|
SOLUTION,SODIUM CHL,0.9,IRG,10
|
Facility
OP
|
$3.56
|
|
| Hospital Charge Code |
64901406
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.78
|
| Rate for Payer: Aetna Government |
$1.78
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.85
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.42
|
| Rate for Payer: Group Health Inc Commercial |
$1.78
|
| Rate for Payer: Group Health Inc Medicare |
$1.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.78
|
|
|
SOLUTION,SODIUM CHL,0.9,IRG,50
|
Facility
OP
|
$3.30
|
|
| Hospital Charge Code |
64901969
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.82
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.65
|
| Rate for Payer: Aetna Government |
$1.65
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.24
|
| Rate for Payer: Group Health Inc Commercial |
$1.65
|
| Rate for Payer: Group Health Inc Medicare |
$1.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.65
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.65
|
|
|
SOLUTION,SODIUM CHL,500ML .9
|
Facility
OP
|
$2.76
|
|
| Hospital Charge Code |
64901375
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.52
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.38
|
| Rate for Payer: Aetna Government |
$1.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.88
|
| Rate for Payer: Group Health Inc Commercial |
$1.38
|
| Rate for Payer: Group Health Inc Medicare |
$0.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.38
|
|
|
SOLUTION,SODIUM CHL,INJ,0.9
|
Facility
OP
|
$23.59
|
|
| Hospital Charge Code |
64902279
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.26 |
| Max. Negotiated Rate |
$18.87 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.97
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$11.80
|
| Rate for Payer: Aetna Government |
$11.80
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18.87
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.04
|
| Rate for Payer: Group Health Inc Commercial |
$11.80
|
| Rate for Payer: Group Health Inc Medicare |
$8.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.80
|
|
|
SOLUTION,SODIUM CHLO,0.9,100ML
|
Facility
OP
|
$1.47
|
|
| Hospital Charge Code |
64902280
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.81
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.74
|
| Rate for Payer: Aetna Government |
$0.74
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.00
|
| Rate for Payer: Group Health Inc Commercial |
$0.74
|
| Rate for Payer: Group Health Inc Medicare |
$0.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.74
|
|
|
SOLUTION SUCROSE SWEET EASE
|
Facility
OP
|
$1.31
|
|
| Hospital Charge Code |
64903391
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.72
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.66
|
| Rate for Payer: Aetna Government |
$0.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.05
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.89
|
| Rate for Payer: Group Health Inc Commercial |
$0.66
|
| Rate for Payer: Group Health Inc Medicare |
$0.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.66
|
|
|
SOLUTION TRANSFER SET
|
Facility
OP
|
$25.52
|
|
| Hospital Charge Code |
42905210
|
|
Hospital Revenue Code
|
801
|
| Min. Negotiated Rate |
$8.93 |
| Max. Negotiated Rate |
$20.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.04
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$12.76
|
| Rate for Payer: Aetna Government |
$12.76
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$20.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$17.35
|
| Rate for Payer: Group Health Inc Commercial |
$12.76
|
| Rate for Payer: Group Health Inc Medicare |
$8.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.76
|
|
|
SOLYX SLING SYSTEM
|
Facility
OP
|
$4,520.25
|
|
| Hospital Charge Code |
64907131
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$1,582.09 |
| Max. Negotiated Rate |
$3,616.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,486.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,260.12
|
| Rate for Payer: Aetna Government |
$2,260.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,616.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,073.77
|
| Rate for Payer: Group Health Inc Commercial |
$2,260.12
|
| Rate for Payer: Group Health Inc Medicare |
$1,582.09
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,260.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,260.12
|
|
|
SOMATOMEDIN
|
Facility
OP
|
$53.15
|
|
|
Service Code
|
HCPCS 84305
|
| Hospital Charge Code |
30305721
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.01 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$29.23
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$21.26
|
| Rate for Payer: Aetna Government |
$21.26
|
| Rate for Payer: Cash Price |
$21.26
|
| Rate for Payer: Cash Price |
$21.26
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$21.26
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$33.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$28.60
|
| Rate for Payer: Elderplan Medicare Advantage |
$21.26
|
| Rate for Payer: EmblemHealth Commercial |
$21.26
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$19.13
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$18.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$18.92
|
| Rate for Payer: Fidelis Medicare Advantage |
$21.26
|
| Rate for Payer: Fidelis Qualified Health Plan |
$18.92
|
| Rate for Payer: Group Health Inc Commercial |
$21.26
|
| Rate for Payer: Group Health Inc Medicare |
$21.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$21.26
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$21.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$21.26
|
| Rate for Payer: Healthfirst QHP |
$21.26
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$21.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.26
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$17.01
|
| Rate for Payer: Wellcare Medicare |
$19.13
|
|
|
SONIC CTRL SERRATED AGG KNIFE
|
Facility
OP
|
$1,750.20
|
|
| Hospital Charge Code |
64906004
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$612.57 |
| Max. Negotiated Rate |
$1,400.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$962.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$875.10
|
| Rate for Payer: Aetna Government |
$875.10
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,400.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,190.14
|
| Rate for Payer: Group Health Inc Commercial |
$875.10
|
| Rate for Payer: Group Health Inc Medicare |
$612.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$875.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$875.10
|
|
|
SONO CHECK
|
Facility
OP
|
$13.99
|
|
| Hospital Charge Code |
64903598
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$11.19 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7.69
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.00
|
| Rate for Payer: Aetna Government |
$7.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.19
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9.51
|
| Rate for Payer: Group Health Inc Commercial |
$7.00
|
| Rate for Payer: Group Health Inc Medicare |
$4.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.00
|
|
|
SONOGRAM - LIMITED
|
Facility
OP
|
$339.45
|
|
|
Service Code
|
HCPCS 76815 TC
|
| Hospital Charge Code |
40250900
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$56.52 |
| Max. Negotiated Rate |
