|
EQ UROGRAPHY IV +-KUB TOMOG
|
Facility
|
IP
|
$551.90
|
|
|
Service Code
|
HCPCS 74400 TC
|
| Hospital Charge Code |
41108536
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$212.47
|
|
|
EQ UROGRAPHY IV +-KUB TOMOG
|
Facility
|
OP
|
$551.90
|
|
|
Service Code
|
HCPCS 74400 TC
|
| Hospital Charge Code |
41108536
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$148.73 |
| Max. Negotiated Rate |
$352.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$303.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$212.47
|
| Rate for Payer: Aetna Government |
$212.47
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$148.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$148.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$148.73
|
| Rate for Payer: Brighton Health Commercial |
$212.47
|
| Rate for Payer: Cash Price |
$212.47
|
| Rate for Payer: Cash Price |
$212.47
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$212.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$352.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$298.26
|
| Rate for Payer: Elderplan Medicare Advantage |
$212.47
|
| Rate for Payer: EmblemHealth Commercial |
$148.73
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$180.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$180.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$189.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$212.47
|
| Rate for Payer: Fidelis Qualified Health Plan |
$189.10
|
| Rate for Payer: Group Health Inc Commercial |
$191.22
|
| Rate for Payer: Group Health Inc Medicare |
$191.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$275.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$212.47
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$191.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$212.47
|
| Rate for Payer: Healthfirst QHP |
$212.47
|
| Rate for Payer: Humana Medicare |
$216.72
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$212.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$212.47
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$212.47
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$169.98
|
| Rate for Payer: Wellcare Medicare |
$201.85
|
|
|
EQ UROGRAPHY RTRGR +-KUB
|
Facility
|
IP
|
$1,156.53
|
|
|
Service Code
|
HCPCS 74420 TC
|
| Hospital Charge Code |
41107484
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$444.73
|
|
|
EQ UROGRAPHY RTRGR +-KUB
|
Facility
|
OP
|
$1,156.53
|
|
|
Service Code
|
HCPCS 74420 TC
|
| Hospital Charge Code |
41107484
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$298.26 |
| Max. Negotiated Rate |
$636.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$636.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$444.73
|
| Rate for Payer: Aetna Government |
$444.73
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$311.31
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$311.31
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$311.31
|
| Rate for Payer: Brighton Health Commercial |
$444.73
|
| Rate for Payer: Cash Price |
$444.73
|
| Rate for Payer: Cash Price |
$444.73
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$444.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$352.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$298.26
|
| Rate for Payer: Elderplan Medicare Advantage |
$444.73
|
| Rate for Payer: EmblemHealth Commercial |
$311.31
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$378.02
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$378.02
|
| Rate for Payer: Fidelis Essential Plan QHP |
$395.81
|
| Rate for Payer: Fidelis Medicare Advantage |
$444.73
|
| Rate for Payer: Fidelis Qualified Health Plan |
$395.81
|
| Rate for Payer: Group Health Inc Commercial |
$400.26
|
| Rate for Payer: Group Health Inc Medicare |
$400.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$578.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$444.73
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$400.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$444.73
|
| Rate for Payer: Healthfirst QHP |
$444.73
|
| Rate for Payer: Humana Medicare |
$453.62
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$444.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$444.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$444.73
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$355.78
|
| Rate for Payer: Wellcare Medicare |
$422.49
|
|
|
EQ UROGRPHY ANTEGRADE RS&I
|
Facility
|
OP
|
$1,141.00
|
|
|
Service Code
|
HCPCS 74425 TC
|
| Hospital Charge Code |
41102725
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$298.26 |
| Max. Negotiated Rate |
$627.55 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$627.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$444.73
|
| Rate for Payer: Aetna Government |
$444.73
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$311.31
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$311.31
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$311.31
