|
CC DES AB X RX 2.75MMX28MM
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528961
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$265.52 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,145.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$265.52
|
| Rate for Payer: Aetna Government |
$265.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,950.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,242.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,095.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,950.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,535.00
|
|
|
CC DES AB X RX 2.75X8MM
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$265.52 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,145.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$265.52
|
| Rate for Payer: Aetna Government |
$265.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,950.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,242.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,095.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,950.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,535.00
|
|
|
CC DES AB X RX 2.75X8MM
|
Facility
IP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
|
|
CC DES AB X RX 3.0MMX 12MM
|
Facility
IP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528963
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
|
|
CC DES AB X RX 3.0MMX 12MM
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528963
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$265.52 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,145.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$265.52
|
| Rate for Payer: Aetna Government |
$265.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,950.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,242.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,095.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,950.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,535.00
|
|
|
CC DES AB X RX 3.0MMX 15MM
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$265.52 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,145.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$265.52
|
| Rate for Payer: Aetna Government |
$265.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,950.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,242.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,095.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,950.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,535.00
|
|
|
CC DES AB X RX 3.0MMX 15MM
|
Facility
IP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
|
|
CC DES AB X RX 3.0MMX 18MM
|
Facility
IP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528965
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
|
|
CC DES AB X RX 3.0MMX 18MM
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528965
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$265.52 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,145.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$265.52
|
| Rate for Payer: Aetna Government |
$265.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,950.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,242.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,095.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,950.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,535.00
|
|
|
CC DES AB X RX 3.0MMX28MM
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528966
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$265.52 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,145.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$265.52
|
| Rate for Payer: Aetna Government |
$265.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,950.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,242.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,095.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,950.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,535.00
|
|
|
CC DES AB X RX 3.0MMX28MM
|
Facility
IP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528966
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
|
|
CC DES AB X RX 3.0MMX8MM
|
Facility
IP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528967
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
|
|
CC DES AB X RX 3.0MMX8MM
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528967
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$265.52 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,145.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$265.52
|
| Rate for Payer: Aetna Government |
$265.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,950.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,242.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,095.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,950.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,535.00
|
|
|
CC DES AB X RX 3.5MMX12MM
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528968
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$265.52 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,145.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$265.52
|
| Rate for Payer: Aetna Government |
$265.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,950.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,242.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,095.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,950.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,535.00
|
|
|
CC DES AB X RX 3.5MMX12MM
|
Facility
IP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528968
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
|
|
CC DES AB X RX 3.5MMX 15MM
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528969
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$265.52 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,145.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$265.52
|
| Rate for Payer: Aetna Government |
$265.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,950.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,242.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,095.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,950.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,535.00
|
|
|
CC DES AB X RX 3.5MMX 15MM
|
Facility
IP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528969
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
|
|
CC DES AB X RX 3.5MMX18MM
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$265.52 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,145.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$265.52
|
| Rate for Payer: Aetna Government |
$265.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,950.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,242.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,095.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,950.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,535.00
|
|
|
CC DES AB X RX 3.5MMX18MM
|
Facility
IP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
|
|
CC DES AB X RX 3.5MMX23MM
|
Facility
IP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
|
|
CC DES AB X RX 3.5MMX23MM
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$265.52 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,145.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$265.52
|
| Rate for Payer: Aetna Government |
$265.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,950.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,242.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,095.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,950.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,535.00
|
|
|
CC DES AB X RX 3.5MMX28MM
|
Facility
IP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528972
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
|
|
CC DES AB X RX 3.5MMX28MM
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528972
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$265.52 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,145.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$265.52
|
| Rate for Payer: Aetna Government |
$265.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,950.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,242.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,095.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,950.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,535.00
|
|
|
CC DES AB X RX 3.5MMX8MM
|
Facility
IP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528973
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
|
|
CC DES AB X RX 3.5MMX8MM
|
Facility
OP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
66528973
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$265.52 |
| Max. Negotiated Rate |
$4,095.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,145.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$265.52
|
| Rate for Payer: Aetna Government |
$265.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,950.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,242.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,095.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,950.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,365.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,950.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,950.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,535.00
|
|
