: Aetna Government |
$10.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.68
|
| Rate for Payer: Group Health Inc Commercial |
$10.06
|
| Rate for Payer: Group Health Inc Medicare |
$7.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.08
|
|
|
SODIUM HYPOCHLORITE 0.25% SOLUTION
|
Facility
OP
|
$20.12
|
|
| Hospital Charge Code |
41642014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.04 |
| Max. Negotiated Rate |
$16.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.06
|
| Rate for Payer: Aetna Government |
$10.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.68
|
| Rate for Payer: Group Health Inc Commercial |
$10.06
|
| Rate for Payer: Group Health Inc Medicare |
$7.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.08
|
|
|
SODIUM PHOSPHATE-BIPHOSPHATE LIQUID
|
Facility
OP
|
$5.00
|
|
| Hospital Charge Code |
41640186
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.50
|
| Rate for Payer: Aetna Government |
$2.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.40
|
| Rate for Payer: Group Health Inc Commercial |
$2.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.25
|
|
|
SODIUM PHOSPHATE-BIPHOSPHATE LIQUID
|
Facility
OP
|
$5.00
|
|
| Hospital Charge Code |
41650186
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.50
|
| Rate for Payer: Aetna Government |
$2.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.40
|
| Rate for Payer: Group Health Inc Commercial |
$2.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.25
|
|
|
SODIUM PHOSPHATE INJ
|
Facility
OP
|
$2.44
|
|
| Hospital Charge Code |
41651027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.34
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.22
|
| Rate for Payer: Aetna Government |
$1.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.95
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.66
|
| Rate for Payer: Group Health Inc Commercial |
$1.22
|
| Rate for Payer: Group Health Inc Medicare |
$0.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.59
|
|
|
SODIUM PHOSPHATE INJ
|
Facility
OP
|
$2.44
|
|
| Hospital Charge Code |
41641027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.34
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.22
|
| Rate for Payer: Aetna Government |
$1.22
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.95
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.66
|
| Rate for Payer: Group Health Inc Commercial |
$1.22
|
| Rate for Payer: Group Health Inc Medicare |
$0.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.59
|
|
|
SODIUM POLYSTYRENE SULFONATE SUSPENSION
|
Facility
OP
|
$12.00
|
|
| Hospital Charge Code |
41650520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.00
|
| Rate for Payer: Aetna Government |
$6.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.16
|
| Rate for Payer: Group Health Inc Commercial |
$6.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.80
|
|
|
SODIUM POLYSTYRENE SULFONATE SUSPENSION
|
Facility
OP
|
$12.00
|
|
| Hospital Charge Code |
41640520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.00
|
| Rate for Payer: Aetna Government |
$6.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.16
|
| Rate for Payer: Group Health Inc Commercial |
$6.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.80
|
|
|
SODIUM TETRADECYL SULFATE
|
Facility
IP
|
$3.90
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41640314
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.95
|
|
|
SODIUM TETRADECYL SULFATE
|
Facility
OP
|
$3.90
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41650314
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.95
|
| Rate for Payer: Aetna Government |
$1.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.95
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.24
|
| Rate for Payer: Group Health Inc Commercial |
$1.95
|
| Rate for Payer: Group Health Inc Medicare |
$1.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.54
|
|
|
SODIUM TETRADECYL SULFATE
|
Facility
IP
|
$3.90
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41650314
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.95
|
|
|
SODIUM TETRADECYL SULFATE
|
Facility
OP
|
$3.90
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41640314
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.95
|
| Rate for Payer: Aetna Government |
$1.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.95
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.24
|
| Rate for Payer: Group Health Inc Commercial |
$1.95
|
| Rate for Payer: Group Health Inc Medicare |
$1.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.54
|
|
|
SODIUM THIOSULFATE 10% INJ
|
Facility
OP
|
$27.25
|
|
| Hospital Charge Code |
41651576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.54 |
| Max. Negotiated Rate |
$21.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.99
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$13.62
|
| Rate for Payer: Aetna Government |
$13.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$21.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$18.53
|
| Rate for Payer: Group Health Inc Commercial |
$13.62
|
| Rate for Payer: Group Health Inc Medicare |
$9.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$17.71
|
|
|
SODIUM THIOSULFATE 10% INJ
|
Facility
OP
|
$27.25
|
|
| Hospital Charge Code |
41641576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.54 |
| Max. Negotiated Rate |
$21.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.99
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$13.62
|
| Rate for Payer: Aetna Government |
$13.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$21.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$18.53
|
| Rate for Payer: Group Health Inc Commercial |
$13.62
|
| Rate for Payer: Group Health Inc Medicare |
$9.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$13.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$17.71