|
| Rate for Payer: Brighton Health Commercial |
$444.73
|
| Rate for Payer: Cash Price |
$444.73
|
| Rate for Payer: Cash Price |
$444.73
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$444.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$352.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$298.26
|
| Rate for Payer: Elderplan Medicare Advantage |
$444.73
|
| Rate for Payer: EmblemHealth Commercial |
$311.31
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$378.02
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$378.02
|
| Rate for Payer: Fidelis Essential Plan QHP |
$395.81
|
| Rate for Payer: Fidelis Medicare Advantage |
$444.73
|
| Rate for Payer: Fidelis Qualified Health Plan |
$395.81
|
| Rate for Payer: Group Health Inc Commercial |
$400.26
|
| Rate for Payer: Group Health Inc Medicare |
$400.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$570.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$444.73
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$400.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$444.73
|
| Rate for Payer: Healthfirst QHP |
$444.73
|
| Rate for Payer: Humana Medicare |
$453.62
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$444.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$444.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$444.73
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$355.78
|
| Rate for Payer: Wellcare Medicare |
$422.49
|
|
|
EQ UROGRPHY ANTEGRADE RS&I
|
Facility
|
IP
|
$1,141.00
|
|
|
Service Code
|
HCPCS 74425 TC
|
| Hospital Charge Code |
41102725
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$444.73
|
|
|
EQ VENOUS SAMPLING
|
Facility
|
IP
|
$13,920.70
|
|
|
Service Code
|
HCPCS 75893 TC
|
| Hospital Charge Code |
41102701
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$6,354.94
|
|
|
EQ VENOUS SAMPLING
|
Facility
|
OP
|
$13,920.70
|
|
|
Service Code
|
HCPCS 75893 TC
|
| Hospital Charge Code |
41102701
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$3,432.09 |
| Max. Negotiated Rate |
$7,656.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7,656.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,354.94
|
| Rate for Payer: Aetna Government |
$6,354.94
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$4,448.46
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$4,448.46
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$4,448.46
|
| Rate for Payer: Brighton Health Commercial |
$6,354.94
|
| Rate for Payer: Cash Price |
$6,354.94
|
| Rate for Payer: Cash Price |
$6,354.94
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,354.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,056.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,432.09
|
| Rate for Payer: Elderplan Medicare Advantage |
$6,354.94
|
| Rate for Payer: EmblemHealth Commercial |
$4,448.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$5,401.70
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,401.70
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5,655.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,354.94
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5,655.90
|
| Rate for Payer: Group Health Inc Commercial |
$5,719.45
|
| Rate for Payer: Group Health Inc Medicare |
$5,719.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6,960.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,354.94
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$5,719.45
|
| Rate for Payer: Healthfirst Medicare Advantage |
$6,354.94
|
| Rate for Payer: Healthfirst QHP |
$6,354.94
|
| Rate for Payer: Humana Medicare |
$6,482.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,354.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,354.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,354.94
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,083.95
|
| Rate for Payer: Wellcare Medicare |
$6,037.19
|
|
|
EQ VISCERAL W/WO FLUSH
|
Facility
|
IP
|
$13,920.70
|
|
|
Service Code
|
HCPCS 75726 TC
|
| Hospital Charge Code |
41102576
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$6,354.94
|
|
|
EQ VISCERAL W/WO FLUSH
|
Facility
|
OP
|
$13,920.70
|
|
|
Service Code
|
HCPCS 75726 TC
|
| Hospital Charge Code |
41102576
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$3,432.09 |
| Max. Negotiated Rate |
$7,656.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7,656.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,354.94
|
| Rate for Payer: Aetna Government |
$6,354.94
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$4,448.46
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$4,448.46
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$4,448.46
|
| Rate for Payer: Brighton Health Commercial |
$6,354.94
|
| Rate for Payer: Cash Price |
$6,354.94
|
| Rate for Payer: Cash Price |
$6,354.94
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6,354.94
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,056.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,432.09
