|
DARBEPOETIN 60 MCG/ 0.3ML INJ FOR NON ES
|
Facility
OP
|
$5.10
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
41645167
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$3.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.93
|
| Rate for Payer: Aetna Government |
$2.93
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2.93
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.55
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.93
|
| Rate for Payer: Elderplan Medicare Advantage |
$2.93
|
| Rate for Payer: EmblemHealth Commercial |
$2.93
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$2.93
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2.93
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$2.93
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3.08
|
| Rate for Payer: Group Health Inc Commercial |
$2.93
|
| Rate for Payer: Group Health Inc Medicare |
$2.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.55
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$2.94
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2.49
|
| Rate for Payer: Healthfirst QHP |
$2.93
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2.93
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$3.08
|
| Rate for Payer: SOMOS Essential |
$3.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.32
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2.34
|
| Rate for Payer: Wellcare Medicare |
$2.78
|
|
|
DARBEPOETIN 60 MCG/ 0.3ML INJ FOR NON ES
|
Facility
IP
|
$5.10
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
41655167
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.55
|
|
|
DARBEPOETIN 60 MCG/ 0.3ML INJ FOR NON ES
|
Facility
IP
|
$5.10
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
41645167
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.55
|
|
|
DARBEPOETIN 60 MCG/ 0.3ML INJ FOR NON ES
|
Facility
OP
|
$5.10
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
41655167
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$3.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.93
|
| Rate for Payer: Aetna Government |
$2.93
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2.93
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.55
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.93
|
| Rate for Payer: Elderplan Medicare Advantage |
$2.93
|
| Rate for Payer: EmblemHealth Commercial |
$2.93
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$2.93
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2.93
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$2.93
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3.08
|
| Rate for Payer: Group Health Inc Commercial |
$2.93
|
| Rate for Payer: Group Health Inc Medicare |
$2.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.55
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$2.94
|
| Rate for Payer: Healthfirst Medicare Advantage |
$2.49
|
| Rate for Payer: Healthfirst QHP |
$2.93
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2.93
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$3.08
|
| Rate for Payer: SOMOS Essential |
$3.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.32
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2.34
|
| Rate for Payer: Wellcare Medicare |
$2.78
|
|
|
DARBEPOETIN ALPHA ERSD 200MCG/1ML
|
Facility
OP
|
$944.40
|
|
| Hospital Charge Code |
41646078
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$330.54 |
| Max. Negotiated Rate |
$755.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$519.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$472.20
|
| Rate for Payer: Aetna Government |
$472.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$755.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$642.19
|
| Rate for Payer: Group Health Inc Commercial |
$472.20
|
| Rate for Payer: Group Health Inc Medicare |
$330.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$472.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$472.20
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$613.86
|
|
|
DARBEPOETIN ALPHA ERSD 25MCG/1ML
|
Facility
OP
|
$122.06
|
|
| Hospital Charge Code |
41656076
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.72 |
| Max. Negotiated Rate |
$97.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$67.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$61.03
|
| Rate for Payer: Aetna Government |
$61.03
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$97.65
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$83.00
|
| Rate for Payer: Group Health Inc Commercial |
$61.03
|
| Rate for Payer: Group Health Inc Medicare |
$42.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$61.03
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$61.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$79.34
|
|
|
DARBEPOETIN ALPHA ERSD 40 MCG/1ML
|
Facility
OP
|
$195.32
|
|
| Hospital Charge Code |
41656079
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.36 |
| Max. Negotiated Rate |
$156.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$107.43
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$97.66
|
| Rate for Payer: Aetna Government |
$97.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$156.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$132.82
|
| Rate for Payer: Group Health Inc Commercial |
$97.66
|
| Rate for Payer: Group Health Inc Medicare |
$68.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$97.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$97.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$126.96
|
|
|
DARBEPOETIN ALPHA ERSD 60 MCG/1ML
|
Facility
OP
|
$292.98
|
|
| Hospital Charge Code |
41656077
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.54 |
