|
CA_19-9
|
Facility
OP
|
$52.03
|
|
|
Service Code
|
HCPCS 86301
|
| Hospital Charge Code |
40609142
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$33.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$28.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.81
|
| Rate for Payer: Aetna Government |
$20.81
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$20.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$33.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$28.00
|
| Rate for Payer: Elderplan Medicare Advantage |
$20.81
|
| Rate for Payer: EmblemHealth Commercial |
$20.81
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$18.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$17.69
|
| Rate for Payer: Fidelis Essential Plan QHP |
$18.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$20.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$18.52
|
| Rate for Payer: Group Health Inc Commercial |
$20.81
|
| Rate for Payer: Group Health Inc Medicare |
$20.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.81
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$20.81
|
| Rate for Payer: Healthfirst Medicare Advantage |
$20.81
|
| Rate for Payer: Healthfirst QHP |
$20.81
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$20.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$20.81
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$16.65
|
| Rate for Payer: Wellcare Medicare |
$18.73
|
|
|
CA_27.29
|
Facility
OP
|
$52.03
|
|
|
Service Code
|
HCPCS 86300
|
| Hospital Charge Code |
40609745
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$33.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$28.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$20.81
|
| Rate for Payer: Aetna Government |
$20.81
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$20.81
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$33.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$28.00
|
| Rate for Payer: Elderplan Medicare Advantage |
$20.81
|
| Rate for Payer: EmblemHealth Commercial |
$20.81
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$18.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$17.69
|
| Rate for Payer: Fidelis Essential Plan QHP |
$18.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$20.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$18.52
|
| Rate for Payer: Group Health Inc Commercial |
$20.81
|
| Rate for Payer: Group Health Inc Medicare |
$20.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.81
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$20.81
|
| Rate for Payer: Healthfirst Medicare Advantage |
$20.81
|
| Rate for Payer: Healthfirst QHP |
$20.81
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$20.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$20.81
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$16.65
|
| Rate for Payer: Wellcare Medicare |
$18.73
|
|
|
CABAZITAXEL 60MG/1.5ML INJ
|
Facility
OP
|
$482.00
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
41646050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$168.36 |
| Max. Negotiated Rate |
$313.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$265.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$210.45
|
| Rate for Payer: Aetna Government |
$210.45
|
| Rate for Payer: Cash Price |
$210.45
|
| Rate for Payer: Cash Price |
$210.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$210.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$241.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$277.15
|
| Rate for Payer: Elderplan Medicare Advantage |
$210.45
|
| Rate for Payer: EmblemHealth Commercial |
$210.45
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$210.45
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$210.45
|
| Rate for Payer: Fidelis Essential Plan QHP |
$220.98
|
| Rate for Payer: Fidelis Medicare Advantage |
$210.45
|
| Rate for Payer: Fidelis Qualified Health Plan |
$220.98
|
| Rate for Payer: Group Health Inc Commercial |
$210.45
|
| Rate for Payer: Group Health Inc Medicare |
$210.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$241.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$241.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$206.03
|
| Rate for Payer: Healthfirst Medicare Advantage |
$178.89
|
| Rate for Payer: Healthfirst QHP |
$210.45
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$210.45
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$224.46
|
| Rate for Payer: SOMOS Essential |
$224.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$313.30
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$168.36
|
| Rate for Payer: Wellcare Medicare |
$199.93
|
|
|
CABAZITAXEL 60MG/1.5ML INJ
|
Facility
IP
|
$482.00
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
41656050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$241.00 |
| Max. Negotiated Rate |
$241.00 |
| Rate for Payer: Cash Price |
$210.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$241.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$241.00
|
|
|
CABAZITAXEL 60MG/1.5ML INJ
|
Facility
IP
|
$482.00
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
41646050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$241.00 |
| Max. Negotiated Rate |
$241.00 |
| Rate for Payer: Cash Price |
$210.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$241.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$241.00
|
|
|
CABAZITAXEL 60MG/1.5ML INJ
|
Facility
OP
|
$482.00
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
41656050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$168.36 |
| Max. Negotiated Rate |
$313.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$265.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$210.45
|
| Rate for Payer: Aetna Government |
$210.45
|
| Rate for Payer: Cash Price |
$210.45
|
| Rate for Payer: Cash Price |
