|
EEG W/O VID 2-12 HR UNMNTR
|
Facility
|
IP
|
$814.65
|
|
|
Service Code
|
HCPCS 95705
|
| Hospital Charge Code |
41001011
|
|
Hospital Revenue Code
|
740
|
| Rate for Payer: Cash Price |
$362.98
|
|
|
EEG WO VID EA 12-26HR UNMNTR
|
Facility
|
OP
|
$1,502.55
|
|
|
Service Code
|
HCPCS 95710
|
| Hospital Charge Code |
41001012
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$433.87 |
| Max. Negotiated Rate |
$1,202.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$826.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$619.82
|
| Rate for Payer: Aetna Government |
$619.82
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$433.87
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$433.87
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$433.87
|
| Rate for Payer: Brighton Health Commercial |
$1,126.91
|
| Rate for Payer: Cash Price |
$619.82
|
| Rate for Payer: Cash Price |
$619.82
|
| Rate for Payer: Cash Price |
$619.82
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$619.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,202.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,021.73
|
| Rate for Payer: Elderplan Medicare Advantage |
$619.82
|
| Rate for Payer: EmblemHealth Commercial |
$619.82
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$526.85
|
| Rate for Payer: Fidelis Essential Plan QHP |
$551.64
|
| Rate for Payer: Fidelis Medicare Advantage |
$619.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$551.64
|
| Rate for Payer: Group Health Inc Commercial |
$619.82
|
| Rate for Payer: Group Health Inc Medicare |
$619.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$751.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$619.82
|
| Rate for Payer: Healthfirst Medicare Advantage |
$526.85
|
| Rate for Payer: Healthfirst QHP |
$619.82
|
| Rate for Payer: Humana Medicare |
$632.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$619.82
|
| Rate for Payer: United Healthcare Commercial |
$822.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$619.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$619.82
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$495.86
|
| Rate for Payer: Wellcare Medicare |
$588.83
|
|
|
EEG WO VID EA 12-26HR UNMNTR
|
Facility
|
IP
|
$1,502.55
|
|
|
Service Code
|
HCPCS 95710
|
| Hospital Charge Code |
41001012
|
|
Hospital Revenue Code
|
740
|
| Rate for Payer: Cash Price |
$619.82
|
|
|
EEG W/O VID ONT MONITOR
|
Facility
|
OP
|
$766.58
|
|
|
Service Code
|
HCPCS 95707
|
| Hospital Charge Code |
40111004
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$94.00 |
| Max. Negotiated Rate |
$613.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$421.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$362.98
|
| Rate for Payer: Aetna Government |
$362.98
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$254.09
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$254.09
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$254.09
|
| Rate for Payer: Brighton Health Commercial |
$574.94
|
| Rate for Payer: Cash Price |
$362.98
|
| Rate for Payer: Cash Price |
$362.98
|
| Rate for Payer: Cash Price |
$362.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$362.98
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$613.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$521.27
|
| Rate for Payer: Elderplan Medicare Advantage |
$362.98
|
| Rate for Payer: EmblemHealth Commercial |
$362.98
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$308.53
|
| Rate for Payer: Fidelis Essential Plan QHP |
$323.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$362.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$323.05
|
| Rate for Payer: Group Health Inc Commercial |
$362.98
|
| Rate for Payer: Group Health Inc Medicare |
$362.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$383.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$362.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$308.53
|
| Rate for Payer: Healthfirst QHP |
$362.98
|
| Rate for Payer: Humana Medicare |
$370.24
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$362.98
|
| Rate for Payer: United Healthcare Commercial |
$94.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$362.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$362.98
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$290.38
|
| Rate for Payer: Wellcare Medicare |
$344.83
|
|
|
EEG W/O VID ONT MONITOR
|
Facility
|
IP
|
$766.58
|
|
|
Service Code
|
HCPCS 95707
|
| Hospital Charge Code |
40111004
|
|
Hospital Revenue Code
|
920
|
| Rate for Payer: Cash Price |
$362.98
|
|
|
EFAVIRENZ 200 MG CAP
|
Facility
|
OP
|
$12.65
|
|
| Hospital Charge Code |
41651941
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$10.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.32
|
| Rate for Payer: Aetna Government |
