|
RAD TRMT DELIVERY, > 1 MV, COMPL
|
Facility
|
OP
|
$715.88
|
|
|
Service Code
|
HCPCS 77412
|
| Hospital Charge Code |
66548537
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$217.55 |
| Max. Negotiated Rate |
$572.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$393.73
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$310.79
|
| Rate for Payer: Aetna Government |
$310.79
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$217.55
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$217.55
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$217.55
|
| Rate for Payer: Brighton Health Commercial |
$536.91
|
| Rate for Payer: Cash Price |
$310.79
|
| Rate for Payer: Cash Price |
$310.79
|
| Rate for Payer: Cash Price |
$310.79
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$310.79
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$572.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$486.80
|
| Rate for Payer: Elderplan Medicare Advantage |
$310.79
|
| Rate for Payer: EmblemHealth Commercial |
$310.79
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$310.79
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$310.79
|
| Rate for Payer: Group Health Inc Medicare |
$310.79
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$357.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$310.79
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$279.71
|
| Rate for Payer: Healthfirst Medicare Advantage |
$310.79
|
| Rate for Payer: Healthfirst QHP |
$310.79
|
| Rate for Payer: Humana Medicare |
$317.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$310.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$310.79
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$310.79
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$248.63
|
| Rate for Payer: Wellcare Medicare |
$295.25
|
|
|
RAD TRMT DELIVERY, > 1 MV, COMPL
|
Facility
|
IP
|
$715.88
|
|
|
Service Code
|
HCPCS 77412
|
| Hospital Charge Code |
66548537
|
|
Hospital Revenue Code
|
333
|
| Rate for Payer: Cash Price |
$310.79
|
|
|
RAD TRMT DELIVEY, > 1 MEV SIMPLE
|
Facility
|
OP
|
$371.65
|
|
|
Service Code
|
HCPCS 77402
|
| Hospital Charge Code |
66541323
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$97.07 |
| Max. Negotiated Rate |
$297.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$204.41
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$138.67
|
| Rate for Payer: Aetna Government |
$138.67
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$97.07
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$97.07
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$97.07
|
| Rate for Payer: Brighton Health Commercial |
$278.74
|
| Rate for Payer: Cash Price |
$138.67
|
| Rate for Payer: Cash Price |
$138.67
|
| Rate for Payer: Cash Price |
$138.67
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$138.67
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$297.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$252.72
|
| Rate for Payer: Elderplan Medicare Advantage |
$138.67
|
| Rate for Payer: EmblemHealth Commercial |
$138.67
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$138.67
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$138.67
|
| Rate for Payer: Group Health Inc Medicare |
$138.67
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$185.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$138.67
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$124.80
|
| Rate for Payer: Healthfirst Medicare Advantage |
$138.67
|
| Rate for Payer: Healthfirst QHP |
$138.67
|
| Rate for Payer: Humana Medicare |
$141.44
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$138.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$138.67
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$138.67
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$110.94
|
| Rate for Payer: Wellcare Medicare |
$131.74
|
|
|
RAD TRMT DELIVEY, > 1 MEV SIMPLE
|
Facility
|
IP
|
$371.65
|
|
|
Service Code
|
HCPCS 77402
|
| Hospital Charge Code |
66541323
|
|
Hospital Revenue Code
|
333
|
| Rate for Payer: Cash Price |
$138.67
|
|
|
RAD TRMT DEL MULT-11-19 MEV
|
Facility
|
OP
|
$698.38
|
|
|
Service Code
|
HCPCS G6009
|
| Hospital Charge Code |
66542971
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$244.43 |
| Max. Negotiated Rate |
$558.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$384.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$257.39
|
| Rate for Payer: Aetna Government |
$257.39
|
| Rate for Payer: Brighton Health Commercial |
$523.78
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$558.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$474.90
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$349.19
|
| Rate for Payer: Group Health Inc Medicare |
$244.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$349.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$349.19
|
|
|
RAD TRMT DEL MULT-20+ MEV
|
Facility
|
OP
|
$698.38
|
|
|
Service Code
|
HCPCS G6010
|
| Hospital Charge Code |
66542972
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$244.43 |
| Max. Negotiated Rate |
$558.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$384.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$256.93
|
| Rate for Payer: Aetna Government |
$256.93
|
| Rate for Payer: Brighton Health Commercial |
$523.78
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$558.70
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$474.90
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$349.19
|
| Rate for Payer: Group Health Inc Medicare |
$244.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$349.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$349.19
|
|
|
RAD TRMT DEL MULT-6-10 MEV
|
Facility
|
OP
|
$630.86
|
|
|
Service Code
|
HCPCS G6008
|
| Hospital Charge Code |
66542970
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$220.80 |
| Max. Negotiated Rate |
$504.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$346.97
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$260.17
|
| Rate for Payer: Aetna Government |
$260.17
|
| Rate for Payer: Brighton Health Commercial |