| Max. Negotiated Rate |
$234.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$161.14
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$146.49
|
| Rate for Payer: Aetna Government |
$146.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$234.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$199.23
|
| Rate for Payer: Group Health Inc Commercial |
$146.49
|
| Rate for Payer: Group Health Inc Medicare |
$102.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$146.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$146.49
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$190.44
|
|
|
DARBEPOETIN APLHA ERSD 100MCG/1ML
|
Facility
OP
|
$488.32
|
|
| Hospital Charge Code |
41656080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$170.91 |
| Max. Negotiated Rate |
$390.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$268.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$244.16
|
| Rate for Payer: Aetna Government |
$244.16
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$390.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$332.06
|
| Rate for Payer: Group Health Inc Commercial |
$244.16
|
| Rate for Payer: Group Health Inc Medicare |
$170.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$244.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$244.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$317.41
|
|
|
DARBEPOETIN APLHA ERSD 200MCG/1ML
|
Facility
OP
|
$944.40
|
|
| Hospital Charge Code |
41656078
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$330.54 |
| Max. Negotiated Rate |
$755.52 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$519.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$472.20
|
| Rate for Payer: Aetna Government |
$472.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$755.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$642.19
|
| Rate for Payer: Group Health Inc Commercial |
$472.20
|
| Rate for Payer: Group Health Inc Medicare |
$330.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$472.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$472.20
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$613.86
|
|
|
DARUNAVIR 400 MG TAB
|
Facility
OP
|
$33.86
|
|
| Hospital Charge Code |
41645080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$27.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.93
|
| Rate for Payer: Aetna Government |
$16.93
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$23.02
|
| Rate for Payer: Group Health Inc Commercial |
$16.93
|
| Rate for Payer: Group Health Inc Medicare |
$11.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.93
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.93
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$22.01
|
|
|
DARUNAVIR 400 MG TAB
|
Facility
OP
|
$33.86
|
|
| Hospital Charge Code |
41655080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$27.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.93
|
| Rate for Payer: Aetna Government |
$16.93
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$23.02
|
| Rate for Payer: Group Health Inc Commercial |
$16.93
|
| Rate for Payer: Group Health Inc Medicare |
$11.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.93
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.93
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$22.01
|
|
|
DARUNAVIR 600 MG TAB
|
Facility
OP
|
$33.86
|
|
| Hospital Charge Code |
41655056
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$27.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.93
|
| Rate for Payer: Aetna Government |
$16.93
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$23.02
|
| Rate for Payer: Group Health Inc Commercial |
$16.93
|
| Rate for Payer: Group Health Inc Medicare |
$11.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.93
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.93
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$22.01
|
|
|
DARUNAVIR 600 MG TAB
|
Facility
OP
|
$33.86
|
|
| Hospital Charge Code |
41645056
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$27.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$16.93
|
| Rate for Payer: Aetna Government |
$16.93
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$23.02
|
| Rate for Payer: Group Health Inc Commercial |
$16.93
|
| Rate for Payer: Group Health Inc Medicare |
$11.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.93
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.93
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$22.01
|
|
|
DARUNAVIR/COBICISTAT 800-150MG TA
|
Facility
OP
|
$128.60
|
|
| Hospital Charge Code |
41656632
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.01 |
| Max. Negotiated Rate |
$102.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$70.73
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$64.30
|
| Rate for Payer: Aetna Government |
$64.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$102.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$87.45
|
| Rate for Payer: Group Health Inc Commercial |
$64.30
|
| Rate for Payer: Group Health Inc Medicare |
$45.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$64.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$64.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$83.59
|
|
|
DARUNAVIR/COBICISTAT/EMTRICITABIN
|
Facility
OP
|
$309.88
|
|
| Hospital Charge Code |
41648893
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.46 |
| Max. Negotiated Rate |
$247.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$170.43
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$154.94
|
| Rate for Payer: Aetna Government |
$154.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$247.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$210.72