$6.32
|
| Rate for Payer: Brighton Health Commercial |
$9.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10.12
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.60
|
| Rate for Payer: Group Health Inc Commercial |
$6.32
|
| Rate for Payer: Group Health Inc Medicare |
$4.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8.22
|
|
|
EFAVIRENZ 200 MG CAP
|
Facility
|
OP
|
$12.65
|
|
| Hospital Charge Code |
41641941
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$10.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.32
|
| Rate for Payer: Aetna Government |
$6.32
|
| Rate for Payer: Brighton Health Commercial |
$9.49
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10.12
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.60
|
| Rate for Payer: Group Health Inc Commercial |
$6.32
|
| Rate for Payer: Group Health Inc Medicare |
$4.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8.22
|
|
|
EFAVIRENZ 200 MG PO CAPS [23900]
|
Facility
|
OP
|
$11.77
|
|
|
Service Code
|
NDC 64980040709
|
| Hospital Charge Code |
64980040709
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.12 |
| Max. Negotiated Rate |
$9.41 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6.47
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$5.88
|
| Rate for Payer: Aetna Government |
$5.88
|
| Rate for Payer: Brighton Health Commercial |
$8.83
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$9.41
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8.00
|
| Rate for Payer: Group Health Inc Commercial |
$5.88
|
| Rate for Payer: Group Health Inc Medicare |
$4.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5.88
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7.65
|
|
|
EFAVIRENZ 50 MG CAP
|
Facility
|
OP
|
$4.00
|
|
| Hospital Charge Code |
41651939
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.00
|
| Rate for Payer: Aetna Government |
$2.00
|
| Rate for Payer: Brighton Health Commercial |
$3.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.72
|
| Rate for Payer: Group Health Inc Commercial |
$2.00
|
| Rate for Payer: Group Health Inc Medicare |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
|
|
EFAVIRENZ 50 MG CAP
|
Facility
|
OP
|
$4.00
|
|
| Hospital Charge Code |
41641939
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.00
|
| Rate for Payer: Aetna Government |
$2.00
|
| Rate for Payer: Brighton Health Commercial |
$3.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.72
|
| Rate for Payer: Group Health Inc Commercial |
$2.00
|
| Rate for Payer: Group Health Inc Medicare |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
|
|
EFAVIRENZ 50 MG PO CAPS [23898]
|
Facility
|
OP
|
$2.94
|
|
|
Service Code
|
NDC 64980040603
|
| Hospital Charge Code |
64980040603
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.62
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.47
|
| Rate for Payer: Aetna Government |
$1.47
|
| Rate for Payer: Brighton Health Commercial |
$2.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.00
|
| Rate for Payer: Group Health Inc Commercial |
$1.47
|
| Rate for Payer: Group Health Inc Medicare |
$1.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.47
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.47
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.91
|
|
|
EFAVIRENZ 50 MG PO CAPS [23898]
|
Facility
|
OP
|
$3.27
|
|
|
Service Code
|
NDC 00056047030
|
| Hospital Charge Code |
00056047030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.64
|
| Rate for Payer: Aetna Government |
$1.64
|
| Rate for Payer: Brighton Health Commercial |
$2.45
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.22
|
| Rate for Payer: Group Health Inc Commercial |
$1.64
|
| Rate for Payer: Group Health Inc Medicare |
$1.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.13
|
|
|
EFAVIRENZ 600 MG PO TABS [32298]
|
Facility
|
OP
|
$37.26
|
|
|
Service Code
|
NDC 64380088904
|
| Hospital Charge Code |
64380088904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.04 |
| Max. Negotiated Rate |
$29.81 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.63
|
| Rate for Payer: Aetna Government |
$18.63
|
| Rate for Payer: Brighton Health Commercial |
$27.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$29.81
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$25.34
|
| Rate for Payer: Group Health Inc Commercial |
$18.63
|
| Rate for Payer: Group Health Inc Medicare |
$13.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.63
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.63
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.22
|
|
|
EFAVIRENZ 600 MG PO TABS [32298]
|
Facility
|
OP
|
$37.26
|
|
|
Service Code
|
NDC 31722050430
|
| Hospital Charge Code |
31722050430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.04 |
| Max. Negotiated Rate |