|
| Rate for Payer: Elderplan Medicare Advantage |
$6,354.94
|
| Rate for Payer: EmblemHealth Commercial |
$4,448.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$5,401.70
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5,401.70
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5,655.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,354.94
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5,655.90
|
| Rate for Payer: Group Health Inc Commercial |
$5,719.45
|
| Rate for Payer: Group Health Inc Medicare |
$5,719.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6,960.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,354.94
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$5,719.45
|
| Rate for Payer: Healthfirst Medicare Advantage |
$6,354.94
|
| Rate for Payer: Healthfirst QHP |
$6,354.94
|
| Rate for Payer: Humana Medicare |
$6,482.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6,354.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,354.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,354.94
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,083.95
|
| Rate for Payer: Wellcare Medicare |
$6,037.19
|
|
|
EQ WHITAKER TEST
|
Facility
|
OP
|
$8,393.53
|
|
|
Service Code
|
HCPCS 37700 TC
|
| Hospital Charge Code |
41107483
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$6,295.15 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,686.08
|
| Rate for Payer: Aetna Government |
$3,686.08
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,580.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,580.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,580.26
|
| Rate for Payer: Brighton Health Commercial |
$6,295.15
|
| Rate for Payer: Cash Price |
$3,686.08
|
| Rate for Payer: Cash Price |
$3,686.08
|
| Rate for Payer: Cash Price |
$3,686.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,686.08
|
| 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 |
$3,686.08
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,133.17
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,280.61
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,686.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,280.61
|
| Rate for Payer: Group Health Inc Commercial |
$3,686.08
|
| Rate for Payer: Group Health Inc Medicare |
$3,686.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,196.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,686.08
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,133.17
|
| Rate for Payer: Healthfirst QHP |
$3,686.08
|
| Rate for Payer: Humana Medicare |
$3,759.80
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,686.08
|
| Rate for Payer: United Healthcare Commercial |
$1,835.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,686.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,686.08
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$2,948.86
|
| Rate for Payer: Wellcare Medicare |
$3,501.78
|
|
|
EQ WHITAKER TEST
|
Facility
|
IP
|
$8,393.53
|
|
|
Service Code
|
HCPCS 37700 TC
|
| Hospital Charge Code |
41107483
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$3,686.08
|
|
|
EQ WRIST ARTHOGRAM
|
Facility
|
IP
|
$1,156.53
|
|
|
Service Code
|
HCPCS 73115 TC
|
| Hospital Charge Code |
41102468
|
|
Hospital Revenue Code
|
320
|
| Rate for Payer: Cash Price |
$444.73
|
|
|
EQ WRIST ARTHOGRAM
|
Facility
|
OP
|
$1,156.53
|
|
|
Service Code
|
HCPCS 73115 TC
|
| Hospital Charge Code |
41102468
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$311.31 |
| Max. Negotiated Rate |
$636.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$636.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$444.73
|
| Rate for Payer: Aetna Government |
$444.73
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$311.31
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$311.31
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$311.31
|
| Rate for Payer: Brighton Health Commercial |
$444.73
|
| Rate for Payer: Cash Price |
$444.73
|
| Rate for Payer: Cash Price |
$444.73
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$444.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$550.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$465.78
|
| Rate for Payer: Elderplan Medicare Advantage |
$444.73
|
| Rate for Payer: EmblemHealth Commercial |
$311.31
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$378.02
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$378.02
|
| Rate for Payer: Fidelis Essential Plan QHP |
$395.81
|
| Rate for Payer: Fidelis Medicare Advantage |
$444.73
|
| Rate for Payer: Fidelis Qualified Health Plan |
$395.81
|
| Rate for Payer: Group Health Inc Commercial |
$400.26
|
| Rate for Payer: Group Health Inc Medicare |
$400.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$578.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$444.73
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$400.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$444.73