$473.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$504.69
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$428.98
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$315.43
|
| Rate for Payer: Group Health Inc Medicare |
$220.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$315.43
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$315.43
|
|
|
RAD TRMT DEL SMPL-11-10 MEV
|
Facility
|
OP
|
$510.10
|
|
|
Service Code
|
HCPCS G6005
|
| Hospital Charge Code |
66542967
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$178.54 |
| Max. Negotiated Rate |
$408.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$280.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$187.68
|
| Rate for Payer: Aetna Government |
$187.68
|
| Rate for Payer: Brighton Health Commercial |
$382.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$408.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$346.87
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$255.05
|
| Rate for Payer: Group Health Inc Medicare |
$178.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$255.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$255.05
|
|
|
RAD TRMT DEL SMPL-20+ MEV
|
Facility
|
OP
|
$507.50
|
|
|
Service Code
|
HCPCS G6006
|
| Hospital Charge Code |
66542968
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$177.62 |
| Max. Negotiated Rate |
$406.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$279.12
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$187.22
|
| Rate for Payer: Aetna Government |
$187.22
|
| Rate for Payer: Brighton Health Commercial |
$380.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$406.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$345.10
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$253.75
|
| Rate for Payer: Group Health Inc Medicare |
$177.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$253.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$253.75
|
|
|
RAD TRMT DEL SMPL-6-10 MEV
|
Facility
|
OP
|
$455.56
|
|
|
Service Code
|
HCPCS G6004
|
| Hospital Charge Code |
66542966
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$159.45 |
| Max. Negotiated Rate |
$364.45 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$250.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$188.14
|
| Rate for Payer: Aetna Government |
$188.14
|
| Rate for Payer: Brighton Health Commercial |
$341.67
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$364.45
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$309.78
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$227.78
|
| Rate for Payer: Group Health Inc Medicare |
$159.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$227.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$227.78
|
|
|
RAD TRMT MGMT 5 TREAT
|
Facility
|
OP
|
$740.78
|
|
|
Service Code
|
HCPCS 77427
|
| Hospital Charge Code |
66542950
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$232.13 |
| Max. Negotiated Rate |
$592.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$407.43
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$232.13
|
| Rate for Payer: Aetna Government |
$232.13
|
| Rate for Payer: Brighton Health Commercial |
$555.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$592.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$503.73
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$370.39
|
| Rate for Payer: Group Health Inc Medicare |
$259.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$370.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$370.39
|
|
|
RAD TRMTT DEL CUST-11-19 MEV
|
Facility
|
OP
|
$933.41
|
|
|
Service Code
|
HCPCS G6013
|
| Hospital Charge Code |
66542974
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$279.92 |
| Max. Negotiated Rate |
$746.73 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$513.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$343.27
|
| Rate for Payer: Aetna Government |
$343.27
|
| Rate for Payer: Brighton Health Commercial |
$700.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$746.73
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$634.72
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$466.70
|
| Rate for Payer: Group Health Inc Medicare |
$326.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$466.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$466.70
|
|
|
RAD TRMTT DEL CUST-20+ MEV
|
Facility
|
OP
|
$933.41
|
|
|
Service Code
|
HCPCS G6014
|
| Hospital Charge Code |
66542975
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$279.92 |
| Max. Negotiated Rate |
$746.73 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$513.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$343.27
|
| Rate for Payer: Aetna Government |
$343.27
|
| Rate for Payer: Brighton Health Commercial |
$700.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$746.73
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$634.72
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$466.70
|
| Rate for Payer: Group Health Inc Medicare |
$326.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$466.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$466.70
|
|
|
RAD TRMTT DEL CUST-6-10 MEV
|
Facility
|
OP
|
$828.23
|
|
|
Service Code
|
HCPCS G6012
|
| Hospital Charge Code |
66542973
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$279.92 |
| Max. Negotiated Rate |
$662.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$455.53
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$342.81
|
| Rate for Payer: Aetna Government |
$342.81
|
| Rate for Payer: Brighton Health Commercial |
$621.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$662.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$563.20
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$279.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$279.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.00
|
| Rate for Payer: Group Health Inc Commercial |
$414.12
|
| Rate for Payer: Group Health Inc Medicare |
$289.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$414.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$414.12
|
|
|
RAILS 35MM
|
Facility
|
OP
|
$1,110.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40205094