$29.81 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.63
|
| Rate for Payer: Aetna Government |
$18.63
|
| Rate for Payer: Brighton Health Commercial |
$27.95
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$29.81
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$25.34
|
| Rate for Payer: Group Health Inc Commercial |
$18.63
|
| Rate for Payer: Group Health Inc Medicare |
$13.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.63
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.63
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.22
|
|
|
EFAVIRENZ 600 MG PO TABS [32298]
|
Facility
|
OP
|
$35.77
|
|
|
Service Code
|
NDC 69097030102
|
| Hospital Charge Code |
69097030102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.52 |
| Max. Negotiated Rate |
$28.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$19.68
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.89
|
| Rate for Payer: Aetna Government |
$17.89
|
| Rate for Payer: Brighton Health Commercial |
$26.83
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$28.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$24.33
|
| Rate for Payer: Group Health Inc Commercial |
$17.89
|
| Rate for Payer: Group Health Inc Medicare |
$12.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.89
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$17.89
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$23.25
|
|
|
EFAVIRENZ 600 MG TAB
|
Facility
|
OP
|
$37.90
|
|
| Hospital Charge Code |
41642789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.26 |
| Max. Negotiated Rate |
$30.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.84
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.95
|
| Rate for Payer: Aetna Government |
$18.95
|
| Rate for Payer: Brighton Health Commercial |
$28.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$30.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$25.77
|
| Rate for Payer: Group Health Inc Commercial |
$18.95
|
| Rate for Payer: Group Health Inc Medicare |
$13.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.64
|
|
|
EFAVIRENZ 600 MG TAB
|
Facility
|
OP
|
$37.90
|
|
| Hospital Charge Code |
41652789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.26 |
| Max. Negotiated Rate |
$30.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$20.84
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$18.95
|
| Rate for Payer: Aetna Government |
$18.95
|
| Rate for Payer: Brighton Health Commercial |
$28.42
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$30.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$25.77
|
| Rate for Payer: Group Health Inc Commercial |
$18.95
|
| Rate for Payer: Group Health Inc Medicare |
$13.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.95
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.64
|
|
|
EFAVIRENZ-EMTRICITAB-TENOFO DF 600-200-300 MG PO TABS [188730]
|
Facility
|
OP
|
$113.80
|
|
|
Service Code
|
NDC 65862049730
|
| Hospital Charge Code |
65862049730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.83 |
| Max. Negotiated Rate |
$91.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$62.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$56.90
|
| Rate for Payer: Aetna Government |
$56.90
|
| Rate for Payer: Brighton Health Commercial |
$85.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$91.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$77.38
|
| Rate for Payer: Group Health Inc Commercial |
$56.90
|
| Rate for Payer: Group Health Inc Medicare |
$39.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$56.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$73.97
|
|
|
EFAVIRENZ-EMTRICITAB-TENOFO DF 600-200-300 MG PO TABS [188730]
|
Facility
|
OP
|
$113.80
|
|
|
Service Code
|
NDC 31722073630
|
| Hospital Charge Code |
31722073630
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.83 |
| Max. Negotiated Rate |
$91.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$62.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$56.90
|
| Rate for Payer: Aetna Government |
$56.90
|
| Rate for Payer: Brighton Health Commercial |
$85.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$91.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$77.38
|
| Rate for Payer: Group Health Inc Commercial |
$56.90
|
| Rate for Payer: Group Health Inc Medicare |
$39.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$56.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$73.97
|
|
|
EFAVIRENZ-EMTRICITAB-TENOFO DF 600-200-300 MG PO TABS [188730]
|
Facility
|
OP
|
$113.80
|
|
|
Service Code
|
NDC 69097021002
|
| Hospital Charge Code |
69097021002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.83 |
| Max. Negotiated Rate |
$91.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$62.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$56.90