|
| Rate for Payer: Healthfirst QHP |
$444.73
|
| Rate for Payer: Humana Medicare |
$453.62
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$444.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$444.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$444.73
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$355.78
|
| Rate for Payer: Wellcare Medicare |
$422.49
|
|
|
ERAVACYCLINE 50MG/5ML INJ
|
Facility
|
OP
|
$2.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41653891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.10
|
| Rate for Payer: Aetna Government |
$1.10
|
| Rate for Payer: Brighton Health Commercial |
$1.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.26
|
| Rate for Payer: Group Health Inc Commercial |
$1.10
|
| Rate for Payer: Group Health Inc Medicare |
$0.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.43
|
|
|
ERAVACYCLINE 50MG/5ML INJ
|
Facility
|
IP
|
$2.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41643891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.10
|
|
|
ERAVACYCLINE 50MG/5ML INJ
|
Facility
|
OP
|
$2.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41643891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.10
|
| Rate for Payer: Aetna Government |
$1.10
|
| Rate for Payer: Brighton Health Commercial |
$1.32
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.26
|
| Rate for Payer: Group Health Inc Commercial |
$1.10
|
| Rate for Payer: Group Health Inc Medicare |
$0.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.43
|
|
|
ERAVACYCLINE 50MG/5ML INJ
|
Facility
|
IP
|
$2.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41653891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.10
|
|
|
ERAVACYCLINE DIHYDROCHLORIDE 50 MG IV SOLR [162998]
|
Facility
|
OP
|
$73.80
|
|
|
Service Code
|
HCPCS J0122
|
| Hospital Charge Code |
71773005012
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$47.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$40.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.37
|
| Rate for Payer: Aetna Government |
$1.37
|
| Rate for Payer: Brighton Health Commercial |
$44.28
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$36.90
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$42.44
|
| Rate for Payer: Elderplan Medicare Advantage |
$1.37
|
| Rate for Payer: EmblemHealth Commercial |
$36.90
|
| Rate for Payer: Fidelis Medicare Advantage |
$1.37
|
| Rate for Payer: Group Health Inc Commercial |
$1.37
|
| Rate for Payer: Group Health Inc Medicare |
$1.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$36.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$36.90
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1.16
|
| Rate for Payer: Healthfirst QHP |
$1.37
|
| Rate for Payer: Humana Medicare |
$1.40
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$47.97
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1.10
|
|
|
ERAVACYCLINE DIHYDROCHLORIDE 50 MG IV SOLR [162998]
|
Facility
|
IP
|
$73.80
|
|
|
Service Code
|
HCPCS J0122
|
| Hospital Charge Code |
71773005012
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$36.90 |
| Max. Negotiated Rate |
$36.90 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$36.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$36.90
|
|
|
ERBULIN 1MG/2ML INJ
|
Facility
|
OP
|
$258.50
|
|
|
Service Code
|
HCPCS J9179
|
| Hospital Charge Code |
41646650
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.95 |
| Max. Negotiated Rate |
$10,295.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$142.18
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.02
|
| Rate for Payer: Aetna Government |
$134.02
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$231.64
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$231.64
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$102.95
|
| Rate for Payer: Amida Care Medicaid |
$102.95
|
| Rate for Payer: Brighton Health Commercial |
$155.10
|
| Rate for Payer: Cash Price |
$134.02
|
| Rate for Payer: Cash Price |
$134.02
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$134.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$129.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$148.64
|
| Rate for Payer: Elderplan Medicare Advantage |
$134.02
|
| Rate for Payer: EmblemHealth Commercial |
$134.02
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$10,295.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$102.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$102.95
|
| Rate for Payer: Fidelis Medicare Advantage |
$134.02
|
| Rate for Payer: Fidelis Qualified Health Plan |
$108.10
|
| Rate for Payer: Group Health Inc Commercial |
$134.02
|
| Rate for Payer: Group Health Inc Medicare |
$134.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$102.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$129.25
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$102.95
|
| Rate for Payer: Healthfirst Essential Plan |
