|
ESTAB PT WELL CHILD CARE 12-17 YR
|
Facility
OP
|
$358.69
|
|
|
Service Code
|
HCPCS 99394
|
| Hospital Charge Code |
30301283
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.44 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$71.44
|
| Rate for Payer: Aetna Government |
$71.44
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$179.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.34
|
|
|
ESTAB PT WELL CHILD CARE 12-17 YR
|
Facility
OP
|
$358.63
|
|
|
Service Code
|
HCPCS 99394
|
| Hospital Charge Code |
30400226
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.44 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$71.44
|
| Rate for Payer: Aetna Government |
$71.44
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$179.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.32
|
|
|
ESTAB PT WELL CHILD CARE 1-4 YEAR
|
Facility
OP
|
$358.69
|
|
|
Service Code
|
HCPCS 99392
|
| Hospital Charge Code |
30301281
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.75 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$66.75
|
| Rate for Payer: Aetna Government |
$66.75
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$179.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.34
|
|
|
ESTAB PT WELL CHILD CARE 1-4 YR
|
Facility
OP
|
$358.63
|
|
|
Service Code
|
HCPCS 99392
|
| Hospital Charge Code |
30400223
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.75 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$66.75
|
| Rate for Payer: Aetna Government |
$66.75
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$179.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.32
|
|
|
ESTAB PT WELL CHILD CARE 18+ YEAR
|
Facility
OP
|
$358.69
|
|
|
Service Code
|
HCPCS 99395
|
| Hospital Charge Code |
30301284
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.27 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$66.27
|
| Rate for Payer: Aetna Government |
$66.27
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$179.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.34
|
|
|
ESTAB PT WELL CHILD CARE <1 YEAR
|
Facility
OP
|
$358.69
|
|
|
Service Code
|
HCPCS 99391
|
| Hospital Charge Code |
30301280
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$59.50 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$59.50
|
| Rate for Payer: Aetna Government |
$59.50
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$179.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.34
|
|
|
ESTAB PT WELL CHILD CARE 5-11YEAR
|
Facility
OP
|
$358.69
|
|
|
Service Code
|
HCPCS 99393
|
| Hospital Charge Code |
30301282
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.88 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$62.88
|
| Rate for Payer: Aetna Government |
$62.88
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$179.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.34
|
|
|
EST PT PRE AGE 12-17
|
Facility
OP
|
$358.63
|
|
|
Service Code
|
HCPCS 99394
|
| Hospital Charge Code |
30400225
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.44 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$71.44
|
| Rate for Payer: Aetna Government |
$71.44
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$179.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.32
|
|
|
EST PT PRE AGE 18-39 YR
|
Facility
OP
|
$358.63
|
|
|
Service Code
|
HCPCS 99395
|
| Hospital Charge Code |
30400227
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.27 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$66.27
|
| Rate for Payer: Aetna Government |
$66.27
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$179.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.32
|
|
|
EST PT PRE AGE 40-64 YRS
|
Facility
OP
|
$358.63
|
|
|
Service Code
|
HCPCS 99396
|
| Hospital Charge Code |
30400228
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.08 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$72.08
|
| Rate for Payer: Aetna Government |
$72.08
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$179.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.32
|
|
|
EST PT PRE AGE 65 - OLDER
|
Facility
OP
|
$358.63
|
|
|
Service Code
|
HCPCS 99397
|
| Hospital Charge Code |
30400229
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.81 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$75.81
|
| Rate for Payer: Aetna Government |
$75.81
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$179.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.32
|
|
|
EST PT WELL CHILD CARE 5-11 YEAR
|
Facility
OP
|
$358.63
|
|
|
Service Code
|
HCPCS 99393
|
| Hospital Charge Code |
30400224
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.88 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$197.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$62.88
|
| Rate for Payer: Aetna Government |
$62.88
|
| Rate for Payer: Brighton Health Commercial |
$233.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$204.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$173.89
|
| 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 |
$179.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.32
|
|
|
ESTRAMUSTINE 140 MG CAP
|
Facility
OP
|
$7.00
|
|
| Hospital Charge Code |
41641227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.50
|
| Rate for Payer: Aetna Government |
$3.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.76
|
| Rate for Payer: Group Health Inc Commercial |
$3.50
|
| Rate for Payer: Group Health Inc Medicare |
$2.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.55
|
|
|
ESTRAMUSTINE 140 MG CAP
|
Facility
OP
|
$7.00
|
|
| Hospital Charge Code |
41651227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.50
|
| Rate for Payer: Aetna Government |
$3.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.76
|
| Rate for Payer: Group Health Inc Commercial |
$3.50
|
| Rate for Payer: Group Health Inc Medicare |
$2.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.55
|
|
|
ESTRONE LC/MS/MS
|
Facility
OP
|
$62.38
|
|
|
Service Code
|
HCPCS 82679
|
| Hospital Charge Code |
30303359
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.96 |
| Max. Negotiated Rate |
$39.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.95
|
| Rate for Payer: Aetna Government |
$24.95
|
| Rate for Payer: Cash Price |
$24.95
|
| Rate for Payer: Cash Price |
$24.95
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$24.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$39.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$33.57
|
| Rate for Payer: Elderplan Medicare Advantage |
$24.95
|
| Rate for Payer: EmblemHealth Commercial |
$24.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$22.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$21.21
|
| Rate for Payer: Fidelis Essential Plan QHP |
$22.21
|
| Rate for Payer: Fidelis Medicare Advantage |