|
| Rate for Payer: Aetna Government |
$56.90
|
| Rate for Payer: Brighton Health Commercial |
$85.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$91.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$77.38
|
| Rate for Payer: Group Health Inc Commercial |
$56.90
|
| Rate for Payer: Group Health Inc Medicare |
$39.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$56.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$73.97
|
|
|
EFAVIRENZ-EMTRICITAB-TENOFO DF 600-200-300 MG PO TABS [188730]
|
Facility
|
OP
|
$113.80
|
|
|
Service Code
|
NDC 00093523456
|
| Hospital Charge Code |
00093523456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.83 |
| Max. Negotiated Rate |
$91.04 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$62.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$56.90
|
| Rate for Payer: Aetna Government |
$56.90
|
| Rate for Payer: Brighton Health Commercial |
$85.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$91.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$77.38
|
| Rate for Payer: Group Health Inc Commercial |
$56.90
|
| Rate for Payer: Group Health Inc Medicare |
$39.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$56.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$56.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$73.97
|
|
|
EFFICA BED
|
Facility
|
OP
|
$382.73
|
|
| Hospital Charge Code |
40209268
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$133.96 |
| Max. Negotiated Rate |
$306.18 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$210.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$191.36
|
| Rate for Payer: Aetna Government |
$191.36
|
| Rate for Payer: Brighton Health Commercial |
$287.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$306.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$260.26
|
| Rate for Payer: Group Health Inc Commercial |
$191.36
|
| Rate for Payer: Group Health Inc Medicare |
$133.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$191.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$191.36
|
|
|
EFICARE BED
|
Facility
|
OP
|
$348.71
|
|
| Hospital Charge Code |
40209130
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$122.05 |
| Max. Negotiated Rate |
$278.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$191.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$174.36
|
| Rate for Payer: Aetna Government |
$174.36
|
| Rate for Payer: Brighton Health Commercial |
$261.53
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$278.97
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$237.12
|
| Rate for Payer: Group Health Inc Commercial |
$174.36
|
| Rate for Payer: Group Health Inc Medicare |
$122.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$174.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$174.36
|
|
|
EGD US EXAM DUODENUM/JEJUNUM
|
Facility
|
OP
|
$4,716.98
|
|
|
Service Code
|
HCPCS 43259
|
| Hospital Charge Code |
41112832
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$955.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2,200.46
|
| Rate for Payer: Aetna Government |
$2,200.46
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,540.32
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,540.32
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,540.32
|
| Rate for Payer: Brighton Health Commercial |
$955.00
|
| Rate for Payer: Cash Price |
$2,200.46
|
| Rate for Payer: Cash Price |
$2,200.46
|
| Rate for Payer: Cash Price |
$2,200.46
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$2,200.46
|
| 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 |
$2,200.46
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,870.39
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,958.41
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,200.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,958.41
|
| Rate for Payer: Group Health Inc Commercial |
$2,200.46
|
| Rate for Payer: Group Health Inc Medicare |
$2,200.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,358.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,200.46
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,870.39
|
| Rate for Payer: Healthfirst QHP |
$2,200.46
|
| Rate for Payer: Humana Medicare |
$2,244.47
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$2,200.46
|
| Rate for Payer: United Healthcare Commercial |
$1,409.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,200.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,200.46
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,760.37
|
| Rate for Payer: Wellcare Medicare |
$2,090.44
|
|
|
EGD US EXAM DUODENUM/JEJUNUM
|
Facility
|
IP
|
$4,716.98
|
|
|
Service Code
|
HCPCS 43259
|
| Hospital Charge Code |
41112832
|
|
Hospital Revenue Code
|
750
|
| Rate for Payer: Cash Price |
$2,200.46
|
|