$231.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$113.91
|
| Rate for Payer: Healthfirst QHP |
$102.95
|
| Rate for Payer: Humana Medicare |
$136.70
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$134.02
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$102.95
|
| Rate for Payer: SOMOS Essential |
$102.95
|
| Rate for Payer: United Healthcare Commercial |
$126.63
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$231.64
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$113.24
|
| Rate for Payer: United Healthcare Medicaid |
$102.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$134.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$168.02
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$107.21
|
| Rate for Payer: Wellcare Medicare |
$127.32
|
|
|
ERBULIN 1MG/2ML INJ
|
Facility
|
IP
|
$258.50
|
|
|
Service Code
|
HCPCS J9179
|
| Hospital Charge Code |
41646650
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.25 |
| Max. Negotiated Rate |
$129.25 |
| Rate for Payer: Cash Price |
$134.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$129.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$129.25
|
|
|
ERCP DIAGNOSTIC
|
Facility
|
IP
|
$9,083.48
|
|
|
Service Code
|
HCPCS 43260
|
| Hospital Charge Code |
40014287
|
|
Hospital Revenue Code
|
360
|
| Rate for Payer: Cash Price |
$4,428.82
|
|
|
ERCP DIAGNOSTIC
|
Facility
|
OP
|
$9,083.48
|
|
|
Service Code
|
HCPCS 43260
|
| Hospital Charge Code |
40014287
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$955.00 |
| Max. Negotiated Rate |
$4,541.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,428.82
|
| Rate for Payer: Aetna Government |
$4,428.82
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,100.17
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,100.17
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,100.17
|
| Rate for Payer: Brighton Health Commercial |
$955.00
|
| Rate for Payer: Cash Price |
$4,428.82
|
| Rate for Payer: Cash Price |
$4,428.82
|
| Rate for Payer: Cash Price |
$4,428.82
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4,428.82
|
| 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 |
$4,428.82
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,764.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,941.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,428.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,941.65
|
| Rate for Payer: Group Health Inc Commercial |
$4,428.82
|
| Rate for Payer: Group Health Inc Medicare |
$4,428.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,541.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,428.82
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,764.50
|
| Rate for Payer: Healthfirst QHP |
$4,428.82
|
| Rate for Payer: Humana Medicare |
$4,517.40
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4,428.82
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,428.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4,428.82
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3,543.06
|
| Rate for Payer: Wellcare Medicare |
$4,207.38
|
|
|
ERCP DIAGNOSTIC
|
Facility
|
OP
|
$9,083.48
|
|
|
Service Code
|
HCPCS 43260
|
| Hospital Charge Code |
41118921
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$955.00 |
| Max. Negotiated Rate |
$4,541.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,888.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,428.82
|
| Rate for Payer: Aetna Government |
$4,428.82
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,100.17
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,100.17
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3,100.17
|
| Rate for Payer: Brighton Health Commercial |
$955.00
|
| Rate for Payer: Cash Price |
$4,428.82
|
| Rate for Payer: Cash Price |
$4,428.82
|
| Rate for Payer: Cash Price |
$4,428.82
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4,428.82
|
| 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 |
$4,428.82
|
| Rate for Payer: EmblemHealth Commercial |
$1,505.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,764.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,941.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,428.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,941.65
|
| Rate for Payer: Group Health Inc Commercial |
$4,428.82
|
| Rate for Payer: Group Health Inc Medicare |
$4,428.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,541.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,428.82
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,764.50
|
| Rate for Payer: Healthfirst QHP |
$4,428.82
|
| Rate for Payer: Humana Medicare |
$4,517.40
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4,428.82
|
| Rate for Payer: United Healthcare Commercial |
$1,468.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,428.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4,428.82
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3,543.06
|
| Rate for Payer: Wellcare Medicare |
$4,207.38
|
|