$210.45
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$210.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$241.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$277.15
|
| Rate for Payer: Elderplan Medicare Advantage |
$210.45
|
| Rate for Payer: EmblemHealth Commercial |
$210.45
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$210.45
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$210.45
|
| Rate for Payer: Fidelis Essential Plan QHP |
$220.98
|
| Rate for Payer: Fidelis Medicare Advantage |
$210.45
|
| Rate for Payer: Fidelis Qualified Health Plan |
$220.98
|
| Rate for Payer: Group Health Inc Commercial |
$210.45
|
| Rate for Payer: Group Health Inc Medicare |
$210.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$241.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$241.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$206.03
|
| Rate for Payer: Healthfirst Medicare Advantage |
$178.89
|
| Rate for Payer: Healthfirst QHP |
$210.45
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$210.45
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$224.46
|
| Rate for Payer: SOMOS Essential |
$224.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$313.30
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$168.36
|
| Rate for Payer: Wellcare Medicare |
$199.93
|
|
|
CABLE 20 BEADED
|
Facility
OP
|
$1,280.00
|
|
| Hospital Charge Code |
64905856
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$448.00 |
| Max. Negotiated Rate |
$1,024.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$704.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$640.00
|
| Rate for Payer: Aetna Government |
$640.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,024.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$870.40
|
| Rate for Payer: Group Health Inc Commercial |
$640.00
|
| Rate for Payer: Group Health Inc Medicare |
$448.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$640.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$640.00
|
|
|
CABLE 3 LEAD LIFEPAK
|
Facility
OP
|
$244.38
|
|
| Hospital Charge Code |
64903102
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$85.53 |
| Max. Negotiated Rate |
$195.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$134.41
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$122.19
|
| Rate for Payer: Aetna Government |
$122.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$195.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$166.18
|
| Rate for Payer: Group Health Inc Commercial |
$122.19
|
| Rate for Payer: Group Health Inc Medicare |
$85.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.19
|
|
|
CABLE MAS PLIF LIGHT, STERILE
|
Facility
OP
|
$1,539.35
|
|
| Hospital Charge Code |
64906131
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$538.77 |
| Max. Negotiated Rate |
$1,231.48 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$846.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$769.68
|
| Rate for Payer: Aetna Government |
$769.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,231.48
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,046.76
|
| Rate for Payer: Group Health Inc Commercial |
$769.68
|
| Rate for Payer: Group Health Inc Medicare |
$538.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$769.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$769.68
|
|
|
CABLE ORTHOPEDIC 2MM DIA COBAL
|
Facility
OP
|
$1,288.63
|
|
| Hospital Charge Code |
64905780
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$451.02 |
| Max. Negotiated Rate |
$1,030.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$708.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$644.32
|
| Rate for Payer: Aetna Government |
$644.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,030.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$876.27
|
| Rate for Payer: Group Health Inc Commercial |
$644.32
|
| Rate for Payer: Group Health Inc Medicare |
$451.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$644.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$644.32
|
|
|
CABLE PACEMAKER LONG 12FTL ART
|
Facility
IP
|
$168.75
|
|
|
Service Code
|
HCPCS C1785
|
| Hospital Charge Code |
64901115
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$84.38 |
| Max. Negotiated Rate |
$84.38 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$84.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$84.38
|
|
|
CABLE PACEMAKER LONG 12FTL ART
|
Facility
OP
|
$168.75
|
|
|
Service Code
|
HCPCS C1785
|
| Hospital Charge Code |
64901115
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$59.06 |
| Max. Negotiated Rate |
$275.42 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$92.81
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$275.42
|
| Rate for Payer: Aetna Government |
$275.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$84.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$97.03
|
| Rate for Payer: Fidelis Medicare Advantage |
$177.19
|
| Rate for Payer: Group Health Inc Commercial |
$84.38
|
| Rate for Payer: Group Health Inc Medicare |
$59.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$84.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$84.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$109.69
|
|
|
CABLE PATIENT SEER LIGHT
|
Facility
OP
|
$533.88
|
|
| Hospital Charge Code |
64903314
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$186.86 |
| Max. Negotiated Rate |
$427.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$293.63
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$266.94
|
| Rate for Payer: Aetna Government |
$266.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$427.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$363.04
|
| Rate for Payer: Group Health Inc Commercial |
$266.94
|
| Rate for Payer: Group Health Inc Medicare |