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$1,165.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$610.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Brighton Health Commercial |
$666.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$555.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$638.25
|
| Rate for Payer: EmblemHealth Commercial |
$555.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,165.50
|
| Rate for Payer: Group Health Inc Commercial |
$555.00
|
| Rate for Payer: Group Health Inc Medicare |
$388.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$555.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$555.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$721.50
|
|
|
RAILS 35MM
|
Facility
|
IP
|
$1,110.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40205094
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.00 |
| Max. Negotiated Rate |
$555.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$555.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$555.00
|
|
|
RALTEGRAVIR 100MG TAB
|
Facility
|
OP
|
$0.01
|
|
| Hospital Charge Code |
41650352
|
|
Hospital Revenue Code
|
250
|
| 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: Brighton Health Commercial |
$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
|
|
|
RALTEGRAVIR 100MG TAB
|
Facility
|
OP
|
$0.01
|
|
| Hospital Charge Code |
41640352
|
|
Hospital Revenue Code
|
250
|
| 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: Brighton Health Commercial |
$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
|
|
|
RALTEGRAVIR 400 MG TAB
|
Facility
|
OP
|
$33.77
|
|
| Hospital Charge Code |
41654847
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.82 |
| Max. Negotiated Rate |
$27.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.88
|
| Rate for Payer: Aetna Government |
$16.88
|
| Rate for Payer: Brighton Health Commercial |
$25.33
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$22.96
|
| Rate for Payer: Group Health Inc Commercial |
$16.88
|
| Rate for Payer: Group Health Inc Medicare |
$11.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.88
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.95
|
|
|
RALTEGRAVIR 400 MG TAB
|
Facility
|
OP
|
$33.77
|
|
| Hospital Charge Code |
41644847
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.82 |
| Max. Negotiated Rate |
$27.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.88
|
| Rate for Payer: Aetna Government |
$16.88
|
| Rate for Payer: Brighton Health Commercial |
$25.33
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$22.96
|
| Rate for Payer: Group Health Inc Commercial |
$16.88
|
| Rate for Payer: Group Health Inc Medicare |
$11.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.88
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$21.95
|
|
|
RALTEGRAVIR 600MG TABLET
|
Facility
|
OP
|
$62.45
|
|
| Hospital Charge Code |
41648889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.86 |
| Max. Negotiated Rate |
$49.96 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$31.22
|
| Rate for Payer: Aetna Government |
$31.22
|
| Rate for Payer: Brighton Health Commercial |
$46.84
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$49.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$42.47
|
| Rate for Payer: Group Health Inc Commercial |
$31.22
|
| Rate for Payer: Group Health Inc Medicare |
$21.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$40.59
|
|
|
RALTEGRAVIR 600MG TABLET
|
Facility
|
OP
|
$62.45
|
|
| Hospital Charge Code |
41658892
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.86 |
| Max. Negotiated Rate |
$49.96 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$31.22
|
| Rate for Payer: Aetna Government |
$31.22
|
| Rate for Payer: Brighton Health Commercial |
$46.84
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$49.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$42.47
|
| Rate for Payer: Group Health Inc Commercial |
$31.22
|
| Rate for Payer: Group Health Inc Medicare |
$21.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$40.59
|
|
|
RALTEGRAVIR 600MG TABLET
|
Facility
|
OP
|
$62.45
|
|
| Hospital Charge Code |
41658889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.86 |
| Max. Negotiated Rate |
$49.96 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$31.22
|
| Rate for Payer: Aetna Government |
$31.22
|
| Rate for Payer: Brighton Health Commercial |
$46.84
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$49.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$42.47
|
| Rate for Payer: Group Health Inc Commercial |
$31.22
|
| Rate for Payer: Group Health Inc Medicare |
$21.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$40.59
|
|
|
RALTEGRAVIR 600MG TABLET
|
Facility
|
OP
|
$62.45
|
|
| Hospital Charge Code |
41648892
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.86 |
| Max. Negotiated Rate |
$49.96 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$31.22
|
| Rate for Payer: Aetna Government |
$31.22
|
| Rate for Payer: Brighton Health Commercial |
$46.84
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$49.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$42.47
|
| Rate for Payer: Group Health Inc Commercial |
$31.22
|
| Rate for Payer: Group Health Inc Medicare |
$21.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$40.59
|
|
|
RALTEGRAVIR POTASSIUM 400 MG PO TABS [88608]
|
Facility
|
OP
|
$39.94
|
|
|
Service Code
|
NDC 00006022761
|
| Hospital Charge Code |
00006022761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.98 |
| Max. Negotiated Rate |
$31.95 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$21.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.97
|
| Rate for Payer: Aetna Government |
$19.97
|
| Rate for Payer: Brighton Health Commercial |
$29.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$31.95
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$27.16
|
| Rate for Payer: Group Health Inc Commercial |
$19.97
|
| Rate for Payer: Group Health Inc Medicare |
$13.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.97
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$25.96
|
|