|
| Rate for Payer: Group Health Inc Commercial |
$154.94
|
| Rate for Payer: Group Health Inc Medicare |
$108.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$154.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$154.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$201.42
|
|
|
DARUNAVIR/COBICISTAT/EMTRICITABIN
|
Facility
OP
|
$309.88
|
|
| Hospital Charge Code |
41658893
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.46 |
| Max. Negotiated Rate |
$247.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$170.43
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$154.94
|
| Rate for Payer: Aetna Government |
$154.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$247.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$210.72
|
| Rate for Payer: Group Health Inc Commercial |
$154.94
|
| Rate for Payer: Group Health Inc Medicare |
$108.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$154.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$154.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$201.42
|
|
|
DARUNAVIR/COBICSTAT 800-150MG TAB
|
Facility
OP
|
$128.60
|
|
| Hospital Charge Code |
41646632
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.01 |
| Max. Negotiated Rate |
$102.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$70.73
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$64.30
|
| Rate for Payer: Aetna Government |
$64.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$102.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$87.45
|
| Rate for Payer: Group Health Inc Commercial |
$64.30
|
| Rate for Payer: Group Health Inc Medicare |
$45.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$64.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$64.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$83.59
|
|
|
DATASENSOR W/10' CABLE ADULT
|
Facility
OP
|
$312.50
|
|
| Hospital Charge Code |
64903158
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$109.38 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$171.88
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$156.25
|
| Rate for Payer: Aetna Government |
$156.25
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$250.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$212.50
|
| Rate for Payer: Group Health Inc Commercial |
$156.25
|
| Rate for Payer: Group Health Inc Medicare |
$109.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$156.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$156.25
|
|
|
DAV-BAR MSH VNT LW BIORSRB 4.5 IN
|
Facility
IP
|
$1,520.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
40204258
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$760.00 |
| Max. Negotiated Rate |
$760.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$760.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$760.00
|
|
|
DAV-BAR MSH VNT LW BIORSRB 4.5 IN
|
Facility
OP
|
$1,520.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
40204258
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$69.35 |
| Max. Negotiated Rate |
$1,596.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$836.00
|
| 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 |
$760.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$874.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,596.00
|
| Rate for Payer: Group Health Inc Commercial |
$760.00
|
| Rate for Payer: Group Health Inc Medicare |
$532.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$760.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$760.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$988.00
|
|
|
DAV MESH VENTRA ELLIPSE 4X6
|
Facility
OP
|
$762.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
40008304
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$69.35 |
| Max. Negotiated Rate |
$800.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$419.10
|
| 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 |
$381.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$438.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$800.10
|
| Rate for Payer: Group Health Inc Commercial |
$381.00
|
| Rate for Payer: Group Health Inc Medicare |
$266.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$381.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$381.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$495.30
|
|
|
DAV MESH VENTRA ELLIPSE 4X6
|
Facility
IP
|
$762.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
40008304
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$381.00 |
| Max. Negotiated Rate |
$381.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$381.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$381.00
|
|
|
DAVOL MESH 4X4 3/4 OVAL
|
Facility
OP
|
$838.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
40206234
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$69.35 |
| Max. Negotiated Rate |
$879.90 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$460.90
|
| 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 |
$419.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$481.85
|
| Rate for Payer: Fidelis Medicare Advantage |
$879.90
|
| Rate for Payer: Group Health Inc Commercial |
$419.00
|
| Rate for Payer: Group Health Inc Medicare |
$293.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$419.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$419.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$544.70
|
|
|
DAVOL MESH 4X4 3/4 OVAL
|
Facility
IP
|
$838.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
40206234
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$419.00 |
| Max. Negotiated Rate |
$419.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$419.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$419.00
|
|