$186.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$266.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$266.94
|
|
|
CABLE PLTE BONE 1.8MM-00223200318
|
Facility
IP
|
$360.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64906409
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$180.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$180.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$180.00
|
|
|
CABLE PLTE BONE 1.8MM-00223200318
|
Facility
OP
|
$360.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64906409
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$378.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$198.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$180.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$207.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$378.00
|
| Rate for Payer: Group Health Inc Commercial |
$180.00
|
| Rate for Payer: Group Health Inc Medicare |
$126.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$180.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$180.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$234.00
|
|
|
CABLE SPO2 REUSEABLE 2533
|
Facility
OP
|
$320.00
|
|
| Hospital Charge Code |
64906829
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$112.00 |
| Max. Negotiated Rate |
$256.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$176.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$160.00
|
| Rate for Payer: Aetna Government |
$160.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$256.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$217.60
|
| Rate for Payer: Group Health Inc Commercial |
$160.00
|
| Rate for Payer: Group Health Inc Medicare |
$112.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$160.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$160.00
|
|
|
CABLE, SURG SST 1.8MM X 559
|
Facility
OP
|
$1,260.00
|
|
| Hospital Charge Code |
64906176
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$441.00 |
| Max. Negotiated Rate |
$1,008.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$693.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$630.00
|
| Rate for Payer: Aetna Government |
$630.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,008.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$856.80
|
| Rate for Payer: Group Health Inc Commercial |
$630.00
|
| Rate for Payer: Group Health Inc Medicare |
$441.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$630.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$630.00
|
|
|
CABLE WAND CAPSURE30 3.0MM
|
Facility
OP
|
$1,055.00
|
|
| Hospital Charge Code |
64903101
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$369.25 |
| Max. Negotiated Rate |
$844.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$580.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$527.50
|
| Rate for Payer: Aetna Government |
$527.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$844.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$717.40
|
| Rate for Payer: Group Health Inc Commercial |
$527.50
|
| Rate for Payer: Group Health Inc Medicare |
$369.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$527.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$527.50
|
|
|
CABLE WCRIMP 1.8MM
|
Facility
OP
|
$1,130.00
|
|
| Hospital Charge Code |
64907047
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$395.50 |
| Max. Negotiated Rate |
$904.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$621.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$565.00
|
| Rate for Payer: Aetna Government |
$565.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$904.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$768.40
|
| Rate for Payer: Group Health Inc Commercial |
$565.00
|
| Rate for Payer: Group Health Inc Medicare |
$395.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$565.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$565.00
|
|
|
CABOTEGRAVIR
|
Facility
OP
|
$0.01
|
|
| Hospital Charge Code |
41640248
|
|
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: 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
|
|
|
CABOTEGRAVIR
|
Facility
OP
|
$0.01
|
|
| Hospital Charge Code |
41650248
|
|
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: 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
|
|
|
CABOTEGRAVIR 200MG/ML
|
Facility
IP
|
$14.80
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41640334
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.40 |
| Max. Negotiated Rate |
$7.40 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.40
|
|
|
CABOTEGRAVIR 200MG/ML
|
Facility
OP
|
$14.80
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41650334
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$9.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.40
|
| Rate for Payer: Aetna Government |
$7.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.51
|
| Rate for Payer: Group Health Inc Commercial |
$7.40
|
| Rate for Payer: Group Health Inc Medicare |
$5.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.62
|
|
|
CABOTEGRAVIR 200MG/ML
|
Facility
OP
|
$14.80
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41640334
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$9.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.40
|
| Rate for Payer: Aetna Government |
$7.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$7.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.51
|
| Rate for Payer: Group Health Inc Commercial |
$7.40
|
| Rate for Payer: Group Health Inc Medicare |
$5.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9.62
|
|
|
CABOTEGRAVIR 200MG/ML
|
Facility
IP
|
$14.80
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41650334
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.40 |
| Max. Negotiated Rate |
$7.40 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.40
|
|