|
|
|
SODIUM THIOSULFATE 25% INJ
|
Facility
OP
|
$30.00
|
|
| Hospital Charge Code |
41644756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$15.00
|
| Rate for Payer: Aetna Government |
$15.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$20.40
|
| Rate for Payer: Group Health Inc Commercial |
$15.00
|
| Rate for Payer: Group Health Inc Medicare |
$10.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.50
|
|
|
SODIUM THIOSULFATE 25% INJ
|
Facility
OP
|
$30.00
|
|
| Hospital Charge Code |
41654756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$16.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$15.00
|
| Rate for Payer: Aetna Government |
$15.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$20.40
|
| Rate for Payer: Group Health Inc Commercial |
$15.00
|
| Rate for Payer: Group Health Inc Medicare |
$10.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.50
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE
|
Facility
OP
|
$55.85
|
|
| Hospital Charge Code |
41640365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$44.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$30.72
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$27.92
|
| Rate for Payer: Aetna Government |
$27.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$44.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$37.98
|
| Rate for Payer: Group Health Inc Commercial |
$27.92
|
| Rate for Payer: Group Health Inc Medicare |
$19.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.92
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$36.30
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE
|
Facility
OP
|
$55.85
|
|
| Hospital Charge Code |
41650365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$44.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$30.72
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$27.92
|
| Rate for Payer: Aetna Government |
$27.92
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$44.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$37.98
|
| Rate for Payer: Group Health Inc Commercial |
$27.92
|
| Rate for Payer: Group Health Inc Medicare |
$19.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$27.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$27.92
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$36.30
|
|
|
SOD NITRITE-SOD THIOSULF 30-250MG
|
Facility
OP
|
$300.00
|
|
| Hospital Charge Code |
41647993
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$165.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$150.00
|
| Rate for Payer: Aetna Government |
$150.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$240.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$204.00
|
| Rate for Payer: Group Health Inc Commercial |
$150.00
|
| Rate for Payer: Group Health Inc Medicare |
$105.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$150.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$150.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$195.00
|
|
|
SOD NITRITE-SPD THIOSULF 30-250MG
|
Facility
OP
|
$300.00
|
|
| Hospital Charge Code |
41657993
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$165.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$150.00
|
| Rate for Payer: Aetna Government |
$150.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$240.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$204.00
|
| Rate for Payer: Group Health Inc Commercial |
$150.00
|
| Rate for Payer: Group Health Inc Medicare |
$105.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$150.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$150.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$195.00
|
|
|
SOFSILK BK
|
Facility
OP
|
$2.38
|
|
| Hospital Charge Code |
64907073
|
|
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
|
|
|
SOFT ANCHOR SELF
|
Facility
OP
|
$1,100.00
|
|
| Hospital Charge Code |
64907518
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$385.00 |
| Max. Negotiated Rate |
$880.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$605.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$550.00
|
| Rate for Payer: Aetna Government |
$550.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$880.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$748.00
|
| Rate for Payer: Group Health Inc Commercial |
$550.00
|
| Rate for Payer: Group Health Inc Medicare |
$385.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$550.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$550.00
|
|
|
SOFT DISP SNARE 25MM X 230
|
Facility
OP
|
$9.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
64906240
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$69.35 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$69.35
|
| Rate for Payer: Aetna Government |
$69.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.18
|
| Rate for Payer: Fidelis Medicare Advantage |
$9.45
|
| 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
|
|
|
SOFT DISP SNARE 25MM X 230
|
Facility
IP
|
$9.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
64906240
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.50
|
|
|
SOFT TISSUE ALLOGRAFT
|
Facility
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS D4275
|
| Hospital Charge Code |
42303393
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$500.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$550.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,763.60
|
| Rate for Payer: Aetna Government |
$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 |
$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 |
$1,763.60
|
| Rate for Payer: Group Health Inc Medicare |
$1,763.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$500.00
|
| 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: Senior Whole Health 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
|
|