$24.95
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22.21
|
| Rate for Payer: Group Health Inc Commercial |
$24.95
|
| Rate for Payer: Group Health Inc Medicare |
$24.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.95
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$24.95
|
| Rate for Payer: Healthfirst Medicare Advantage |
$24.95
|
| Rate for Payer: Healthfirst QHP |
$24.95
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$24.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.95
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$19.96
|
| Rate for Payer: Wellcare Medicare |
$22.46
|
|
|
ESTRONE, SERUM
|
Facility
OP
|
$62.38
|
|
|
Service Code
|
HCPCS 82679
|
| Hospital Charge Code |
40609070
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.96 |
| Max. Negotiated Rate |
$39.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$34.31
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.95
|
| Rate for Payer: Aetna Government |
$24.95
|
| Rate for Payer: Cash Price |
$24.95
|
| Rate for Payer: Cash Price |
$24.95
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$24.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$39.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$33.57
|
| Rate for Payer: Elderplan Medicare Advantage |
$24.95
|
| Rate for Payer: EmblemHealth Commercial |
$24.95
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$22.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$21.21
|
| Rate for Payer: Fidelis Essential Plan QHP |
$22.21
|
| Rate for Payer: Fidelis Medicare Advantage |
$24.95
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22.21
|
| Rate for Payer: Group Health Inc Commercial |
$24.95
|
| Rate for Payer: Group Health Inc Medicare |
$24.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.95
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$24.95
|
| Rate for Payer: Healthfirst Medicare Advantage |
$24.95
|
| Rate for Payer: Healthfirst QHP |
$24.95
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$24.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.95
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$19.96
|
| Rate for Payer: Wellcare Medicare |
$22.46
|
|
|
ESWL LITHOTRIPSY BILE DUCT
|
Facility
OP
|
$14,479.95
|
|
|
Service Code
|
HCPCS 43265
|
| Hospital Charge Code |
40019526
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$460.63 |
| Max. Negotiated Rate |
$7,239.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,590.73
|
| Rate for Payer: Aetna Government |
$6,590.73
|
| Rate for Payer: Brighton Health Commercial |
$955.00
|
| Rate for Payer: Cash Price |
$6,590.73
|
| Rate for Payer: Cash Price |
$6,590.73
|
| Rate for Payer: Cash Price |
$6,590.73
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,590.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$6,590.73
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$460.63
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,602.12
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5,865.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,590.73
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5,865.75
|
| Rate for Payer: Group Health Inc Commercial |
$6,590.73
|
| Rate for Payer: Group Health Inc Medicare |
$6,590.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7,239.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,590.73
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$511.81
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5,602.12
|
| Rate for Payer: Healthfirst QHP |
$6,590.73
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,590.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,590.73
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,272.58
|
| Rate for Payer: Wellcare Medicare |
$6,261.19
|
|
|
ETESEVIMAB
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0245
|
| Hospital Charge Code |
41650247
|
|
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
|
|
|
ETESEVIMAB
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0245
|
| Hospital Charge Code |
41640247
|
|
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
|
|
|
ETESEVIMAB
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0245
|
| Hospital Charge Code |
41640247
|
|
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
|
|
|
ETESEVIMAB
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0245
|
| Hospital Charge Code |
41650247
|
|
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
|
|
|
ETHACRYNATE SODIUM 50MG INJ
|
Facility
OP
|
$1,314.46
|
|
| Hospital Charge Code |
41654944
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$460.06 |
| Max. Negotiated Rate |
$1,051.57 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$722.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$657.23
|
| Rate for Payer: Aetna Government |
$657.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,051.57
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$893.83
|
| Rate for Payer: Group Health Inc Commercial |
$657.23
|
| Rate for Payer: Group Health Inc Medicare |
$460.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$657.23
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$657.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$854.40
|
|
|
ETHACRYNATE SODIUM 50MG INJ
|
Facility
OP
|
$1,314.46
|
|
| Hospital Charge Code |
41644944
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$460.06 |
| Max. Negotiated Rate |
$1,051.57 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$722.95
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$657.23
|
| Rate for Payer: Aetna Government |
$657.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,051.57
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$893.83
|
| Rate for Payer: Group Health Inc Commercial |
$657.23
|
| Rate for Payer: Group Health Inc Medicare |
$460.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$657.23
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$657.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$854.40
|
|
|
ETHACRYNIC ACID 25 MG TAB
|
Facility
OP
|
$7.00
|
|
| Hospital Charge Code |
41643955
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.50
|
| Rate for Payer: Aetna Government |
$3.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.76
|
| Rate for Payer: Group Health Inc Commercial |
$3.50
|
| Rate for Payer: Group Health Inc Medicare |
$2.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.55
|
|
|
ETHACRYNIC ACID 25 MG TAB
|
Facility
OP
|
$7.00
|
|
| Hospital Charge Code |
41653955
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.50
|
| Rate for Payer: Aetna Government |
$3.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4.76
|
| Rate for Payer: Group Health Inc Commercial |
$3.50
|
| Rate for Payer: Group Health Inc Medicare |
$2.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.55
|
|