$271.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$186.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$169.72
|
| Rate for Payer: Aetna Government |
$169.72
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cash Price |
$127.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$271.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$230.83
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$56.52
|
| Rate for Payer: Group Health Inc Commercial |
$169.72
|
| Rate for Payer: Group Health Inc Medicare |
$118.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$169.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$169.72
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$62.80
|
|
|
SORBITOL 70% SOLUTION
|
Facility
OP
|
$1.23
|
|
| Hospital Charge Code |
41652361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.68
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.62
|
| Rate for Payer: Aetna Government |
$0.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.98
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.84
|
| Rate for Payer: Group Health Inc Commercial |
$0.62
|
| Rate for Payer: Group Health Inc Medicare |
$0.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.80
|
|
|
SORBITOL 70% SOLUTION
|
Facility
OP
|
$1.23
|
|
| Hospital Charge Code |
41642361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.68
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.62
|
| Rate for Payer: Aetna Government |
$0.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.98
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.84
|
| Rate for Payer: Group Health Inc Commercial |
$0.62
|
| Rate for Payer: Group Health Inc Medicare |
$0.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.80
|
|
|
SOTALOL 80 MG TAB
|
Facility
OP
|
$0.22
|
|
| Hospital Charge Code |
41651531
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.11
|
| Rate for Payer: Aetna Government |
$0.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.15
|
| Rate for Payer: Group Health Inc Commercial |
$0.11
|
| Rate for Payer: Group Health Inc Medicare |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.11
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.14
|
|
|
SOTALOL 80 MG TAB
|
Facility
OP
|
$0.22
|
|
| Hospital Charge Code |
41641531
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.11
|
| Rate for Payer: Aetna Government |
$0.11
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.15
|
| Rate for Payer: Group Health Inc Commercial |
$0.11
|
| Rate for Payer: Group Health Inc Medicare |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.11
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.11
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.14
|
|
|
SOTA MED CATH FISH SPLIT 32
|
Facility
OP
|
$800.00
|
|
| Hospital Charge Code |
40009361
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$280.00 |
| Max. Negotiated Rate |
$640.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$440.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$400.00
|
| Rate for Payer: Aetna Government |
$400.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$640.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$544.00
|
| Rate for Payer: Group Health Inc Commercial |
$400.00
|
| Rate for Payer: Group Health Inc Medicare |
$280.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$400.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$400.00
|
|
|
SOTA MED CATH FISH SPLIT 32
|
Facility
OP
|
$800.00
|
|
| Hospital Charge Code |
40203377
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$280.00 |
| Max. Negotiated Rate |
$640.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$440.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$400.00
|
| Rate for Payer: Aetna Government |
$400.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$640.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$544.00
|
| Rate for Payer: Group Health Inc Commercial |
$400.00
|
| Rate for Payer: Group Health Inc Medicare |
$280.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$400.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$400.00
|
|
|
SOTRADECOL 1% 2ML INJ
|
Facility
OP
|
$50.00
|
|
| Hospital Charge Code |
41658005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$27.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$25.00
|
| Rate for Payer: Aetna Government |
$25.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$40.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$34.00
|
| Rate for Payer: Group Health Inc Commercial |
$25.00
|
| Rate for Payer: Group Health Inc Medicare |
$17.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$25.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$25.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$32.50
|
|
|
SOTRADECOL 1% 2ML INJ
|
Facility
OP
|
$50.00
|
|
| Hospital Charge Code |
41648005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$27.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$25.00
|
| Rate for Payer: Aetna Government |
$25.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$40.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$34.00
|
| Rate for Payer: Group Health Inc Commercial |
$25.00
|
| Rate for Payer: Group Health Inc Medicare |
$17.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$25.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$25.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$32.50
|
|
|
SOTROVIMAB 500MG/8ML(COVID-19MAB)
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0247
|
| Hospital Charge Code |
41640288
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
SOTROVIMAB 500MG/8ML(COVID-19MAB)
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0247
|
| Hospital Charge Code |
41650288
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
SOTROVIMAB 500MG/8ML(COVID-19MAB)
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0247
|
| Hospital Charge Code |
41650288
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
SOTROVIMAB 500MG/8ML(COVID-19MAB)
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0247
|
| Hospital Charge Code |
41640288
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
|
|
SOTROVIMAB INFUSION
|
Facility
OP
|
$1,357.80
|
|
|
Service Code
|
HCPCS M0247
|
| Hospital Charge Code |
30302526
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$250.00 |
| Max. Negotiated Rate |
$1,086.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$746.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$546.78
|
| Rate for Payer: Aetna Government |
$546.78
|
| Rate for Payer: Cash Price |
$546.78
|
| Rate for Payer: Cash Price |
$546.78
|
| Rate for Payer: Cash Price |
$546.78
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$546.78
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,086.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$923.30
|
| Rate for Payer: Elderplan Medicare Advantage |
$546.78
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$464.76
|
| Rate for Payer: Fidelis Essential Plan QHP |
$486.63
|
| Rate for Payer: Fidelis Medicare Advantage |
$546.78
|
| Rate for Payer: Fidelis Qualified Health Plan |
$486.63
|
| 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 |
$678.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$546.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$464.76
|
| Rate for Payer: Healthfirst QHP |
$546.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$546.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$546.78
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$437.42
|
| Rate for Payer: Wellcare Medicare |
$519.44
|
|
